Every finding on record at Prohealth Hospice-Gadsden, LLC

Upon patient record review, 9 of 23 (Patient #4,5,7,10,11,13,15,16,17) 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 #4: There is evidence in the medical record of an order for Oxygen 2-5 L/Min as needed for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #5: There is evidence of duplicate medications on the medication record. Morphine SL q 1 hour PRN for Pain and SOB and Morphine SL q 1 hour PRN for Pain. Additionally, Voltaren 2Xdaily and Voltaren Q 12 hours. (Corrected on site.) Patient #7: There is evidence of an order for Oxygen 2-5 L/Min as needed for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #10: There is evidence in the medical record of an order for Oxygen 2-4 L/Min with the "route" listed as "oxygen" and there is not a scale for titration or route of delivery. Additionally, eye drops did not indicate which eye or both. Also, Senna 1-3 tablets, does not indicate when to take an increase in tablets. (Corrected on site.) Patient #11: There is evidence in the medical record of an order for Oxygen 2-4 L/Min for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #13: There is evidence in the medical record of an order for Oxygen 2-4 L/Min with the "route" listed as "oxygen" and there is not a scale for titration or route of delivery. Additionally, hyoscyamine disintegrating tablet route was oral instead of SL. Also, Senna 1-3 tablets, does not indicate when to take an increase in tablets. (Corrected on site.) Patient #15: There is evidence on the medication record of Lorazepam intensol 2 mg/ml, 0.25 - 1 ml every 4 hours PRN. There is no titration scale. (Corrected on site.) The instructions state "take 0.5 to 1 ml every 4 hours as needed for agitation. The dosage is not clear. Patient #16: There is evidence on the medication record of Oxygen 2-4 L/min as needed for SOB. There is no titration scale or route of delivery. Additionally, the route was listed as "oxygen" rather than "nasal cannula". (Corrected on site.) Patient #17: There is evidence on the medical record of Miralax 17 gm. daily. There is no diluent listed. Additionally, on the medication record, Oxygen 2-5 L/min as needed for SOB. There is no titration scale or route of delivery. (Corrected on site.)

Upon patient record review, 3 of 23 (Patient #2, 10, 12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: There is evidence in the medical record that the patient was admitted with primary diagnosis of Prostate Cancer. The initial plan of care did not include Cancer Patient #10: There is evidence in the medical record that the patient was admitted with primary diagnosis of Chronic Respiratory Failure. The initial plan of care did not include Respiratory. Patient #12: There is evidence in the medical record the patient was admitted with a primary diagnosis of breast cancer. The initial plan of care did not include Cancer.

Upon patient record review, 9 of 23 (Patient #4,5,7,10,11,13,15,16,17) 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 #4: There is evidence in the medical record of an order for Oxygen 2-5 L/Min as needed for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #5: There is evidence of duplicate medications on the plan of care. Morphine SL q 1 hour PRN for Pain and SOB and Morphine SL q 1 hour PRN for Pain. Additionally, Voltaren 2Xdaily and Voltaren Q 12 hours. (Corrected on site.) Patient #7: There is evidence of an order for Oxygen 2-5 L/Min as needed for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #10: There is evidence in the medical record of an order for Oxygen 2-4 L/Min with the "route" listed as "oxygen" and there is not a titration scale or route of delivery. Additionally, eye drops did not indicate which eye or both. Also, Senna 1-3 tablets, does not indicate when to take an increase in tablets. (Corrected on site.) Patient #11: There is evidence in the medical record of an order for Oxygen 2-4 L/Min for SOB. There is not a titration scale or route of delivery. (Corrected on site.) Patient #13: There is evidence in the medical record of an order for Oxygen 2-4 L/Min with the "route" listed as "oxygen" and there is not a scale for titration. Additionally, hyoscyamine disintegrating tablet route was oral instead of SL. Also, Senna 1-3 tablets, does not indicate when to take an increase in tablets. (Corrected on site.) Patient #15: There is evidence on the medication record of Lorazepam intensol 2 mg/ml, 0.25 - 1 ml every 4 hours PRN. There is no titration scale. (Corrected on site.) Patient #16: There is evidence on the medication record of Oxygen 2-4 L/min as needed for SOB. There is not a titration scale or route of delivery. The route was listed as "oxygen" rather than "nasal canula". (Corrected on site.) Patient #17: There is evidence on the medical record of Miralax 17 gm. daily. There is no diluent listed. Additionally, on the medication record, Oxygen 2-5 L/min as needed for SOB. There is not a titration scale or route of delivery. (Corrected on site.)

