Every finding on record at Rafaella Hospice Inc

Upon patient record review, 2 of 11 (Patient #2,#3) 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. Patient 2: The medication profile contains D-Mannose 400mg 1 tsp twice daily with no evidence of concentration. The medication profile contains CBD tincture 1 drop at night no evidence of concentration. Upon home visit and discussion with caregiver and sight of the bottle the CBD tincture medication's name on the bottle is Original Hemp with a dose of 1000mg 1 full dropper SL twice daily. Corrected on site. Patient 3: The medication profile contains CBD tincture 1 drop at night no evidence of concentration. Upon home visit, discussion with caregiver and sight of the bottle, the CBD tincture medication is called Original Hemp with a dose of 1000mg 1 full dropper SL twice daily. Corrected on site.

Upon patient record review, 2 of 11 (Patient #2,#3) 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 2: The POC contains D-Mannose 400mg 1 tsp twice daily with no evidence of concentration. The POC contains CBD tincture 1 drop at night no evidence of concentration. Upon home visit, discussion with caregiver and sight of the bottle, the CBD tincture medication is called Original Hemp with a dose of 1000mg 1 full dropper SL twice daily. Corrected on site. Patient 3: The POC contains CBD tincture 1 drop at night no evidence of concentration. Upon home visit, discussion with caregiver and sight of the bottle, the CBD tincture medication is called Original Hemp with a dose of 1000mg 1 full dropper SL twice daily. Corrected on site.

Upon patient record review, 3 of 11 (Patient #5, #6 and #11) 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 equipment and supply needs. Patient 5: The comprehensive assessment indicates pt is incontinent of bladder, there is no evidence of incontinence care items or any other DME listed on the POC. Corrected on site. Patient 6: The comprehensive assessment indicates pt is incontinent and bed bound and that pt has a hospital bed, air mattress, w/c, walker, hoyer lift and shower bench. There are no DME items listed on the POC. Corrected on site. Patient 11: The comprehensive assessment contains evidence of the pt having a bed, air mattress, w/c, hoyer, bedpan, shower chair, no evidence of an order for the DME identified.

Upon patient client record review, 1 of 11 (Patient #9) 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 9: The end of life summary completed by the physician was dated 1-5-22. 1-5-22 is the SOC date, patient expired on 1-24-22. Corrected on site.