Every finding on record at Liborah Hospice

Upon patient record review, 1 of 5 (Patient #3) 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 #3 4/9/23 Medication list lists Lovastatin 20mg to be given with "every meal"; upon patient home visit, the medication bottle states "with evening meal"; the same medication profile stated that Tylenol 500mg is taken daily. Upon patient interview, the patient was taking Tylenol every 12 hours as needed. Corrected on site.

Upon patient record review, 1 of 5 (Patient #3) 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 #3 MSW visit note of 4/11/23 identifies anxiety and denial as a problem but there is no evidence of problems, goals and interventions for anxiety or denial.

Upon patient record review, 1 of 5 (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 during the home visit presence of cane was observed but no evidence of cane order under DME.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4 Aide POC established by RN on 1/12/23 included option for "Tub/Shower" to be done every visit; the same care plan stated "assist with ambulation wheel chair/walker/cane with no specific direction on which DME for Aide to assist.

Upon patient client record review, 1 of 5 (Patient #3) 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 #3 IDG note of 4/21/23 stated "patient was seen by MSW on 3/13/23 and Chaplain on 3/14/23. According to medical record, patient's SOC was 4/9/23, and MSW visit was 4/10/23 and Chaplain visit was 4/11/23.