Every finding on record at Healthy Way Hospice Inc.

Upon patient record review, 1 of 14 (Patient #3) 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 #3-Oxygen was not listed on the medication list.

Upon patient record review, 2 of 14 (Patient #3,10) 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. #3-Plan of care dated 01/09/24 did not include incontinent supplies. #4-Plan of care dated 02/16/24 did not include incontinent supplies.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training #2-Plan of care dated 06/28/24 does not include an order for aide services, the plan of care states aide services were declined. Aide services are being provided at a frequency of 2 x wk.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) 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. All records lack legible staff signatures on consent forms. All paper forms and electronic records contain incorrect agency address.