Every finding on record at Dhs Hospice Care

Upon patient record review 3 of 14 (Patient #2, 3, 11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: Spiritual comprehensive assessment was not completed within 5 days of SOC. SC documented a phone call on 8/4. Information obtained during that call was not a comprehensive assessment. CG declined spiritual services at the time of the call. Patient #3: Spiritual comprehensive assessment was not completed within 5 days of SOC. SC documented a phone call on 9/2. Information obtained during that call was not a comprehensive assessment. CG declined spiritual services at the time of the call. Patient #11: Spiritual comprehensive assessment was not completed within 5 days of SOC. SC documented a phone call on 8/25. Information obtained during that call was not a comprehensive assessment. CG declined spiritual services at the time of the call.

Upon patient record review, 5 of 14 (Patient #2, #4, #5, #6, #12) 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 #2: Econazole nitrate “thin layer topical once a day as needed skin irritation – no location listed. Patient #4: Lidocaine 5 percent 2 gram topical two times a day pain. No location listed. Patient #5: Latanaprost 0.005 percent 1 drop ophthalmic once a day glaucoma. No site listed - which eye. Patient #6: Medication order dated 8/18 for "Imodium 1 mg 1 tablet sublingual see direction. " No directions listed. Patient #12: Oxygen 2 litter inhalation as needed SOB ordered on initial POC. No route listed.

Upon patient record review, 12 of 14 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12) 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 #1, 2, 3, 4, 5, 6, 10, 12: Patient is listed as a Full Code and no funeral arrangements at SOC. No goals or interventions to support advance directive education, code status or plan to assist patient/cg with end of life planning. Patient #7, 8, 9, 11: Patient with no funeral arrangements at SOC. No goals or interventions to support assist patient/cg with end of life planning.

Upon client record review, 6 of 14 (Patient #1, 2, 4, 6, 10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Initial POC dated 4/27 ordered SC once a month. No evidence of an SC visit during the month of May. Patient #2: Initial POC dated 8/1 ordered SC monthly. No in person visits made by SC in September or October. SC documented a phone call on 9/29 and 10/19 to check on patient but no evidence of any attempt to visit the patient. Patient #4: Initial POC ordered RN every 14 days. No evidence of an RN visit from 9/20 - 10/10. Patient #6: Initial POC ordered SC monthly. No evidence of a visit for September. Record indicates a phone call to the CG in September and October but no evidence to support a visit was attempted. Patient #10: Initial POC ordered SC at recert. No SC visit made in September at time of recert. SC documented a phone call but no evidence to support a visit was attempted. Patient #11: Initial POC ordered SC monthly. No evidence of an in person visit by SC in September. Phone call documented by SC on 9/24 but no evidence of any attempt to visit the patient.

Upon patient record review 1 of 14 (Patient #8) 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 #8: Aide order 3x wk starting 8/4. No evidence of an aide visit week of 8/4.

Upon patient record review 1 of 14 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8: No evidence of an RN supervisory visit 8/5 - 9/1.

Upon patient client record review, 2 of 14 (Patient #2, #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: POC dated 8/1 listed "bleeding precautions due to aspirin" Patient is not on aspirin but on clopidogrel. Initial POC ordered Aide services 1xwk. 2 aide visits documented on 9/30 in error, one visit documented twice. Patient #3: Consent listed both that patient has and does not have advance directives. Unclear as to which is correct.