Every finding on record at Hidden Hills Hospice LLC

Upon patient record review, 3 of 5 records (Patient #1, #2, #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 Patient #1: Medication profile included these PRN medications, no evidence of a prn indication: Oxycodone, Lorazepam, Hydrocodone/Acetaminophen, Calmoseptine ointment, Tylenol, Vitamin A & D ointment. Medication profile included Tylenol 325mg oral tablets, take 2 tablets every 8 hours as needed and hydrocodone/acetaminophen 5-325mg by mouth take 1 tablet every 4-6 hours as needed but did not have evidence of a maximum allowable dose. [corrected on site] Patient #2: Medication profile included Lorazepam as needed did not have evidence of an indicator for PRN use. [corrected on site] Patient #3: Medication profile included Lorazepam as needed did not have evidence of an indicator for PRN use. Medication profile included Tylenol 325mg oral tablets, take 2 tablets every 4 hours as needed for pain/fever did not have evidence of a maximum allowable dose. [corrected on site]

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 4) 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: The record indicated on nurse assessment dated 05/19/2022 that wound care was performed, however, there was no evidence of updates to the plan of care for any problems/interventions/goals for wound care or integumentary. Patient #2: The record indicated on nurse assessment dated 05/23/2022 patient has wound on rt. elbow with small purulent drainage however, there was no evidence of updates to the plan of care with problems/interventions/goals for wound care or integumentary. Patient #3: The record indicated on two of the nurse assessments that patient was using oxygen or oxygen was applied however, there was no evidence of updates to the plan of care with problems/interventions/goals for respiratory. The record indicated upon admission a DNR was signed and in record, however plan of care showed DNR marked as "NO" and physician order dated 05/13/2022 stated FULL CODE. [corrected on site] Patient #4: The record indicated upon admission a DNR was signed and in record, however plan of care showed DNR marked as "NO" and physician order dated 08/01/2021 stated FULL CODE. [corrected on site]

Upon patient record review, 3 of 5 records (Patient #1, #2, #3) 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: Admission orders dated 05/16/2022 there was no evidence of an indicator for those prescribed PRN: Oxycodone, Lorazepam, Hydrocodone/Acetaminophen, Calmoseptine ointment, Tylenol, Vitamin A & D ointment. Admission orders dated 04/04/2022 and signed 05/16/2022 for Tylenol 325mg oral tablets, take 2 tablets every 8 hours as needed and hydrocodone/acetaminophen 5-325mg by mouth take 1 tablet every 4-6 hours as needed but did not have evidence of a maximum allowable dose. [corrected on site] Patient #2: Order dated 05/13/2022 Lorazepam as needed did not have evidence of an indicator for PRN use. [corrected on site] Patient #3: Order dated 03/30/2022 Lorazepam as needed did not have evidence of an indicator for PRN use. Nurse assessments on 06/01/2022 and 06/08/2022 indicated patient was using oxygen however, there was no evidence for oxygen order. [corrected on site] Admission orders dated 03/30/2022 for Tylenol 325mg oral tablets, take 2 tablets every 4 hours as needed for pain/fever did not have evidence of a maximum allowable dose. [corrected on site]

Upon client record review, 2 of 5 (Patient #1 and 2) 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 nurse assessment dated 05/19/2022 documented that wound care was performed, however, there was no evidence of an order for wound care. Patient #2: The nurse assessment dated 05/23/2022 patient has wound on rt. elbow with small purulent drainage however, there was no evidence of an order for wound care.

Upon patient client record review, 2 of 5 (Patient #2 and 5) 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 #2: The record revealed the consents were signed by POA however, signature was located in beneficiary area and documents were not marked "beneficiary unable to sign". Patient #5: The record indicated that the admitting diagnosis on order dated 04/09/2021 and plan of care dated 04/09/2021 the terminal diagnosis was COPD however, the CTI completed by medical director on 04/09/2021 indicated terminal diagnosis was CHF.

Upon personnel record review, 1 of 4 applicable records (Personnel #7) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #7: Agency unable to obtain evidence of completed criminal background check from contracted agency.