Every finding on record at Primecare Palliative & Hospice LLC

Upon patient record review 1 of 6 (Patient #2) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 2: The comprehensive assessment failed to identify the patient and family's spiritual needs related to the terminal illness.

Upon patient record review, 1 of 6 (Patient #1) 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 1: The physician's order for oxygen therapy indicates oxygen 2 L/min via nasal canula PRN shortness of breath; however, the medication list fails to include the PRN indication and its specifier for use. (corrected on site)

Upon patient record review and direct observation during the home visit, 1 of 6 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: It was reported to the surveyor by the patient's family that the hospice aide visits the patient to provide personal care and a bath each week. However, there was no evidence of orders for aide services nor a plan of care, or documentation. (corrected onsite)

Upon client record review, 2 of 6 (Patient #4, 6) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 4, 6: There was no evidence that the patients, who revoked hospice services, had discharge summaries or that any communication was provided to the attending physician on revocation of hospice services.