Every finding on record at Ray Hospice Inc.

Upon patient record review, 1 of 5 (Patient #4) 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 04: The medication profile includes diclofenac sodium 1% topical gel apply to affected area twice a day for pain. There is no application site included.

Upon patient record review, 1 of 5 (Patient #3) 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 03: The patient was admitted on 7/5/23 with a diagnosis of congestive heart failure, his medication regimen includes aspirin 81mg by mouth daily and clopidogrel 75mg by mouth, once daily. The plan of care does not include interventions and goals for the risk for bleeding.

Upon patient record review, 1of 5 (Patient #4) 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 04: The medication orders on 7/1/23 for diclofenac sodium 1% topical gel apply to affected area twice a day for pain, does not include instructions for an application site.

Upon patient record review, 2 of 5 (Patient #1, 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 equipment and supply needs. Patient 01: The patient was admitted on 7/5/23, the initial comprehensive RN assessment indicates that the patient uses a walker for ambulation, this is not included in the plan of care. Patient 03: The patient was admitted on 7/6/23, the initial comprehensive RN assessment indicates that the patient uses a cane or walker for ambulation, this is not included in the plan of care.