Every finding on record at Release Hospice, Inc

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #12: There is no evidence that the patient or representative right to choose their attending physician was honored. The election statement did not include the Name of the Hospice.

Upon patient record review, 1 of 14 (Patient #1) 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: During medication reconciliation at the ALF, the hospice medication record included guaifenesin/dextromethorphan 100mg/10mL/5mL give 10mL Q8 hours as needed. This was not included on ALF medication record. Additionally, benzonatate 200mg every 8 hours PRN was duplicated on hospice medication record and listed only once on the ALF medication record.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: The initial bereavement assessment was completed. However, it was incomplete as there was no primary bereaved identified.

Upon patient record review, 2 of 14 (Patients #1,2) 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: This patient had a fall mat next to the bed. This item was not included on the Plan of Care. Patient #2: This patient had APP mattress and nebulizer machine. These were not included on the Plan of Care.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #12: The election statement did not include the following required items (blank space on the form): • Contact information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). • Name of the Hospice • Effective date for hospice to start

Upon patient record review, 1 of 5 (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. Patient #3: The patients medication profile indicates that the patient takes Ibuprofen 800mg BID, but the patient verbalizes that she does not take the medication twice daily as scheduled, but "as needed" for pain up to 2 times per day.

Upon patient record review, 1 of 5 (Patient #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 #3: The patients medication order indicates that the patient takes Ibuprofen 800mg BID, but the patient verbalizes that she does not take the medication twice daily as scheduled, but "as needed" for pain up to 2 times per day.

Upon personnel record review, 1 of 9 applicable (Personnel #2) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #2 The registered nurse license on file is expired effective 1/31/2022. Corrected on site.