Every finding on record at Hospice of Southern Illinois, Inc

Based on document review and interview, it was determined for 1 of 4 (Pt #5) patients observed during a nursing home visit, the agency failed to ensure the patient's medication profiles were updated to reflect the most current medication changes. --- 1. Pt #5 SOC: 5/13/2023 Diagnosis: Parkinsons Disease. The Medication Profile for certification period 8/11/2023 thru 11/8/2023 was reviewed during Pt #5s nursing home visit on 8/30/2023 at approximately 11:15 AM. The Hospice Medication Profile had the following discrepancies confirmed with the Physician Order dated 6/28/2023 at 9:00 AM a. Ropinirole 0.5 mg orally at night was discontinued on 6/28/2023 per a physician order dated 6/28/2023, and was on the current medication profile dated 8/30/2023, as an active medication. b. Carbidopa-Levo Sinemet dopa 25 mg orally four times a day was on the current medication profile dated 8/30/2023, and the physician order dated 6/28/2023 indicates the dosing was changed to three times a day. 2. The policy titled "Standard of Performance for Medication Reconciliation" (reviewed 6/2023) was reviewed on 8/31/2023 at approximately 2:00 PM. The policy required, "The clinical record will contain evidence that medications have been reconciled and monitored during the initial assessment, with each update to the comprehensive assessment, and for medication or patient condition changes." 3. During the interview on 8/30/203 at approximately 11:30 AM, E #4 verbally agreed the 6/28/2023 physician order was not acknowledged or reflected on the ";Medication Profile" list dated 8/30/2023.

Based on document review and interview, it was determined for 1 of 2 (Pt #1) patient's records reviewed with wounds and a urinary catheter, the Hospice failed to ensure the Plan of Care (POC) was individualized and accurately reflected the care and services to be provided. --- Findings include: 1. The policy titled "Catherization of Bladder" was reviewed on 8/31/23. The policy noted "...A Physician's order is required to insert...a catheter". 2. The policy titled "Wound Care management" was reviewed on 8/31/23. The policy noted "...A physician's order is required for all wound treatments, regardless of the type of wound or treatment. The order must include the location of the wound, the cleaning instructions, all products used to treat the wound and the frequency of the dressing change..." 3. The clinical record of Pt. #1 was reviewed on 8/31/23. The record noted on 5/3/23 the SN inserted a catheter with return of "200 of yellow urine". The record lacked an order for the catheter insertion of the catheter. The record also noted from 7/3/23 to 7/28/23, that 9 of the 11 SN visits noted wound care/ dressing changes were conducted. The record lacked an order for the wound/ dressing changes. 4. During an interview with the Regulatory Compliance Education manager (E#2), E#2 verbally confirmed the lack of orders for the catheter and wound care.