Every finding on record at Delta Health Hospice

Upon patient record review, 1 of 14 (Patient #2) 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 Patient 2: The medication list indicates acetaminophen 500mg 1 tab po q 6 hrs mild pain or fever and tramadol 50mg 1 tab po bid moderate to severe pain. However, the medication list fails to include the PRN status of these medications as is indicated in the related physician's orders. (corrected onsite)

Upon patient record review, 6 of 14 (Patient #1, 2, 3, 5, 6, 8) 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 1, 2, 3, 5, 6, 8: The plan of care does not include a order for the PRN use of oxygen, though the oxygen appears on the medication list and the DME appears on the plan of care. (corrected onsite)

Upon patient record review, 2 of 14 (Patient #11, 13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 11, 13: There was no evidence of the bereavement care plan being updated after the patient's death, and no evidence of bereavement services being offered to the surviving family per the hospice's bereavement plan.

Upon patient record review 1 of 14 (Patient #7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 7: HA visits are ordered for 2 x weekly; however, during the week of 08.04.2024, there was only evidence that 1 HA visit was completed on 08.10.2024.