Every finding on record at Red Maple Holdings Inc

Upon patient record review, 1 of 14 (Patient #12) 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 12: On admission, the patient's medication profile included entry of oxygen to be delivered at 2 liters per minute as needed for shortness of breath. There is no indication of the route for delivery of oxygen.

Upon patient record review, 1 of 14 (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 3: Upon admission there is nursing documentation that the patient is using oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence of problems, goals and interventions related to oxygen use. Corrected on site.

Upon patient record review, 1 of 14 (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 4:Upon admission, the medical record contained an order for a 16 French foley catheter to be placed. The order did not indicate the balloon inflation amount. Corrected on site.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1:The aide plan of care indicated the task of bed bath to be completed every Tuesday. Visit documentation on 9/19/23, 9/26/23 and 10/3/23 indicates that shower was completed by aide.