Every finding on record at St. Luke's Hospice Inc.

Upon patient record review, 1 of 14 (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. 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 medication profile contains orders on 5/6/22 for Diclofenac 1%, apply topically every 8 hours as needed for joint pain, and an additional order on 5/10/22 for Voltaren cream, apply topically every 8 hours as needed for arthritis pain. The medications are the same, neither order specifies where to apply the medication. (Corrected at the time of survey)

Upon patient record review, 1 of 14 (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 medications and treatments. Patient #5 The medication order on 5/6/22 for Diclofenac 1%, apply every 8 hours as needed for joint pain, does not specify where to apply the medication. The medication order on 5/10/22 for Valtoren cream, apply every 8 hours as needed for arthritis pain does not specify the dose of the medication and does not specify where to apply the medication. (Corrected at the time of survey.)

Upon patient record review, 1 of 14 (Patient #6) 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 #6 The plan of care includes interventions and goals to assist with the completion of funeral arrangements for the patient, per documentation on 3/3/23, the family has completed all final arrangements for the patient and has provided the hospice with with a funeral home contact. The plan of care has not been updated to reflect the completed interventions and goals. (Corrected during the survey.)

Upon patient client record review, 1 of 14 (Patient #14) 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 #14 The RN visit made on 2/11/23 was not signed and appropriately authenticated by the visiting RN within 48 hours, per the agency policy.