Every finding on record at Reconnect Hospice, Inc

Upon patient record review, 3 of 5 (Patient #1, 4, 5) 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 #1: The medication profile contained three PRN medications without indicator-clonidine HCL 0.1mg 1 tablet every 12 hours PRN, Ventolin HFA 90 mcg 1 puff every 6 hours PRN, and ibuprofen 800mg 1 tablet twice a day PRN. [corrected on site] Patient #4: The medication profile contained three PRN medications without indicator-tramadol HCL 50mg 1 tablet every 8 hours PRN, Proair HFA 90 mcg 2 puffs every 6 hours PRN, and lorazepam 0.5mg 1 tablet twice a day PRN. Patient #5: The medication profile contained three PRN medications without indicator-tramadol HCL 50mg 1 tablet every 8 hours PRN, clonidine HCL 0.1mg 1 tablet every 6 hours PRN, and docusate sodium 100mg once daily PRN.

Upon patient record review, 2 of 5 (Patient #2 and 4) 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: The patient was admitted with Parkinson's disease however, the plan of care did not contain problems/interventions/goals for neurologic. [corrected on site] Patient #4: The patient was admitted with cerebral infarct however, the plan of care did not contain problems/interventions/goals for neurologic.

Upon patient record review, 3 of 5 records (Patient #1, #4, #5) 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 #1: The record contained orders for three PRN medications without indicator-clonidine HCL 0.1mg 1 tablet every 12 hours PRN, Ventolin HFA 90 mcg 1 puff every 6 hours PRN, and ibuprofen 800mg 1 tablet twice a day PRN. [corrected on site] Patient #4: The record contained orders for three PRN medications without indicator-tramadol HCL 50mg 1 tablet every 8 hours PRN, Proair HFA 90 mcg 2 puffs every 6 hours PRN, and lorazepam 0.5mg 1 tablet twice a day PRN. Patient #5: The record contained orders for three PRN medications without indicator-tramadol HCL 50mg 1 tablet every 8 hours PRN, clonidine HCL 0.1mg 1 tablet every 6 hours PRN, and docusate sodium 100mg once daily PRN.

Upon patient record review, 3 of 5 records (Patient #1, #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 equipment and supply needs. Patient #1: The record indicated on comprehensive assessment that patient has bedside commode, shower bench, walker, and cane however, these were not listed on plan of care. [corrected on site] Patient #2: The record indicated on comprehensive assessment that patient has bedside commode however, this was not listed on plan of care. [corrected on site] In addition, oxygen was added on 09/13 nurse visit and the equipment was not added to the plan of care. [corrected on site] Patient #3: The record indicated on comprehensive assessment that patient has grab bar and shower bench however, these were not listed on plan of care. [corrected on site]

Upon patient client record review, 2 of 5 records (Patient #2, #3) 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. Patients #2 and #3: The election of non-covered items was mark as "elected" and "declined" so it was unclear of patient desire however, there was no evidence of notice of non-coverage addendum being delivered to either. Owner was unsure and unable to confirm.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Confirmed with owner that a copy was not being given to patients. [corrected on site]