Every finding on record at Superior Hospice Inc.

It is required that each patient's individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 7 (29%) clinical records reviewed, the agency did not ensure that the physician's medication orders were complete. The Agency's policy, Protocol Physician Orders and Oversite, stated in part, "All orders to include medication, dose, route, frequency, and indication." Clinical Record 1: A review of the clinical record revealed the plan of care (POC) and medication list did not include a complete physician order per the agency's policy. The POC/medication list dated 10/03/2024 stated, "Metamucil, take by mouth as directed, as needed." The order did not include the dose or an indication of use for the as needed frequency. The POC also included, "Mucinex Fast-Max Cold-Flu Sore Throat 200 mg tablet, suck 1 tab by mouth, as needed." The order did not include an indication for use of the as needed frequency. Clinical Record 5: A review of the clinical record revealed the plan of care and medication list did not include a complete physician order per the agency's policy. The POC/medication list dated 10/07/2024 stated, "Epinephrine 0.15mg/0.3 ml injection, autoinjector per instructions, as needed, inject subq (subcutaneous) as needed." The order did not include the dose or an indication of use for the as needed frequency. During an interview on 10/10/2024, the Administrator confirmed the finding and stated, "The policy is that the medication orders need to include the dose, route, frequency, and indication. All of these were not included in these cases."