Upon patient record review, 8 of 23 (Patient #1,3,8,9,12,13,14,18) 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: There is evidence in the medical record that on 8/29/22 Imminent death was added to the Plan of Care. The POC has not been updated (Corrected on site.). Patient #3: There is evidence in the medical record that on 7/17/23 Imminent death was added to the Plan of Care. The POC has not been updated. Additionally, on 7/24/24, an order for nebulizer treatments for wheezing was ordered. Inhalation or Respiratory was not added to the Plan of Care. (Corrected on site.) Patient #8: There is evidence in the medical record that on 7/17/24 an order to decrease SN visits to 1Xwk. The POC has not been updated to discontinue Imminent death. (Corrected on site.) Patient #9: There is evidence in the medical record of a call from the facility nurse on 7/19/24 to report the patient was having bloody stools and coffee ground emesis. The Plan of Care was not updated to include Risk of Bleeding. (Corrected on site.) Patient #12: There is evidence in the medical record on 9/5/24, an order for Meclizine for dizziness and the on call nurse made a visit due to the patient "going limp with swimmy head". The POC was not updated to include fall risk. (Corrected on site.) Patient #13: There is evidence in the medical record on 8/8/24, an order for Keflex for infection right heel. The POC was not updated to include infection. Additionally, on 8/21/24, an order was added for wound care. The POC was not updated to include Wound. (Corrected on site.) Patient #14: There is evidence in the medical record on 9/5/24, an order for Levaquin for urinary tract infection. The POC was not updated to include infection. (Corrected on site.) Patient #18: There is evidence in the medical record on 6/25/24, an order for Macrobid for urinary tract infection. The POC was not updated to include infection. (Corrected on site.)

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5: Upon observation of the nurse making a home visit, the equipment was re-contaminated after cleaning as evidence by as the nurse cleaned the equipment tried to hold all the equipment in one hand as she cleaned it. The equipment was exposed to the clean hand that she washed. The nurse did not have a clean area to put down the equipment to dry.

Upon patient record review, 8 of 23 (Patient #1,2,4,5,8,9,14,17) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There is evidence in the medical record that the patient has a diagnosis of dysphagia. The aide POC did not include aspiration precautions. (Corrected on site.) Patient #2: There is evidence in the medical record that the patient is on bleeding and fall precautions. The aide POC did not include bleeding and fall precautions. (Corrected on site.) Patient #4: There is evidence in the medical record that the patient is on bleeding, seizure, aspiration and fall precautions. The aide POC did not include bleeding, seizure, aspiration and fall precautions. (Corrected on site.) Patient #5: There is evidence in the medical record that the patient is on oxygen, aspiration and fall precautions. The aide POC did not include oxygen, aspiration and fall precautions. (Corrected on site.) Patient #8: There is evidence in the medical record that the patient is on oxygen and seizure precautions. The aide POC did not include oxygen and seizure precautions. (Corrected on site.) Patient #9: There is evidence in the medical record that the patient is on oxygen and bleeding precautions. The aide POC did not include oxygen and bleeding precautions. (Corrected on site.) Patient #14: There is evidence in the medical record that the patient is on oxygen precautions. The aide POC did not include oxygen precautions. Additionally, the aide POC indicated "report to RN if B/P, respirations, pulse out of parameters. No parameters were indicated. (Corrected on site.) Patient #17: There is evidence in the medical record that the patient is on oxygen and bleeding precautions. The aide POC did not include oxygen and bleeding precautions. (Corrected on site.)

Upon patient record review 3 of 23 (Patient #1,3,17) 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 #1: There is evidence on the aide plan of care that the aide was scheduled to shampoo and change linen weekly. During the weeks of 8/18/24 and 8/25/24 the aide completed the tasks each visit. (Corrected on site.) Patient #3: There is evidence on the aide plan of care that the aide was scheduled to change linen weekly. During the weeks of 8/25/24 and 9/4/24 the aide completed the task each visit. (Corrected on site.) Patient #17: There is evidence on the aide plan of care that the aide was scheduled to shampoo and change linen weekly. During the weeks of 8/18/24 and 8/25/24 the aide completed the tasks each visit. (Corrected on site.)

Upon patient record review, 1 of 23 (Patient #12) 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 #12: There is evidence in the medical record on 7/1/24 the Nursing comprehensive assessment "PPS/FAST/KPS/NYHA Scales: 40%. There is no indication of which scale the 40% refers.