Every finding on record at Eden Hospice at Western Montana, LLC

Upon patient record review, 3 of 14 (Patients #1,6,7) 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: During medication reconciliation with the ALF and Hospice, Morphine Sulfate 0.25mL every 4 hours PRN was not included on the ALF profile. Additionally, Hospice increased Zyprexa from 5mg to 10mg dose on 5/27/25. This change was not reflected on ALF medication profile. Corrected on site. Patient #6: The CTI and Nursing Comprehensive indicated patient was using oxygen at start of care (4/3/25). There was an order for oxygen on 4/11/25. Oxygen not populating on current medication profile. Corrected on site. Patient #7: The POC and Nursing Comprehensive indicated patient was using oxygen at start of care (3/11/25). Oxygen not listed on current medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #11: The patient start of care (SOC) was 7/23/24. The Bereavement Risk Assessment was not completed within 5 days of SOC. The Initial Bereavement Risk Assessment was completed late on 8/16/24.

Upon patient record review, 2 of 14 (Patients #6,7) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: The CTI and Nursing Comprehensive indicated patient was using oxygen at start of care (4/3/25). There was an order for oxygen on 4/11/25. Oxygen directions not included on the POC. Corrected on site. Patient #7: The POC DME listed O2 concentrator and the Nursing Comprehensive indicated patient was using oxygen at start of care (3/11/25). Oxygen directions not listed on POC. Corrected on site.

Upon patient record review, 2 of 14 (Patients #2,10) 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 equipment and supply needs. Patient #2: The record indicated this patient has gel cushion, hospital bed w/side rails, LAL mattress, O2 concentrator. This patient does not have these items or needs this equipment. Corrected on site. Patient #10: The record reflected this patient uses walking sticks for ambulation assist. This item is not include on the POC. Corrected on site.

Upon patient record review, 1 of 14 (Patient #2) 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: Agency not following Policy for Corrections to Medical Records (Ref 13006). The election statement had a cross over mark on physician choice. There was no signature/date next to correction per policy. All documents in the record should be appropriately authenticated according to agency policy.

Upon patient record review 4 of 11 records (Patient #1, #2, #3, #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1: admitted on 5/24 psychosocial assessment was completed on 6/1. Patient #2: admitted on 5/24 psychosocial assessment was completed on 6/2. Patient #3: admitted on 1/27 spiritual assessment was completed 2/2. Patient #10: admitted on 2/23 and both the psychosocial and spiritual assessment completed on 3/1.

Upon patient record review, 2 of 11 (Patient #3 and 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 #3 and 9: The medication profile contained Miralax 17 Gram oral powder; however, there was no diluent included.

Upon patient record review, 2 of 11 (Patient #3, #9) 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 #3 and 9: order for Miralax 17 Gram oral powder; however, there was no diluent included.