Every finding on record at Hope & Light Hospice Inc

Upon patient record review, 2 of 14 (Patients #1, #6) 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 1: Facility has on oxygen on medication profile, Hospice does not list on medication profile. Patient 6: Patient takes hydralazine as needed, vitamin D3 daily, proamatin as needed, lupron injections every three months however, this is not on medication profile. Patient has oxygen concentrator in home. No evidence of route or rate on medication profile.

Upon patient record review, 2 of 14 (Patients #1, #6) 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: Pain identified in admit note as 4/10, patient given pain medication during visit, there are no plans, goals, or interventions for pain in the plan of care. Lidocaine 4%, acetaminophen, diclofenac 1%, Patient 6: Patient with colostomy, no goals, plans or interventions found to manage.

Upon patient record review, 2 of 14 (Patients #1, #6) 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: Patient has oxygen concentrator in room and facility has oxygen ordered at 2 liters via nasal cannula. No order found for oxygen in hospice chart. Patient 6: Patient takes hydralazine as needed, vitamin D3 daily, proamatin as needed, lupron injections every three months, Hospice has no orders for these medications. Patient has oxygen concentrator in home. No orders for rate or route.

Upon patient record review, 8 of 14 (Patients #1-#8) 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. Patient 1: Bed, air mattress, nebs, suction, o2 admit note identifies these as equipment needs to care for the patient. Patient 2: Nebulizer, suction, O2 are identified as needs for the patient on admit. Patient 3: No order written for wheelchair or nebulizer, which are identified as needs for the patient. Patient 4: Nebulizer, suction, O2. Aide care plan has O2 listed at 2 liters. No orders written for listed equipment. Patient 5: No medical equipment orders found. Patient has need for nebulizer due to Duonebs on order. Patient 6: Oxygen and nebulizer listed as identified needs to care for the patient. No orders found for equipment. Patient 7: Oxygen, suction, nebulizer, wheelchair identified as needed to care for patient. No orders found for equipment needs. Patient 8: Cane and oxygen identified as needs to care for patient, no orders written for equipment needs.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 6: Upon admission 1/3/25, the aide frequency was 1 time a week. The family would communicate with the hospice that aide services would not be needed. The aide frequency was never discontinued, no aide visits have been made. Corrected on site.

Upon client record review, 3 of 14 (Patients #3, #4, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Plan of care is for 1 visit a week, the volunteer has been making two visits a week, no evidence of an updated plan increasing the need for two visits a week. Corrected on site. Patient 4: Plan of care is for 1 visit a week, the volunteer has been making two visits a week. Corrected on site Patient 5: Plan of care for volunteer is 1 time a week, volunteer has been making two visits a week. Corrected on site.