Every finding on record at Devoted Hospice Care, Inc.

Upon patient record review, 4 of 5 (Patient #1,2,4,5) 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. Patient #1: Med profile includes acetaminophen 325mg, two tablets, by mouth every 4 hours as needed for pain. Med profile does not include max dosage instructions. Additionally, the care plan for alteration in comfort includes to instruct on effectiveness of medication (Fentanyl patch). There is missing evidence of a Fentanyl patch on the medication profile. Patient #2: Med profile includes acetaminophen 325mg, two tablets, by mouth every 4 hours as needed for pain. Med profile does not include max dosage instructions. Patient #4,5: PRN oxygen orders noted on the plan of care. Med profile does not include oxygen.

Upon patient record review, 1 of 5 (Patient #1) 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. Patient #1: Patient admitted to hospice with terminal diagnosis of atherosclerotic heart disease. There is missing evidence of a care plan related to cardiac issues.

Upon patient record review, 3 of 5 (Patient #1,2,4) 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: Plan of care orders include acetaminophen 325mg, two tablets, by mouth every 4 hours as needed for pain. Order does not include max dosage instructions. Additionally, the care plan for alteration in comfort includes to instruct on effectiveness of medication (Fentanyl patch). There is missing evidence of orders for a Fentanyl patch. Patient #2: Plan of care orders include acetaminophen 325mg, two tablets, by mouth every 4 hours as needed for pain. Order does not include max dosage instructions. Patient #4: Plan of care includes PRN orders for oxygen. The orders do not contain the route of administration.

Upon personnel record review, 3 of 12 (Personnel #2,3,4) did not have evidence that a skills competency assessment completed by the appropriate discipline. Personnel #2: Initial LPN competency completed by the administrator/LPN. Personnel #3: Initial RN competency completed by the administrator/LPN. Personnel #4: Initial RN competency completed by the administrator/LPN.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that all entries are complete. Patient #3: Spiritual assessment, completed 4/8/22, with incomplete documentation - missing the faith/denomination.