Every finding on record at In Home Health, LLC

Upon patient record review, 4 of 13 records (Patient #1,#4,#8,#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. Patient 1: The medication profile contained voltaren gel without a defined area for administration. Medical record contained an order for oxygen but oxygen was not on the medication profile. Corrected on site. Patient 4: The medication profile contained nystatin powder with no defined area for administration and debrox ear drops started 12-26-21 with instructions for four days of administration. Corrected on site. Patient 8: The medication profile contained an order for nystatin topical cream with no defined area for administration. Corrected on site. Patient 9: The medication profile contained an order for a lidocaine patch with no defined area for administration. Corrected on site.

Upon patient record review, 2 of 13 records (Patients #5,#9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component completed within 5 days of the election of hospice. Patient 5: The medical record contained a bereavement assessment completed 2-21-22. Patient admitted to hospice services 12-13-21. Patient 9: The medical record contained a bereavement assessment completed 2-25-22. Patient admitted to hospice services 8-25-20.

Upon patient record review, 1 of 13 records (Patient #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient which includes interventions and goals Patient 12: The medical record contained nursing documentation 7-18-21 identifying patient use of indwelling catheter. There was no evidence of problems, goals, and intervention related to catheter use and care included in the plan of care.

Upon patient record review, 4 of 13 records (Patients #1,#4,#8,#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 medical record contained nursing documentation 2-1-22 identifying patient had an indwelling catheter. There was no evidence of treatment order in the medical record to identify catheter type and size to be maintained. The medical record also contained orders for voltaren gel without a defined area for administration, and oxygen without a defined frequency. Corrected on site. Patient 4: The medical record contained an order for nystatin powder with no defined area for administration. Corrected on site. Patient 8: The medical record contained an order for nystatin topical cream with no defined area for administration. The medication profile contained medications with instructions to administer via feeding tube without evidence of flushing instructions for medication administration via feeding tube. Corrected on site. Patient 9: The medical record contained an order for a lidocaine patch with no defined area for administration. Corrected on site.

Upon patient record review, 5 of 13 records (Patients #1,#4,#5,#11,#12) 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: The medical record contained nursing documentation upon admission identifying patient use of walker and shower chair, and 2-1-22 identifying use of indwelling catheter. There was no evidence of listed DME and supplies included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation 1-4-22 and 2-11-22 identifying patient use of a walker. There was no evidence of the walker included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation 1-28-22 identifying patient use of walker. There was no evidence of the walker included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient use of walker. There was no evidence of the walker included in the plan of care. Patient 12: The medical record contained nursing documentation 7-13-21 identifying patient use of hospital bed and 7-14-21 identifying use of wheelchair. There was no evidence of the listed DME included in the plan of care.

Upon client record review, 1 of 13 records (Patient #1) 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 medical record contained nursing documentation 2-1-22 identifying nurse attempted catheter insertion with 16 Fr coude unsuccessfully, and then 14 Fr for a successful insertion. There was no evidence in the record of an order for an indwelling catheter insertion.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 6: The medical record contained nursing documentation identifying a patient fall 2/19/22. There was no evidence of a fall report and investigation of the incident. Corrected on site.