Every finding on record at Ruby Hospice Care Inc

Upon patient record review, 1 of 5 (Patient #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. Patient #5: PRN oxygen on the med profile. Missing evidence of a route of administration.

Upon patient record review, 1 of 5 (Patient #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 equipment and supply needs. Patient #5: Patient with PRN oxygen orders on the plan of care. Oxygen DME/supplies not listed on the plan of care orders.

Upon personnel record review, 4 of 12 (Personnel #2,3,4,7) did not have evidence of a skills competency assessment completed or completed by the appropriate discipline. Personnel #2: Initial LPN competency completed by the administrator/LPN. Personnel #3: Initial RN competency completed by the administrator/LPN. Personnel #4: Initial RN competency completed by the administrator/LPN. Personnel #7: Initial BC competency is signed by the administrator but the form is not complete. The skills only demonstrate a self-assessment by the BC. Columns for the evaluation method and date/initials of the preceptor are blank.

Upon patient client record review, 3 of 5 (Patient #1, 2, 5) did not have evidence that all entries are complete. Patient #1: Bereavement assessment completed by the MSW on 4/6/22. Form was incomplete. Top section of the form labeled assessment was not complete. MSW did complete section for caregiver risk factors. Patient #2 and 5: Spiritual assessment completed by the chaplain on 3/16/22. Form was incomplete. Fields for faith/denomination, church affiliation, and name of clergy not completed.