Every finding on record at Pathways Hospice

Upon patient record review, 4 of 30 (Patient #1, #13, #14, #20) 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. Patient #1- Nursing documentation on 03/24/23 indicates the patient is allergic to Warfarin. Warfarin is not listed as an allergy on the medication profile. (corrected on site) Patient #13-The plan of care includes orders to flush the patients port a cath. There are no flushes listed on the medication profile. (corrected on site) Patient #14-On 05/08/23 the nurse documents the patient is taking Advil. Advil is not included in the medication profile.(corrected on site) Patient #20 The medication profile includes Alphagan P Ophthalmic solution .1% 1 gtt bid OP for glaucoma and Lantanoprost Opthalmic .005% 1 gtt hs OP glaucoma. The medications are not specified as Rt, Left, or both eyes. (corrected on site)

Upon patient record review, 7 of 30 (Patient #1, #4, #7, #8, #13, #14, #20) 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 specific orders for all medications and treatments. Patient #1-The nursing documentation in IDG on 04/27/23 indicates the patient is to discontinue Eliquis. The plan of care was not updated with orders to discontinue Eliquis. (corrected on site) Patient #4-The patient was admitted 04/22/23 with an ostomy. The plan of care does not address management of the ostomy. (corrected on site) Patient #7-The patient was admitted with a Rt chest port. The plan of care does not address management of the port. The plan of care also includes orders to insert Foley cath prn. The orders do not specify cath type, size, balloon size, frequency and indications for insertion. (corrected on site) Patient #8-The plan of care 05/14/23 contains orders to change dressing to right axilla prn. The orders are not specific for the type of dressing and frequency of dressing changes. The patient was admitted with a Foley catheter and the plan of care does not include orders for management of the Foley. (corrected on site) Patient #13-The plan of care includes orders to flush venous access device. Rt port last flushed 04/23/23. The orders are not specific for the flush to be utilized and frequency. (corrected on site) Patient #14-The plan of care includes orders to insert Foley. The orders are not specific for the size, balloon size, and frequency for insertion. On 04/12/23 orders were received to change dressing to abdomen when soiled and as needed. The orders are not specific for the actual wound care to be performed. On 05/08/23 the nursed documents the patient is taking Advil. Advil is not included in the plan of care. (corrected on site) Patient #20 The plan of care 03/23/23 includes Alphagan P Ophthalmic solution .1% 1 gtt bid OP for glaucoma and Latanoprost Ophthalmic .005% 1 gtt hs OP glaucoma. The medications are not specified as Rt, Left, or both eyes.(corrected on site)

Upon patient record review, 4 of 30 (Patient #1, #6, #17, #20) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1-The initial IDG/revised plan of care documentation on 03/30/23 does not address the nursing findings and progress towards goals. The IDG documentation only addresses the psychosocial findings. Patient #6- The IDG/revised plan of care documentation on 04/27/23 does not address the nursing findings and progress towards goals. The IDG documentation only addresses the psychosocial findings. Patient #17-The IDG/revised plan of care documentation on 03/01/23 and 04/26/23 does not address the nursing findings and progress towards goals. The IDG documentation only addresses the psychosocial findings. (late entry correction on site) Patient #20-The IDG/revised plan of care documentation on 03/28/23 does not address the nursing findings and progress towards goals. The IDG documentation only addresses the psychosocial findings. (late entry correction on site)

Upon client record review, 2 of 30 (Patient #1, #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-The Chaplain is ordered to visit the patient 1-3 times monthly. On 03/29/23 the Chaplain documents a phone conversation with the patients daughter who stated they were open to Chaplain services in addition to the support they receive from their faith community. The Chaplain documents the daughter was to call back to schedule the visit. There is no additional follow up on record to indicate the Chaplain attempted to perform visits. There are no Chaplain visits on record. Patient #3- On 04/20/23 the volunteer documented visiting the patient. There are no orders on record for volunteer services.

Upon patient record review 2 of 30 (Patient #2, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and included in the plan of care. Patient #2- The Aide was assigned to perform a bed bath every visit. On 02/23/23, 02/27/23 and 03/20/23 the Aide documented the patient was unable to understand/perform the task. On 05/10/23 The Aide documented patient Decision for bed bath and oral care. The documentation did not evidence the tasks were performed and/or refused. Patient #13- Effective 04/23/23 the aide is ordered to visit twice weekly. There are no visits on record for the week 04/23/23-04/29/23 and there is no documentation on record regarding the missed visits. (late entry correction on site)

Upon patient client record review, 2 of 30 (Patient #14, #15) did not have evidence that all entries are complete and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #14- The 05/02/23 nursing narrative documents a phone call was received at 16:15. There is no further narrative to indicate the phone conversation. The 05/03/23 nursing narrative documents a phone call was received at 14:45. There is no further narrative to indicate the phone conversation. (late entry on site) Patient #15- The 05/04/23 nursing narrative documents a phone call was received. The documentation does not include the phone conversation. (late entry correction on site)

Upon patient record review 1 of 30 (Patient # 30) did not have evidence that the discharge summary includes all required information. Patient #30 -The discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summaries only included the reason for discharge.

Upon observation, there is not evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association, NFPA 99 and NFPA 80 for all doors. The fire rated doors in the service hallway , door to the boiler room, storage room, and kitchen door had tape over the ratings. NFPA 80 requires the plate door rating to be visible. (corrected on site) Upon observation, there was not evidence fire drills of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The 03/09/23 9am shift drill and the 04/28/23 Fire Drill performed at 7 pm were silent drills. Upon observation, there was no evidence the storage of medical gases in a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The supply room located in the service hall contained e tanks which were not labeled as empty or full and Oxygen signage was not at the outside entry (corrected on site)