Every finding on record at Firstmed Hospice Inc

Upon patient record review, 1 of 14 (Patient #7) 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 Patient 7: On 05.09.2024 the medication list indicates Tylenol 325 2 tabs po q 6 hours PRN pain, then on 06.06.2024 an additional entry was added for acetaminophen 650 1 tab po q 6 hours PRN pain. This represents a duplicate medication entry. (corrected onsite)

Upon patient record review, 3 of 14 (Patient #2, 3, 4) 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 2: There was no evidence of a treatment order for the patient's oxygen therapy. (corrected onsite) Patient 3: There was no evidence of a treatment order for the patient's oxygen therapy or for use of the glucometer to monitor blood glucose levels and administer injectable hypoglycemic agents. (corrected onsite) Patient 4: There was no evidence of a treatment order for the patient's oxygen therapy. (corrected onsite)

Upon patient record review 1 of 14 (Patient #10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 10: On 06.17.2024 a chest X ray and labs were ordered for the patient. These were completed and results were present in the patient record. However, there was no evidence of coordination with the physician to review these results, the IDT to discuss them or related interventions & goals, or the patient for review.

Upon patient client record review, 3 of 14 (Patient #1, 5, 8) 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 1: Discrepancies are present in the patient record related to end of life/advance directive wishes for the patient. The POLST form, completed on admission for hospice services, indicates both do not resuscitate status and that the family prefers full treatment for the patient, including intubation, mechanical ventilation, and cardioversion; these indications on the POLST form are inconsistent instructions. The initial plan of care indicates the patient should be full code status, with CPR performed. The banner bar on the EMR also indicates full code status. The DPCS was able to clarify the wishes of the family; a new POLST was collected to indicate the correct full code status. (corrected onsite) Patient 5: Discrepancies are present in the patient record related to end of life/advance directive wishes for the patient. The POLST form, completed on admission for hospice services, indicates both do not resuscitate status and that the patient prefers full treatment, including intubation, mechanical ventilation, and cardioversion; these indications on the POLST form are inconsistent instructions. The initial comprehensive assessment by the nurse indicates that the patient elects full code status, but with no further treatment or hospitalizations. The banner bar on the EMR indicates full code status. The DPCS was able to clarify the wishes of the family; a new POLST was collected to indicate the correct full code status. (corrected onsite) Patient 8: Discrepancies are present in the patient record related to end of life/advance directive wishes for the patient. The POLST form, completed on admission for hospice services, indicates full code status; however, part B of the form has been left incomplete. The initial comprehensive assessment by the nurse indicates that the family elects for the patient to have CPR performed, but no other life sustaining treatments or hospitalizations. The DPCS was able to clarify the wishes of the family; a new POLST was collected and completed in its entirety to fully indicate the wishes of the family. (corrected onsite)