Every finding on record at Emphaty Palliative Care Inc

Upon patient record review, 1 of 14 (Patient 1) 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 medication profile includes "Voltaren 1% topical gel, apply thin layer to affected areas every 4 hours as needed for pain" with no location identified.

Upon patient record review, 1 of 14 (Patient 1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1 plan of care includes "RN ordered for initial eval, every 14 days, every recert and as needed" with no quantifier for as needed visits.

Upon patient record review, 1 of 14 (Patient 1) 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 includes "Voltaren 1% topical gel, apply thin layer to affected areas every 4 hours as needed for pain" with no location identified.

Upon patient client record review, 1 of 5 (#4) 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 #4: Plan of care listed "BC 1 per week" (bereavement coordinator) in error for SN frequency. RN reports it was a data entry error. Corrected on site.