Every finding on record at Essential Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #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 #9-Medication order for SN to prepare and administer IV infusion of Micafungin 100mg powder. No diluent documented or included on the Medication Profile.

Upon patient record review, 1 of 14 (Patient #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. #9-Medication order for SN to prepare and administer IV infusion of Micafungin 100mg powder. No diluent documented or included on the Plan of Care.

Upon client record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #9-There is an order to change PICC line dressing every 7 days and PRN. There is no documentation in the patient record that the dressing change was done. Patient to receive IV medications through the PICC for 42 days.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, it was noted that the plan of care was not updated with new problems. For example, in record review for home visit #1 it was noted the spiritual counselor documented on the 7/25 visit that the patient was depressed. The Interdisciplinary Group documentation for the 8/5 meeting did not reflect this new problem had been addressed and the care plan was not updated to include this new problem. This was confirmed by the Administrator/DPCS..