Every finding on record at Piedmont Hospice & Palliative Inc

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review and interview. 3 of 8 (38%) records reviewed the hospice did not ensure the medication profile included all the current prescription drugs. Clinical Record 1: The 02/27/2023 registered nurse assessment and the 02/27/2023 hospice plan of care indicated patient was utilizing oxygen at 2 liters per minute continuously via nasal cannula. Oxygen was not on medication profile to date. Clinical Record 6: The 04/06/2023 registered nurse assessment and the 04/06/20233 hospice plan of care indicated patient was utilizing oxygen at 4 liters per minute continuously via nasal cannula. Oxygen was not on medication profile to date. The 04/06/2023 registered nurse assessment also indicated patient was utilizing Levaquin 500 mg daily for 7 days due to a productive cough. Levaquin was not included on the medication profile to date. Clinical Record 7: The 04/09/2023 registered nurse assessment and the 04/09 2023 hospice plan of care indicated patient was utilizing oxygen at 4 liters per minute continuously via nasal cannula. Oxygen was not on medication profile to date. During interview 04/20/2023 the administrator reviewed the associated records and stated these medications has been inadvertently omitted from the medication profile.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review and interview.8 of 8 (100%) records reviewed revealed the agency did not ensure that all entries in the patient record were appropriately authenticated. Clinical Record 1: The hospice election benefit date was 02/27/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 2: The hospice election benefit date was 02/20/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 3: The hospice election benefit date was 04/18/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 4: The hospice election benefit date was 01/25/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 5: The hospice election benefit date was 01/09/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 6: The hospice election benefit date was 04/08/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 7: The hospice election benefit date was 04/09/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. Clinical Record 8: The hospice election benefit date was 04/18/2023. All physician entries (certification, interdisciplinary team meeting, physician order) from the election of benefit date to current contained no credentials with associated signature. During interview 04/20203, administrator agreed the physician's signature did not include credentials.