Every finding on record at Taybian Hospice Inc

Upon patient record review, 5 of 14 (Patient #2,5,6,9,10) 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 #2-3/24/25 Lotrimin Cream 1% apply to affected areas 3x/day until resolved, no evidence of specific location on medication profile. Corrected on site. Patient #5-8/12/25 Norco 5/325mg 1 tab Q4-6 PRN, and additional orders containing acetaminophen on the medication profile with no evidence of not to exceed 4000mg in place on the medication profile. Corrected on site. Patient #6-9/3/25 Oxycodone/Acetaminophen tablet, 1 tab Q4 PRN, and additional orders containing acetaminophen on the medication profile with no evidence of not to exceed 4000mg in place on the medication profile. Corrected on site. Patient #9-7/3/24 Acetaminophen 650mg RS orders in place, and additional orders containing acetaminophen on the medication profile with no evidence of not to exceed 4000mg in place on the medication profile. Corrected on site. Patient #10-5/13/25 Hydrocortisone Cream, apply BID to affected areas, no evidence of specific location on medication profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #4) 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 #4- Wound care orders for right hand written on 7/30/2025 and right leg written 8/19/2025 state to reassess Q14 days, no evidence of wound measurements completed at any SN visit since orders were placed.

Upon patient record review, 5 of 14 (Patient #2,5,6,9,10) 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 #2-3/24/25 Lotrimin Cream 1% apply to affected areas 3x/day until resolved, no evidence of specific location on POC. Corrected on site. Patient #5-8/12/25 Norco 5/325mg 1 tab Q4-6 PRN, and additional orders containing acetaminophen on the plan of care with no evidence of not to exceed 4000mg in place on the POC. Corrected on site. Patient #6-9/3/25 Oxycodone/Acetaminophen tablet, 1 tab Q4 PRN, and additional orders containing acetaminophen on the plan of care with no evidence of not to exceed 4000mg in place on the POC. Corrected on site. Patient #9-7/3/24 Acetaminophen 650mg RS orders in place, and additional orders containing acetaminophen on the plan of care with no evidence of not to exceed 4000mg in place on the POC. Corrected on site. Patient #10-5/13/25 Hydrocortisone Cream, apply BID to affected areas, no evidence of specific location on POC. Corrected on site.

Upon patient record review, 2 of 14 (Patient #2,3) 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 #2-SN assessment states that patient utilizes wheelchair for ambulation, no evidence of wheelchair ordered on the DME list. Corrected on Site. Patient #3-SN assessment states that patient utilizes walker for ambulation, no evidence of walker ordered on the DME list. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9- 6/4/25 referral placed for X-ray to right hip, no evidence of X-ray completion or results provided to physician. 8/20/24 referral placed for podiatry, no evidence of referral completed or visits completed. Corrected on Site.

Upon patient record review 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #6- 9/6/25 MSW Initial assessment states "agreed on weekly visits", however visit frequency orders are written for 1x/month. Corrected on Site.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3-Aide visit frequency orders 2x/week, no evidence of 2 aide visits made the week of 8/10/25.

Upon patient 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- 1/20/25 Report of Death and Disposal of controlled drugs has Morphine and Ativan listed as disposed, no evidence of the amount of each controlled drug that was disposed.

Upon patient record review, 3 of 14 (Patient #1,4,5) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1- POC identifies MSW and Chaplain visit frequency as 1x for initial eval and 1-2PRN, orders written for visit frequency are 1x/month and 1 PRN, no evidence of which is correct. In addition, orders on 10/5/24 for Aspirin QD, no evidence of bleeding precautions on the POC. Corrected On Site. Patient #4- 7/31/25 Chaplain eval states family declined Chaplain services, however orders remain for Chaplain visit frequency 1x/month, no evidence of Chaplain visit frequency being followed as ordered. Corrected on Site. Patient #5- 7/9/25 SN Visit frequency 2x/week, no evidence of 2 visits week of 8/3/2025. Family declined visit on 8/9/2025 with no documentation of missed visit.-Corrected on Site.