Every finding on record at Compassionate Care Hospice of Central Texas, LLC

Upon patient record review, 3 of 14 (Patient #1,#8,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1:The medication profile includes an entry for oxygen 4 liters per minute as needed for shortness of breath. There is evidence that the recertification plan of care dated 6/23/24 includes an order for oxygen 2 liters per minute as needed for shortness of breath. Patient 8:The medication profile includes an entry for oxygen 2 liters per minute via nasal cannula as needed for shortness of breath and includes instructions to increase flow rate as needed to maintain saturation of 90%. There is no evidence that the order for oxygen includes instructions to increase flow rate as needed to maintain saturation of 90%. Patient 9:The medication profile includes an entry on 6/17/24 for Gabapentin 300 q HS x 10 days. The entry remains on the medication profile on 7/2/24.

Upon patient record review, 2 of 14 (Patient #1,#5) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 1:The patient's plan of care includes the use of lidocaine patch, estradiol cream and torsemide as part of the medication profile. There is no evidence that the patient and family received training on the use and side effects of the medications. Patient 5:The patient's plan of care includes the use of hyoscyamine, lorazepam, morphine concentrate and Haloperidol lactate as part of the medication profile. There is no evidence that the patient and family received training on the purpose and side effects of the medications.

Upon patient record review, 4 of 14 (Patient #2,#3,#7,#8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The plan of care includes a visit frequency for the spiritual care coordinator. There is no evidence that the plan of care includes problems, goals and interventions for additional visits to be provided. The medical record contains documentation of the use of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the plan of care includes problems, goals and interventions for the use and safety of oxygen. Patient 3:The medical record contains nursing documentation on 6/27/24 of left lower extremity wraps being applied due to continued edema. There is no evidence that the plan of care includes updates to the goal and interventions for alteration in skin integrity problem to include the treatment being provided. Patient 7:The medical record contains documentation of a primary diagnosis of protein calorie malnutrition. There is no evidence that the plan of care includes goals and interventions for the problem of nutrition. Patient 8:The medical record contains nursing documentation of persistent cough on 6/21/24, and 6/24/24 with pharmalogical interventions on 6/27/24 of Robitussin cough syrup and Mucinex. There is no evidence that the plan of care contains problems, goals and interventions for the management of the symptom.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 10:The medical record contains a wound care order on 6/12/24 to cleanse, apply nickel thick layer of zinc, cover with bordered padded dressing, date time and initial dressing and report signs and symptoms of infection. There is no evidence that the order contains a frequency for providing treatment.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 7: The medical record contains documentation on 6/24/24 and 6/27/24 that patient was experiencing extreme and debilitating dizziness. There is no evidence that the plan of care was updated with problems, goals and interventions to manage the symptom.

Upon client record review, 1 of 14 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1:The medical record contains volunteer visit notes for 4/16/24, 4/30/24, 6/3/24 and 6/11/24. There is no evidence of an order on the plan of care for volunteer visits.