Every finding on record at Natures Care Hospice

Upon patient record review, 3 of 5 (Patient 1,2,3) 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 1: During home visit, patient provided surveyor with bottle of Pregabalin 25mg PO BID . This medication is not included on patient medication profile. The medication profile includes orders for Tylenol 325mg take 2 tablets every 6 hours prn pain and Lortab 5/325mg take 1 tablet every 4 hours prn pain, there are no parameters for the safe dosing of acetaminophen. Patient 2: During home visit, patient provided surveyor with bottle of Docusate 100mg PO BID and Albuterol HFA 90mcg 2 puffs inhaler every 4 hours prn SOB. These medications are not included on patient medication profile. Patient 3: During home visit, patient provided surveyor with bottle of Glipizide 5mg PO QD. This medication is not included on patient medication profile.

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: It was identified in admission assessment that patient has DM Type 2 and is taking two oral antidiabetic agents for management of this disease. Hospice MD has identified that this is a related condition. No evidence that plan of care included problem statement with intervention and goals.

Upon patient record review, 3 of 5 (Patient 1,2,3) 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 medications and treatments. Patient 1: During home visit, patient provided surveyor with bottle of Pregabalin 25mg PO BID. There are no orders for this medication. Medication orders on 7/26/23 for Tylenol 325mg take 2 tablets every 6 hours prn pain and Lortab 5/325mg take 1 tablet every 4 hours prn pain, there are no parameters for the safe dosing of acetaminophen. Patient 2: During home visit, patient provided surveyor with bottle of Docusate 100mg PO BID and Albuterol HFA 90mcg 2 puffs every 4 hours prn SOB. There are no orders for this medication. Patient 3: During home visit, patient provided surveyor with bottle of Glipizide 5mg PO QD. There is no order for this medication.

Upon patient client record review, 1 of 5 (Patient 4) 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 4: Patient was admitted on 10/9/22. The Election of Benefits form was unsigned.