Every finding on record at Mountain States Health Alliance

Upon patient record review, 5 of 26 (Patient #2, 7, 8, 9, 11) 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 02: The medication profile includes camphor-menthol (Sarna) initiated on 9/3/24 with instructions "apply topically as needed for itching, it does not include a frequency of use or application site. The medication profile includes Risamine 0.44%-20.635% ointment initiated on 9/3/24, "apply topically as needed for skin irritation," it does not include a frequency of use or application site. Patient 07: The medication profile includes "Adult Comfort Pak" which does not identify the items included and on site in the patients home. (Morphine, lorazepam, hyoscyamine, compazine, and Tylenol.) Patient 08: The medication profile includes "Adult Comfort Pak" which does not identify the items included and on site in the patients home. (Morphine, lorazepam, hyoscyamine, compazine, and Tylenol.) Patient 09: The medication profile includes polyethylene glycol 17G by mouth daily, it does not include a diluent. Patient 11: The medication profile includes "Adult Comfort Pak" which does not identify the items included and on site in the patients home. (Morphine, lorazepam, hyoscyamine, compazine, and Tylenol.)

Upon patient record review, 1 of 26 (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 03: The patient was admitted on 8/14/24 with a primary diagnosis of Acute myeloid leukemia, with a history of diabetes mellitus, type II and nutritional changes. The patient medication profile includes Lispro insulin injections (based on a sliding scale) and Humulin N 10 units 2 times a day before meals, the plan of care does not include a problem statement with interventions and goals for the management of the diabetes with the nutritional deficits.

Upon patient record review, 2 of 26 (Patient #2,9) 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 02: The medication order on 9/3/24 for camphor-menthol (Sarna) is instructed "apply topically as needed for itching, it does not include a frequency of use or application site. The medication order on 9/3/24 for Risamine 0.44%-20.635% ointment is instructed "apply topically as needed for skin irritation," it does not include a frequency of use or application site. Patient 09: The medication order on 8/28/24 for Polyethylene glycol 17G by mouth daily does not include a diluent.

Upon patient record review, 1 of 26 (Patient #10) 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 10: The patient received physical therapy services with an end date of 8/9/24, the plan of care has not been updated to resolve the problem statement with interventions and goals for the physical therapy needs.

Upon client record review, 1 of 26 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 06: The visit frequency for the MSW is entered as 2 times per month, the record indicates there was 1 visit made in the month of August, with a documented missed visit on 8/23/24 with no indication for the missed visit.

Upon patient record review 1 of 26 (Patient #20) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 20: The patient was admitted on 8/31/24, upon admit the patient/primary care giver accepted/requested volunteer services. There is no evidence in the patient record of an assessment performed by the volunteer coordinator.

Upon personnel record review, 1 of 14 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1: The job requirements for the Administrator/Director role indicates that the role is to be filled with personnel who possess a Bachelor's degree or higher. The personnel record indicates that the current Director possesses an Associates degree.

Upon client record review, 1 of 26 (Patient #3) did not have evidence that all drugs and biologicals are labeled in accordance with currently accepted professional practice and include appropriate usage and cautionary instructions, as well as an expiration date, if applicable. Patient 03: During the home visit it was identified that the patient has two bottles of Diclofenac 75mg pills. One bottle was dated 11/19/21 with no expiration date, the other dated 6/28/22 with no expiration date.

Upon patient record review 4 of 16 (Patient #6, 8, 11, 14) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #6 The SOC was completed on 8/19/21 however the MSW evaluation was not completed until 8/26/21. Patient #8 The SOC was completed 7/27/21 however the SC assessment was not completed until 8/10/21 Patient #11 The SOC was completed on 8/14/21 however the MSW assessment was not completed until 8/30/21. Patient #14 The SOC was completed 4/5/21 however the SC assessment was not completed until 4/23/21

Upon patient record review 1 of 16 (Patient # 6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #6-The SOC was completed on 8/19/21 there was no evidence of a spiritual assessment completed to date.

Upon patient record review, 4 of 16 (Patient #4, 6, 11, 15) 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 #4 The 7/6/21 plan of care includes fleets enema per comfort kit however medication not included on the medication profile Patient #6 The 8/19/21 plan of care reads O2@2-5LPM prn sob however the medication profile reads O2@2-10LPM prn sob Patient #11 The 8/14/21 order reads PAC flush with 10 cc NS and 5 cc heparin flush monthly and prn for site maintenance in which heparin order is incomplete - the med profile reads flush with 100u/5cc heparin monthly and prn deaccess. The heparin instructions are not in the order. Patient #15 The 7/6/21 plan of care reads change IV dressing per facility policy and for maintenance prn and reads flush with 10cc NS prn however med profile reads 3cc.

Upon patient record review, 3 of 16 (Patient #6, 11, 13) 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 #6 The SOC was completed on 8/19/21 however the BRA was not completed until 8/26/21. Patient #11 The SOC was completed on 8/14/21 however the BRA was not completed until 8/30/21. Patient #13 The SOC was completed on 2/2/21 however the BRA was not completed until 2/9/21

Upon patient record review, 6 of 16 (Patient # 4, 6, 7, 11, 13, 15 ) 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 #4 The 7/6/21 plan of care includes fleets enema per comfort kit. The order did not have specific instructions on administration. Patient #6 The 8/26/21 verbal order reads administer SSE per signed order without frequency. Patient #7 The 9/23/21 order reads 30-60cc sterile water for foley irrigation/flush to maintain patency however no frequency noted. Patient #11 The 8/14/21 order reads PAC flush with 10 cc NS and 5 cc heparin flush monthly and prn for site maintenance. The heparin order is incomplete. Patient #13 The 2/21/21 plan of care reads O2@-5 LPM prn without a qualifier. Patient #15 The 7/6/21 plan of care reads change IV dressing per facility policy without specific details of the dressing change.

Upon client record review, 1 of 16 (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 On 10/1/21 admission visit, the nurse documented the presence of a skin tear and that a Tegaderm dressing was applied. There was no order included on the 10/1/21 plan of care addressing the skin tear or orders to apply a Tegaderm dressing.

Upon patient client record review, 13 of 16 (Patient #2, 3, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16) 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. Incomplete signatures- missing date, missing credentials Patient #2 The 9/24/21, 9/30/21 SN, 9/27/21 MSW, and 9/24/21, 9/29/21 Aide visits contained no credentials with associated signature and date. Patient #3 The 9/16/21, 9/27/21 SN, 8/27/21 SC visits contained no credentials with associated signature and date. Patient #4 The 10/1/21 SN and 9/30/21 Aide visits contained no credentials with associated signature and date. Patient #5 The 9/28/21 MSW contained no date and the 10/01/21 SC visit contained no credentials with associated signature. Patient #6 The 8/19/21, 8/20/21 SN, 8/26/21 MSW, visits contained no credentials with associated signature and date. Patient #7 The 9/28/21 SN and the 9/23/21 MSW visits contained no credentials date associated signature and date. Patient #9 The 9/28/21 SN visit contained no credentials with associated signature. Patient #11 The 8/14/21 SN visit contained no credentials or date with associated signature. Patient #12 The 9/28/21 MSW visits contained no date with associated signature. Patient #13 The 2/2/21, 2/15/21, 2/16/21 SN, 2/3/21,2/16/21 MSW, and visits contained no dates with associated signature. Patient #14 The 4/6/21 SN visit contained no date or credentials with associated signature. Patient #15 The 7/6/21, 7/7/21, 7/19-21/21 SN visits contained no date with associated signature. Patient #16 The 5/6/21, 5/28/21 SN visits contained no dates with associated signature.