Every finding on record at Mount Olive Hospice and Palliative Care LLC

Upon patient record review, 2 of 14 (Patient #7,9) 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 7 Medication profile only states O2, 2 LPN N/C and does not include a frequency. Patient 9 Medication profile states 2 LPN NC daily or PRN and does not include specific frequency.

Upon patient record review, 1 of 14 (Patient #2) 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 #2 The initial bereavement assessment was not completed.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient 4 Patient had orders for pain medication. No evidence of pain listed on the plan of care.

Upon patient record review, 3 of 14 (Patient #5,7,9) 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 5 Communication noted patient had a fall on 7/18/24, went to ER and received 5 stitches to the forehead. No evidence in chart of wound orders Patient 7 Order on 3/30/24 for oxygen 2-3 LPM N/C. No evidence of frequency listed within the order. Patient 9 Order on 3/8/24 for oxygen 2-3 LPM N/C. No evidence of frequency listed within the order.

Upon patient record review, 2 of 14 (Patient #5,8) 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 5 Communication noted patient had a fall on 7/18/24, went to ER and received 5 stitches to the forehead. No evidence in chart of plan of care was updated. Patient 8 had an order on 4/19/24 for Doxycycline 100mg 1 bid x 10 days. No evidence of plan of care was updated.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 1 Patient on oxygen and seizure medication. No evidence of oxygen or seizure precautions on the Aide care plan. Patient 2 Patient on Aspirin 81mg daily and high risk for falls per POC. No evidence of bleeding or fall precautions on the Aide care plan. Patient 3 Patient on oxygen and Xarelto 15mg daily. No evidence of oxygen or bleeding precautions on the Aide care plan. Patient 4 Patient on Aspirin 81mg daily and high risk for falls per POC. No evidence of bleeding or falls precautions on the Aide care plan. Patient 5 Patient on oxygen and high risk for falls per POC. No evidence of oxygen or fall precautions on the Aide care plan. Patient 6 Patient on Aspirin 81mg daily and oxygen. No evidence of bleeding or oxygen precautions on the Aide care plan. Patient 7 Patient on oxygen and high risk for falls per POC. No evidence of oxygen or fall precautions on the Aide care plan. Patient 8 Patient on oxygen and high risk for falls per POC. No evidence of oxygen or fall precautions on the Aide care plan. Patient 9 Patient on oxygen and high risk for falls per POC. No evidence of oxygen or fall precautions on the Aide care plan. Patient 10 Patient on oxygen and high risk for falls per POC. No evidence of oxygen or fall precautions on the Aide care plan.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #9 Staff member did not sign the Election of Benefits.

Upon patient client record review, 1 of 14 (Patient #9) 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 9 had an order for Oxygen 2-3 LPM NC. POC had O2 listed as 2 LPM NC daily or PRN. The orders and plan of care do not match so documentation is unclear on correct liter flow of oxygen.