Every finding on record at Real Mind Hospice & Palliative Care Inc

Upon patient record review, 1 of 14 (Patient #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. 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 3:The medication profile includes an entry for oxygen 2-5 liters per minute via nasal cannula as needed for shortness of breath. The entry does not include oxygen sat titration instructions.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Patient 5:The medical record incudes documentation that the visits by the registered nurse on 10/10 and 10/24 were documented as telephone visits and no registered nurse comprehensive assessments were completed every 15 days.

Upon patient record review, 3 of 14 (Patient #4,#5,#6) 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 4:The medical record includes an order for oxygen 2 LPM via NC as needed for shortness of breath. There is no evidence that the plan of care includes problems, goals and interventions for the use and safety of oxygen Patient 5 and 6:The medical record includes an order for oxygen 2 LPM via NC as needed for shortness of breath and documentation to support that the patient is at risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for the use and safety of oxygen and the management of fall risk.