Every finding on record at New Way Hospice and Palliative Care Inc

Upon patient record review 1 of 14 (Patient #4) 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 04: The patient was admitted on 3/15/24, the initial psychosocial and initial spiritual care assessments have not been completed to date.

Upon patient record review, 2 of 14 (Patient #4, 7) 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 04: The medication profile includes Diclofenac 1% apply thin layer 2 times a day, it does not include an application site. Patient 07: The medication profile includes Calmoseptine topical, apply once daily as needed, it does not include an application site or an indication for use.

Upon patient record review, 2 of 14 (Patient #4, 9) 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 04: The patient was admitted on 3/15/24, the initial bereavement assessment has not been completed to date. Patient 09: The patient was admitted on 5/1/24, the initial bereavement assessment has not been completed to date.

Upon patient record review, 2 of 14 (Patient #4, 7) 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 04: Medication orders on 3/15/24 for Diclofenac 1% apply thin layer 2 times a day, do not include an application site. Patient 07: Medication order on 2/20/24 for Calmoseptine topical, apply once daily as needed, it does not include an application site or an indication for use.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 02: The hospice aide task assignment indicates that the patient is to receive a bed bath one time per week, the hospice aide documentation indicates that the patient performs bathing with stand by assist only.