Every finding on record at Go North Hospice Care, Inc

Upon patient record review, 1 of 14 (Patient #4) 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 Patient 4: The medication list recorded, "Docusate Sodium 250mg - 1 capsule 3 times daily as needed for constipation" and "Lactulose 30ml 3 times daily as needed for constipation." There was no documented evidence of further instructions on when to administer one medication versus the other or if administering both medications together for constipation was indicated.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The patient had evidence of a long term seizure disorder with the use of medications for management of the condition. There was no documented evidence of any seizure precautions on the plan of care to ensure patient safety.

Upon patient record review, 1 of 14 (Patient #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 4: The plan of care recorded, "Docusate Sodium 250mg - 1 capsule 3 times daily as needed for constipation" and "Lactulose 30ml 3 times daily as needed for constipation." There was no documented evidence of further instructions on when to administer one medication versus the other or if administering both medications together for constipation was indicated.

Upon contract review, 1 of 4 (Medical Director designee) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. The executed contract present in the personnel file for the "Medial Director Designee" did not specify this individual as the designee. The contract was titled, "Professional Services Agreement Medical Director." There was no addendum present to further clarify the physicians role as Medical Director Designee.

Upon patient record review, 1 of 1 applicable (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties include the task to be provided and the frequency of those tasks. Patient #5: The dated 3/4/22 which included the task to transfer the patient via mechanical lift. The task was incorrectly included on the aide care plan; the patient did not require mechanical lift for transfers.