Every finding on record at Residential Home Health and Hospice Inc

Upon patient record review, 3 of 19 (Patient #5,#9,#11) 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 5:The medical record incudes an entry on 9/1/23 for Amoxicillin 500 mg po BID for mouth ulcer. The medication remains profiled as a current medication on 2/28/24. COS Patient 9: The medical record incudes an entry on 2/16/24 for Lidocaine Patch 4%, apply every 8 hours. There is no indication of the location for application of the patch. Patient 11:The medical record includes duplicate entries for oxygen dated 12/7/23 of 2 LPM continuous via NC and 1/8/24 of 4 LPM continuous via NC. COS

Upon patient record review, 2 of 19 (Patient #8,#10) 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 8:The medical record contains documentation on admission that the patient has cholecystitis to include a drain to right flank. There is no evidence on the plan of care of problem, goals and interventions to care for right flank drain. COS Patient 10: The medical record contains documentation on admission of current anticoagulant therapy using Xarelto. There is no evidence on the plan of care of problem, goals and interventions for potential of bleeding and anticoagulant therapy. COS

Upon patient record review, 1 of 19 (Patient #9) 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 9: The medical record incudes an order on 2/16/24 for Lidocaine Patch 4%, apply every 8 hours. There is no indication in the order of the location for application of the patch.

Upon patient record review, 4 of 19 (Patient #3,#5,#6,#7) 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 3:The medical record contains documentation that the patients equipment and supply needs include a hospital bed, wheelchair and overbed table. There is no evidence of a hospital bed, wheelchair and overbed table on the plan of care. COS Patient 5:The medical record contains documentation that the patients equipment and supply needs include a hospital bed and walker. There is no evidence of a hospital bed and walker on the plan of care. COS Patient 6:The medical record contains documentation that the patients equipment and supply needs include a hospital bed and wheelchair. There is no evidence of a hospital bed and wheelchair on the plan of care. COS Patient 7:The medical record contains documentation that the patients equipment and supply needs include fall mats, bolster and a wheelchair. There is no evidence of fall mats, bolster on the plan of care. COS

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1:The medical record includes documentation of chronic urinary tract infections with subsequent prophylactic order by physician on 2/16/24 of Bactrim 800 mg daily. There is no evidence of an update to problem, goals and interventions on the plan of care to reflect Infection. COS

Upon patient record review, 3 of 19 (Patient #2,7,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2:The aide plan of care dated 12/28/23 does not include seizure precautions. Patient 7:The aide plan of care dated 1/31/24 does not include aspiration precautions. Patient 10:The aide plan of care dated 9/9/23 does not include fall and bleeding precautions.