Every finding on record at Providence Care

Upon patient record review, 2 of 19 (Patient #12, 14) 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 Pt #12- Reviewed medications from AL orders - No evidence of hospice documentation on MAR for potassium chloride ER - on facility MAR order start date was 11/28/23. Facility MAR states Tylenol 325 mg give 2 tablets by mouth 2 times a day for pain. Agency's MAR states Tylenol 325mg 2 tab oral every 4 hours as needed for pain. (Corrected on site) Pt #14- Hospice Medication profile states Ativan 1 mg tab 1 tab every 2 hours as needed for agitation/restlessness/ and anxiety. Pt's prescription and bottle of Ativan states Ativan 1 mg po 2 times a day as needed for anxiety. MiraLax also on Medication profile. Patients son states the nurse told him to stop this 3 months ago which he did. (Corrected on site)

Upon patient record review, 1 of 19 (Patient #7) 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. Pt # 7 - No evidence of care planning, goals or interventions related to patient with a foley catheter in patient record

Upon patient record review, 4 of 19 (Patient #7, 8, #12, #14) 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. Pt #7 - Patient has a foley catheter. No evidence of an order for the foley catheter or changes to the catheter on the plan of care. Pt #8 - No evidence of diet change order on 3/12/24 from soft to pureed (Corrected on site) No evidence of order in patient record for med tech to take BP twice a day and call hospice for a systolic BP over 160. 2/12/24 (Corrected on site) Pt #12- Reviewed medications from AL orders - No evidence of hospice documentation on MAR for potassium chloride ER - on facility MAR order start date was 11/28/23. Facility MAR states Tylenol 325 mg give 2 tablets by mouth 2 times a day for pain. Agency's MAR states Tylenol 325mg 2 tab oral every 4 hours as needed for pain. (Corrected on site) Pt #14- Hospice Medication profile states Ativan 1 mg tab 1 tab every 2 hours as needed for agitation/restlessness/ and anxiety. Pt's prescription and bottle of Ativan states Ativan 1 mg po 2 times a day as needed for anxiety. MiraLax also on Medication profile. Patients son states the nurse told him to stop this 3 months ago which he did. (Corrected on site)

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - Per plan of care, physician to be notified of missed visits however, there was no evidence in patient record that the MD was notified when the aide missed a visit on 2/19/24. (Corrected on site)

Upon personnel record review, 1 of 16 (Personnel #14) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. #14 - Volunteer coordinator job description states a Bachelor's degree is required. No evidence in personnel file that employee had a degree. States staff member did not finish college. (Corrected on site - signed new job description)