Every finding on record at Finest Hospice Inc

Upon patient record review, 3 of 7 (Patient #1,2,3) 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 #1,2,3 Advance directives indicated their wishes to be a full code. There was no evidence of any problems, goals, or interventions related to the full code status.

Upon client record review, 5 of 7 (Patient #1,2,3,4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-5 The spiritual comprehensive assessments contained a section "assessment obtained by" and the options listed were either phone or visit. All of the comprehensive assessments had the box for "phone" visit documented. There was no evidence of any subsequent in person spiritual assessments completed.

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients 1,2,3,4,5: Did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 5 (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. Patient 2: The POC contains an order for Atorvastatin Calcium 80mg PO daily. The medication profile contains Atorvastatin Calcium 20mg po daily. Corrected on site.

Upon patient record review, 2 of 5 (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: Upon home visit review, the POC contains an order for furosemide 40mg 2 tabs po daily. The pill bottle contains an order for furosemide 40mg 1 tab daily. The caregiver reports this is not a new order that pt has always taken 1 tab daily of the furosemide. Corrected on site.The POC contains an order for acetaminophen 500mg 1 tab every 8 hours prn. The home prescription bottle contains an order for acetaminophen 325mg 1 tab every 6 hours prn. The caregiver reports this is not a new order and pt has always taken the Acetaminophen 325mg dose. Corrected on site. Patient 3: Upon home visit review, the patient has an active medication of gabapentin 300mg take 1 tab po daily that was filled on 3-14-22. There is no evidence of an order for the medication on the POC. Corrected on site. The home meds also contain a pill bottle of hydrocodone/acetaminophen 5/325 1 tab bid prn with a fill date of 5-27-22. There is evidence of a SN visit on 5-25-22 and there is no evidence of an order for the hydrocodone/acetaminophen on the POC or a POC update order for this medication or the gabapentin. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) 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 1: The comprehensive assessment indicates pt is incontinent of bowel and bladder, there is no evidence of incontinence supplies ordered on the POC. Corrected on site. Patient 2: The comprehensive assessment indicates pt has walker and heel protectors, is incontinent of bowel and bladder, has a hospital bed. There is no evidence of an order on the POC for DME supplies. Corrected on site. Patient 3, 4 and 5: The comprehensive assessment indicates pt is incontinent of bowel and bladder and is wearing heel protectors. There is no evidence of orders on the POC for incontinence supplies or heel protectors.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The clinical record contains evidence that the RN made 2 visits to the patient on 6-1-22. There is no evidence of an order for a second visit that day/week. There is no evidence of a PRN need or an order for PRN visits.