Every finding on record at Suburban Hospice, Inc

Upon patient record review, 2 of 22 (Patient #8, 12) 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 #8: The medication profile contained Miralax powder by mouth 17 GM. May take 1 scoop/capful, 17GM by mouth daily as needed for constipation. There was not evidence of a diluent. Patient #12: The medication profile contained Miralax by mouth 17 GM. May take 1 scoop/capful, 17GM by mouth daily as needed for constipation. There was not evidence of a diluent.

Upon patient record review, 2 of 22 (Patient #2, 15) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: Documentation in the nurse visit note dated 07/06/23 indicated that the patient has a foley catheter and a coccyx wound. There was no evidence of ongoing assessment and monitoring of the wound or catheter by the hospice nurse. Patient #15: The medical record did not contain documentation of continuous assessment of the coccyx wound which would include wound measurements from 04/19/23- present.

Upon patient record review, 1 of 22 (Patient #15) 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 #15: The record indicated the patient had a catheter and a coccyx wound. The plan of care did not include problems, interventions and goals related to genitourinary or integumentary systems.

Upon patient record review, 4 of 22 (Patient #2, 8, 12, 15) 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: There was evidence in the record the patient had a catheter and a wound. The plan of care did not include orders for the treatment of the wound or catheter. Patient #8: The record contained an order for Miralax powder by mouth 17 GM. May take 1 scoop/capful, 17 GM by mouth daily as needed for constipation. There was not evidence of a diluent included in the order. Patient #12: The record contained an order for Miralax by mouth powder. 17 GM. May take 1 scoop/capful, 17GM by mouth daily as needed for constipation. There was not evidence of a diluent included in the order. Patient #15: Medical records in the patient's chart indicated that the patient has a catheter and a coccyx wound. The orders did not specify who was responsible for the management of these treatments.

Upon patient record review, 8 of 22 (Patient #1,#3,#5,#12,#13,#14,#15,#18) 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 #1: Upon observation, the patient has half rails, fall mat, wheelchair, and over bed table. The plan of care did not include equipment. Patient #3: The agency has an intervention on the plan of care that indicates "a device will be used". The plan of care does not specify what device will be used. There is evidence in the nursing documentation that the patient has a hoyer lift. Patient #5:The record included information that the patient had a wheelchair and was incontinent. The plan of care did not include a wheelchair or incontinence supplies. Patient #12:The record record included evidence the patient was prescribed albuterol to be administered via nebulizer. The plan of care did not include the nebulizer. Patient #13:The record included information that the patient had a wheelchair and is supplied briefs. There is no evidence the plan of care includes a wheelchair or briefs. Patient #14: The agency has nursing documentation indicating the patient is wheelchair bound and is supplied incontinence supplies. The plan of care did not include a wheelchair or incontinence supplies. Patient #15:The agency has a care plan dated 07/25/23 which does not include equipment and supply needs. According to the medical record the patient has a suprapubic catheter and coccyx wound. In addition, the patient also has a walker, low air loss mattress, and roho cushion that are not on the plan of care. Patient #18:The agency has an aide assignment dated 02/15/23, that directs the aide to "transfer the patient from the bed to the wheelchair". The plan of care does not include a wheelchair.

Upon client record review, 1 of 22 (Patient #15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #15: The medical record contains documentation from the wound care physician dated 06/20/23 "acetic acid, 0.25% irrigation, 50-60 ml, w/ catheter change 1 x month" and "1/4 str dakins to coccyx wound daily". There is no evidence the SN performed the wound care.