Every finding on record at Saint Mark Hospice Inc

Upon patient record review, 1 of 5 (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 Patient 1: The record included a physician's order for acetaminophen 500mg po 1tablet 4 x daily PRN pain. However, the medication profile included acetaminophen 650mg po 1tablet q6 hours PRN pain. Additionally, the record included documentation the patient was taking trazodone 50mg po 1tablet HS daily PRN insomnia. The trazodone was not included on the patient's medication profile.

Upon patient record review, 1 of 5 (Patient #1) 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 medical record included documentation the patient was taking trazodone 50mg po 1tablet HS daily PRN insomnia. However, there is no evidence of a physician's order for the medication. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #2) 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. Patient 2: The physician's certification of terminal illness indicates the patient's start of care date is 07.27.2022. All other documentation in the patient record indicates the correct start of care date of 09.06.2022, including another area on the physician's CTI form which indicates the current episode dates. The election of hospice care and consent forms contain the correct date of 09.06.2022.