Every finding on record at Pro-Choice Hospice Inc

Upon patient record review, 5 of 14 (Patient #1,#5,#6,#7,#8) 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 medication profile contained Senna 8.6mg PO daily for constipation. There is no evidence of instructions to hold for loose bowel movements. Corrected on site. Patient#5: The medication profile contained Voltaren 1% gel apply to affected areas as needed. There is no evidence of a specified area of application. Corrected on site. Patient#6: The medication profile contained diclofenac sodium 3% apply once daily to affected area for pain. The medication profile contained hydrocortisone 2.5 topical lotion apply once daily PRN itching. There is no evidence of a specified are of application for these medications. Corrected on site Patient#7 and #8: The medication profile contained Voltaren 1% gel apply to affected areas as needed. There is no evidence of a specified area of application. Corrected on site.

Upon patient record review, 3 of 14 (Patient #3,#5,#6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient#3: The record indicates Initial bereavement completed on 2/7/25. However, there is no evidence of a primary bereaved being identified. Patient#5: The record indicates Initial bereavement completed on 11/15/24. However, there is no evidence of a primary bereaved being identified. Patient#6: The record indicates Initial bereavement completed on 1/3/25. However, there is no evidence of a primary bereaved being identified

Upon patient record review, 5 of 14 (Patient #1,#5,#6,#7,#8) 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 medications and treatments. Patient#1: The record indicates an order Senna 8.6mg PO daily for constipation. There is no evidence of instructions to hold for loose bowel movements. Corrected on site. Patient#5: The record indicates an order on 2/11/25 Voltaren 1% gel apply to affected areas as needed. There is no evidence of a specified area of application. Corrected on site. Patient#6: The record indicates a 2/4/25 order for diclofenac sodium 3% apply once daily to affected area for pain. There is an order on 2/4/25 for hydrocortisone 2.5 topical lotion apply once daily PRN itching. There is no evidence of a specified are of application for these medications. Corrected on site Patient#7 and #8: The record indicates an order on admit for Voltaren 1% gel apply to affected areas as needed. There is no evidence of a specified area of application. Corrected on site.

Upon patient record review 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#5: The record indicates on 12/26 order was placed for abdominal ultrasound related to pain. There is no evidence in chart of ultrasound findings/results or any follow-up with patient.

Upon patient record review, 4 of 14 (Patient #2,#3,#5,#6) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient#2: The record indicates physician signed initial CTI signed by medical director on 02/5/25. There is no evidence of a physician narrative on CTI. Patient#3: The record indicates physician signed initial CTI signed by medical director on 02/4/25. There is no evidence of a physician narrative on CTI. Patient#5: The record indicates physician signed initial CTI signed by medical director on 11/12/24. There is no evidence of a physician narrative on CTI. Patient#6: The record indicates physician signed initial CTI signed by medical director on 12/31/24. There is no evidence of a physician narrative on CTI.

Upon patient record review, 2 of 14 (Patient #4,#5) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient#4: The record indicates physician signed recertification CTI signed by medical director for 1/29/25. There is no evidence of a physician narrative on CTI. Patient#5: The record indicates physician signed recertification CTI signed by medical director on 2/10/25. There is no evidence of a physician narrative on CTI.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Advance Directives. Patient#4: The record indicates patient's brother is legal POA for patient. There is no evidence of POA papers in patient chart.

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#6: Chart face sheet in EMR states patient is a full code. The POLST that patient signed on 12/31/24 states patient wishes to be a DNR comfort care only. Corrected on site.