Every finding on record at St Cyril Hospice Palliative Care Services , Inc

Upon medical record review, 2 of 3 (Patient #1 and #3) did not show evidence that the patient has the right: To exercise his or her rights as a patient of the hospice and identify visiting personnel members through agency generated photo identification Patients #1 and #3 did not show evidence of exercising their rights to be a DNR as a patient of the hospice. Patients #1 and #3 have a DNR in their medical record and the admitting RN employed by hospice agency signed both DNRs as "Witness # 1". Instructions for completing an OOH-DNR order in Texas (on back of DNR form): Witness One (the “qualified” witness) may not be: -person designated to make a treatment decision for the patient; -related to the patient by blood or marriage; -entitled to any part of the estate; -be a person who has a claim against the estate of the patient; -the attending physician or an employee of the attending physician; -an employee of a health care facility in which the patient is being cared for, if he or she is involved in providing direct patient care to the patient (social workers, chaplains and people who provide nutrition services are not considered to provide direct patient care); or -an officer, director, partner, or business office employee of a health care facility in which the patient is being cared for or any parent organization of the health care facility.

Upon patient record review, 3 of 5 (Patient #2, #3 and #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. There was no evidence in the patient record of a medication profile that includes all current patient medications. Patient #2 medication profile includes "Norco 5/325 mg tabs 1 tab po every 6 hours prn pain" and "Tylenol # 3 300-30 mg tab 1 po every 4 hours prn pain" with no dosage daily limits. Patient #3 medication profile includes "Lisinopril 5 mg tab 1 tab po twice daily." During home visit it was observed by Surveyor prescription bottle for Lisinopril in the home is "Lisinopril 5 mg tab 1 tab po once daily". Medication profile included "Gabapentin 30mg po three times daily". Ordered as Gabapentin 300mg. Patient #5 medication profile includes "Hydrocodone/APAP 10/350 mg tab 1 tab po every 4-6 hours for pain", "Acetaminophen 650 mg supp 1 rectally every 8 hours as needed for temp > 100.5" and "Tylenol #3 300mg/30mg tab 1 po four times a day prn pain" with no dosage daily limits.

Upon medical record review, 5 of 5 (Patient #1, #2, #3, #4, and #5) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patient #1 SW and SC visit orders included prn visits without a specific number of prn visits identified. Orders were written as "SW visits 1/month and prn. SC visits prn within 1m." Patient #2 SC visit order written as: "SC visits prn within 1m". Patient #3 SW and SC visit orders included prn visits without a specific number of prn visits identified. Orders were written as "SW visits 1/month and prn. SC visits prn within 1m." Patient #4 SW and SC visit orders included prn visits without a specific number of prn visits identified. Orders were written as "SW visits 1/month and prn. SC visits prn within 1m." Patient #5 SC visit order written as: "SC visits prn within 1m".

Upon patient record review, 3 of 5 (Patient #2, #3 and #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 medications and treatments. Patient #2 medication order includes "Norco 5/325 mg tabs 1 tab po every 6 hours prn pain" and "Tylenol # 3 300-30 mg tab 1 po every 4 hours prn pain" with no dosage daily limits. Patient #3 medication order included "Lisinopril 5 mg tab 1 tab po twice daily." During home visit it was observed by Surveyor prescription bottle for Lisinopril in the home is "Lisinopril 5 mg tab 1 tab po once daily". Verbal physician order for Gabapentin on start of care is "Gabapentin 300mg tab 1 tab po three times daily." Transcribed to plan of care as "Gabapentin 30mg po three times daily". Medication dosage is unclear. Patient #5 medication order includes "Hydrocodone/APAP 10/350 mg tab 1 tab po every 4-6 hours for pain", "Acetaminophen 650 mg supp 1 rectally every 8 hours as needed for temp > 100.5" and "Tylenol # 3 300mg/30mg tab 1 po four times a day prn pain" with no dosage daily limits.

Upon medical record review, 4 of 5 (Patient #1, #2, #4 and #5) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1 comprehensive assessment identified wheelchair, suction machine, pressure relieving device, oxygen and transfer equipment. Plan of Care did not include wheelchair, suction machine, pressure relieving device, oxygen and transfer equipment. Patient #2 comprehensive assessment identified wheelchair and transfer equipment. Plan of Care did not include w/c and transfer equipment. Patient #4 comprehensive assessment identified transfer equipment. Plan of Care did not include transfer equipment. Patient #5 comprehensive assessment identified walker and oxygen. Plan of Care did not include the walker and oxygen.

Upon patient record review, 3 of 5 (Patient #1, 2, 3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1, #2 and #3 did not show evidence that the hospice obtained, no later than 2 calendar days after hospice care was initiated, oral or written certification of the terminal illness by the hospice medical director and the individual's attending physician if the individual has an attending physician.