Every finding on record at Mountain Top Hospice Care Inc

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1,2,3,4,5: The RN comprehensive assessment has a section labeled imminence of death but it was left blank. There was no evidence in the RN documentation that imminence of death was considered.

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) 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: Patient #1: Upon home visit finding, the Melatonin Rx label reads Melatonin 3mg 2 tabs at bedtime. The medication profile shows 1 tab at bedtime. Upon home finding there is a medication called Stimulant Laxative with no dose, give 2 tabs twice daily. Corrected on site. Patient #2: Upon home visit finding, Acetaminophen is labeled 325mg 1 tab twice daily. The medication profile has the acetaminophen 325mg 1 tab every 4-6 hours prn. Corrected on site. Patient #3: Upon home visit finding, Mirtazapine is labeled 30mg 1 tab daily. The medication profile has the mirtazapine 1 tab daily prn. Corrected on site. Patient #5: The medication profile contains Aspirin entered twice. The first entry contains the correct dose, route, frequency the second entry contains only the word "New". Corrected on site.

Upon patient record review, 4 of 5 (Patient #1,#2,#3,#5) 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: Upon home visit finding, the Melatonin bottle label reads Melatonin 3mg 2 tabs at bedtime. The POC order is for 1 tab at bedtime. Corrected on site. Upon home finding there is a medication called Stimulant Laxative with no dose, give 2 tabs twice daily. Corrected on site. Patient #2: Upon home visit finding, Acetaminophen is labeled 325mg 1 tab twice daily. The POC has the acetaminophen 325mg 1 tab every 4-6 hours prn. Corrected on site. Patient #3: Upon home visit finding, Mirtazapine is labeled 30mg 1 tab daily. The POC has the mirtazapine 1 tab daily prn. Corrected on site. Patient #5: The plan of care contains Aspirin entered twice. The first entry contains the correct dose, route, frequency the second entry contains only the word "New". Corrected on site.

Upon patient client record review, 1 of 5 (Patient #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 4: The CTI and comprehensive assessment contains nursing narrative documentation by the RN "Admit to Mountain Top Hospice under routine level of care 4-17-22 for period 4-17-22--7-15-22. The patients SOC date was 1-17-22. The documentation by the physician indicates the correct SOC and cert period.