Every finding on record at Jbns Consulting LLC

Upon patient record review, 1 of 14 (Patient #1) 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 has Miralax powder 17G daily as needed if no BM for 2 days listed. No evidence that instructions were given on how to dilute the powder.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,7,8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1, 2, 3, 4, 5, 7: SW and SC have visit orders for once a month as needed on plan of care. No evidence of the quantity of PRN visits. Patient 8: SC has visit orders for once a month as needed on plan of care. No evidence of the quantity of PRN visits.

Upon patient record review, 1 of 14 (Patient #1) 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: A medication order written on 03/22/2024 for Miralax powder incomplete. Order has Miralax powder 17G daily as needed if no BM for 2 days. No evidence that instructions were given to dilute the medication.

Upon client record review, 1 of 14 (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: Plan of care has SN frequency as twice a week. No evidence that patient received 2 visits for the week of 03/03/2024. No evidence of an order to decrease visits for that week or communication by the patient/caregiver refusing the visit for that week.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: During the home visit, the aide set her work bag down on top of a cloth chair seat without placing a clean barrier between the bag and the chair bottom. Patient 3: While providing wound care to the patient during the home visit, the RN cleaned the sacral wound as ordered but placed the soiled gauze pads back on the clean area of the barrier along with other clean supplies.

Upon patient record review 6 of 14 (Patient #1,2,4,5,7,8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: No evidence that hospice aide received a supervised visit every 14 days. Patient received three on-site visits between the start of care and the start of survey. Those visits occurred on 12/28/2023, 02/08/2024, and 03/25/2024. Patient 2: No evidence that hospice aide received a supervised visit every 14 days. Patient received four on-site visits between the start of care and the start of survey. Those visit occurred on 12/19/2023, 02/10/2024, 02/13/2024 and 03/12/2024. Patient 4: No evidence that hospice aide received a supervised visit every 14 days. Patient received three on-site visits between the start of care and the start of survey. Those visit occurred on 12/28/2023, 02/08/2024, and 03/06/2024. Patient 5: No evidence that hospice aide received a supervised visit every 14 days. Patient received two on-site visits between the start of care and the start of survey. They occurred on 11/30/2023 and 03/04/2024. Patient 7: No evidence that hospice aide received a supervised visit every 14 days. Patient received one on-site visit between the start of care and the start of survey. That visit occurred on 02/24/2024. Patient 8: No evidence that hospice aide received a supervised visit every 14 days. Patient received two on-site visits between the start of care and the start of survey. Those visits occurred on 03/02/024 and 03/09/2024.

Upon patient client record review, 2 of 14 (Patient #1, 4) 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 1: No evidence that the nurse completed visit documentation for the following visits: 03/08/2024, 03/11/2024, and 03/18/2024. The only thing documented for each assessment was the patients pain level and MAC. No other assessment chapters were addressed nor was a narrative entered to explain why no assessment was done. Agency has a policy (Clinical/Service Data Collection 2-011) that states that the staff is to have documentation completed and submitted within 7 days of the clinical visit date. Patient 4: No evidence that the nurse completed visit documentation for the following visits: 03/08/2024, 03/11/2024, and 03/18/2024. The only thing documented for each assessment was the patients pain level and MAC. No other assessment chapters were addressed nor was a narrative entered to explain why no assessment was done. Agency has a policy (Clinical/Service Data Collection 2-011) that states that the staff is to have documentation completed and submitted within 7 days of the clinical visit date.