Every finding on record at Exclusive Hospice Care Inc

Upon patient record review, 2 of 14 (Patient #5,#9) 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 5:The medical record has an order for oxygen at 2 liters per minute as needed for shortness of breath. There is no evidence that the plan of care includes dyspnea problem with intervention of oxygen use. Patient 9:The medical records includes nursing documentation that the patient is at high risk for falls. There is no evidence that the plan of care includes problems, goals and interventions to manage the risk for falls.

Upon patient record review, 1 of 14 (Patient #3) 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 3:The medical record includes nursing documentation that the patient requires a hospital bed and side rails. There is no evidence that the plan of care includes hospital bed and rails as equipment needs.

Upon patient record review, 1 of 5 records (Patient #2) 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 The medication profile listed Timoptic eye drops and indicated a route of inhalation.

Upon patient record review, 1 of 1 applicable record (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide must include indicated precautions and be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #5; The record indicated that the patient was on Eliquis 5mg BID. There was not evidence of bleeding precautions on the aide plan of care.