Every finding on record at Preferred Home Health, LP

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 3 (33%) home visit observations, revealed the hospice did not ensure physician orders were in place. Home Visit 2 (Clinical Record 3): During the observed home visit on 5/31/2023 with the Registered Nurse (Staff 7), the Registered Nurse was observed filling the patient’s medication box with medications including, but not limited to, D3 125mg and Eliquis 5mg tablet. The Registered Nurse was interviewed and stated, “I put the D3 in once a day and Eliquis in twice a day.” The Registered Nurse stated the medication box has been filled this way for at least two weeks. A review of the medication profile on 5/31/2023 revealed Eliquis 5mg, take 0.5 tablet twice a day was listed. There was no documented evidence of a physician’s order for Eliquis 5mg twice day or D3. Additionally, there was no documented evidence of an order to fill the medication box. The Administrator was interviewed on 6/1/2023 and agreed there was no documented evidence of a physician’s order for the D3 or Eliquis 5mg twice daily or to fill the medication box. During observation of Home Visit #2 (Clinical Record 3) on 5/31/2023 with the Registered Nurse (Staff 7), the Registered Nurse was observed filling the patient’s medication box with medications including, but not limited to, D3 125mg and Eliquis 5mg tablet. The Registered Nurse was interviewed and stated, “I put the D3 in once a day and Eliquis in twice a day.” The Registered Nurse stated, the medication box has been filled this way for at least two weeks. A review of the medication profile on 5/31/2023 revealed an order for Eliquis 5mg, take 0.5 tablet twice a day. There was no documented evidence of a physician’s order for Eliquis 5mg twice day or D3. There was no documented evidence of an order to fill the medication box. The Administrator was interviewed on 6/1/2023 and agreed, there was no documented evidence of a physican’s order for the D3, Eliquis 5mg twice daily or to fill the medication box.