Every finding on record at Simple Choice Hospice Inc.

Upon patient record review, 1 of 5 (Patient #4) 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 4: The medical record includes nursing documentation of symptom management of constipation to include use of laxative and the plan of care includes order for Bisacodyl daily as needed. There is no evidence that the medication profile includes Bisacodyl.

Upon patient record review, 1 of 5 (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:The medical record contains nursing documentation with depression and anxiety noted as active problems. The plan of care includes the problems of depression and anxiety with documented interventions, but there is no evidence of goals for the identified problem.