Every finding on record at Pacific Hospice Inc.

Upon patient record review, 1 of 14 (Patient #9) 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 Patient 9: The hand written medication list indicates Immodium 2mg po q 8 hours PRN, but no specifier is included for the PRN use of the medication. For clarification, the MD order included the instructions that the medication is used PRN for diarrhea; this was overlooked on the medication list though. (corrected onsite)

Upon personnel record review, 3 of 10 (Personnel #3, 4, 7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 3, 4, 7: The personnel files contained a checklist of competency items for recently hired agency personnel, which was completed on hire. However, these items were not discipline specific, based on the care and services provided, and did not indicate what method of assessment was utilized to determine the competency of each staff member.