Every finding on record at Hospice Best Care Inc

Upon patient record review, 4 of 14 (Patient #1,#3,#6,#9) 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: The record indicated patient was set up with an oxygen concentrator on admission and to use oxygen as needed. There was not evidence that oxygen rate, frequency, or route was added to the medication profile. Corrected on site. Patient#3: Upon observed home visit, the patient had prescriptions for Ibuprofen 600mg 1 every 8 hours as needed or lidocaine 4% patches daily as needed. There was no evidence that these were added to the medication profile. The patient confirmed she is currently using these medications. Corrected on site. Patient#6: The record indicates patient was sent an oxygen concentrator and would require Oxygen PRN. There was not evidence that oxygen rate, frequency, or route was added to medication profile. Corrected on site. Patient#9: The record indicated for triple antibiotic apply daily as needed. There was no evidence of that a specific location for application was added to medication profile.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#7: The record indicates initial bereavement assessment was completed on 2/3/23. However, there is no evidence of information on a primary bereaved such as a name or contact information.

Upon patient record review, 5 of 14 (Patient #1,#2,#3,#6,#9) 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: The record indicated patient was set up with an oxygen concentrator on admission and to use oxygen as needed. There was not evidence of an order. Corrected on site. Patient#2: 6/13/24 clotrimazole 1% topical apply BID - no specified area. 6/13 Desoximetasone 0.05% topical cream apply BID - no specified area. Corrected on site Patient#3: Upon observed home visit, the patient had prescriptions for Ibuprofen 600mg 1 every 8 hours as needed or lidocaine 4% patches daily as needed. There was no evidence or an order. The patient confirmed she is currently using these medications. Corrected on site. Patient#6: The record indicates patient was sent an oxygen concentrator and would require Oxygen PRN. There was no evidence of an order. Corrected on site. Patient#9: The record indicated for triple antibiotic apply daily as needed. There was no evidence of order that include a specific area of application.

Upon patient record review, 1 of 14 (Patient #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 equipment and supply needs. Patient #3: The record indicates patient being supplied and using a nebulizer. There was no evidence of an order for nebulizer on plan of care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #3) 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#3: The record indicates in the admission assessment that the patient refused oxygen to be placed in the home. The record also included oxygen use on the plan of care order and include problems, goals, and interventions for oxygen use. It was confirmed when speaking with RN that the patient does not have oxygen in the home and has not used oxygen since admission to services.

Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient#7: - The record indicates patient was oriented and alert on admit. Documentation from aide on 4/26/24 indicates patient was disoriented, confused, and "wasn't aware what was going on". There is no evidence in record that aide reported change in patient condition to an RN.

Upon client record review, 4 of 14 (Patient #6,#8,#9,#12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #6, #12: There is no evidence of discharge summary, plan of care, or orders being being sent to physician to assist in continuation of care. Patient #8, #9: There is no evidence of discharge summary, plan of care, or orders being sent to hospital physician to assist in continuation of care.

Upon client record review, 5 of 14 (Patient #6,#8,#9,#10,#12) did not have evidence that the discharge summary includes all required information. Patient#6,#8,#9,#12: The record indicates patient revoked services to seek treatment. There is no evidence the discharge summary included information regarding coordination of care, recent orders, current plan of care, or communication/coordination for continuity of care. Patient#10: The record indicates patient was discharged for extended prognosis. There is no evidence the discharge summary included information regarding, recent orders, current plan of care, or communication/coordination for continuity of care or records sent to patients personnel physician.