Every finding on record at Oyuna Hospice, Inc.

Upon patient record review 1 of 19 (Patient #6) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures. Patient #6) Upon review of the patient record on 05/12/25 documentation stated the patient did not have a bowel movement since 05/08/25. The record did not contain evidence that the aide reported this finding to the nurse.

Upon client record review, 1 of 19 (Patient # 15) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient # 15) The patient medical record did not contain evidence that the completed transfer summary was forwarded to the receiving facility.

Upon patient record review, 3 of 13 (Patient #3,#4,#6) 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 #3, 4 and 6: The medication profile included Miralax oral powder daily as needed for constipation. There was not evidence of a diluent. Corrected on site.

Upon patient record review, 2 of 13 (Patient #9, #11) 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 #9: The medical record contained a social work visit frequency of once monthly. There was no evidence of problems, goals, and interventions related to psychosocial issues included on the plan of care. Patient #11: The medical record contained orders for oxygen and for nursing to obtain oxygen saturation at visits. There was no evidence of problems, goals, and interventions related to respiratory function included on the plan of care.

Upon patient record review, 4 of 13 (Patient #3,#4,#6,#13) 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 #3, 4 and 6: The medical record contained an order on the medication profile for Miralax oral powder daily as needed for constipation. There was not evidence of an order for a diluent and the direction is unclear. Corrected on site. Patient #13: The medical record contained an order for foley catheter size 16 French with 10 cc balloon. There was no evidence of instructions for change frequency and maintenance included on the order. Corrected on site.

Upon client record review, 1 of 13 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: Upon review of the medical record there was no evidence in the record that contained an order for the border pad dressing that was applied on 4/2/22 by the hospice nurse.

Upon patient client record review, 1 of 13 records (Patient #13) 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 #13: The medical record contained nursing documentation 4/18/22, 5/2/22, 5/16/22, and 5/26/22 evaluating a home health aide. There was no evidence that the patient has received home health aide services since July of 2020.