Every finding on record at Great Care Hospice and Palliative Care, Inc

Upon patient record review, 2 of 14 (Patient #3,7) 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 • Drug therapy currently associated with laboratory monitoring Patient #3-The medication profile lists A&D ointment, 1 application topically as needed and does not include indicator or location instruction. Patient #7-The medication profile lists Spiriva HandiHaler 18 mEq powder for inhalation, 1 capsule by mouth once daily. The instructions are for a capsule instead of an inhalation.

Upon patient record review, 2 of 14 (Patient #3,7) 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. #3-The order dated 10/15/24 reads - A&D ointment, 1 application topically as needed. There is no indicator or location instruction included in the order. #7-The order dated 03/31/24 reads- Spiriva HandiHaler 18 mEq powder for inhalation, 1 capsule by mouth once daily. The instructions are for a capsule instead of an inhalation.

Upon patient record review, 3 of 14 (Patient #2,5,7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2,5-LVN is making weekly visits without an order. The only order for nursing is RN every 14 days. Patient #7-LVN is making visits 2x week without an order. The only order for nursing is RN 1 x weekly.