Every finding on record at Family for Hospice and Palliative Care LLC

Upon patient record review, 2 of 6 (Patient #1, #6) 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. Patient #1- The Plan of care 02/14/23 includes Tamsulosin .4 mg po daily. The medication profile does not include Tamsulosin. Patient #6- The Plan of care 02/18/23 includes Oxygen and Albuterol. Oxygen and Albuterol are not listed on the medication profile.

Upon patient record review, 4 of 6 (Patient #1, #4, #5, #6) 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- The medication profile includes the following medications effective 02/14/23 which are not included in the 02/14/23 plan of care: Voriconazole 200mg q12h , Trazadone 150 mg po qhs, Folic Acid 1 mg po qd and Atorvastatin 40mg po qd. Patient #4-The plan of care 02/16/23 includes Lyrica 75 mcg po bid. The correct dosage is Lyrica 75 mg po bid. The plan of care also includes Oxygen 3lpm NC prn. Indications for prn are not specified on the plan of care. Patient #5- The medication profile was updated 03/06/23 with Ativan .5mg po q2h prn anxiety. The plan of care was not updated with orders for Ativan. Patient #6- The medication profile includes Morphine and Ativan effective 02/18/23. The medications are not included in the 02/18/23 plan of care.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence in the personnel file that a complete competency assessment for shampoo was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) (C) Shampoo, sink, tub, and bed Personnel #6-The competency on record documents the aide was observed performing a shampoo. The competency does not evidence a shampoo was observed in the sink, tub and bed.

Upon patient record review, 4 of 6 (Patient #1, #3, #4, #5) 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. Patient #1, #4- The initial nursing assessments on record document weight gain/loss "20". The documentation is not clear regarding the amount of weight the patient has gained or lost within a specific timeframe. Patient #3- The initial nursing assessment performed 04/07/23 does not include a signature and date. Patient #5- The Social Worker visit note 03/01/23 does not include a date by signature.