Every finding on record at Top Line Hospice Care, Inc

Upon patient record review, 1 of 3 (Patient #1) 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 #1: Carbidopa/Levodopa 10-100mg 2 tablets oral twice daily documented on the medication list and the medication bottle in the home reads Carbidopa/Levodopa 10-100mg 2 tablets oral four times per day. Patient verbalized he takes four times a day. Entacapone 200mg 1 tablet oral, directions read take 1 tablet by mouth with each Carbidopa/Levodopa dose. No evidence the correct dose was written on the medication list for the Carbidopa/Levodopa.

Upon patient record review, 3 of 3 (Patient #1,2,3) 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 #1,2,3, MSW initial comprehensive assessment did not document funeral home. No evidence of care plan identifying plan for funeral home arrangements. Patient #2, Upon chart review, patient noted to have Foley catheter 14F 10CC. No evidence of care plan identifying care of Foley catheter.

Upon patient record review, 1 of 3 (Patient #1) 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 #1: Carbidopa/Levodopa 10-100mg 2 tablets oral twice daily documented in the record and the medication bottle in the home reads Carbidopa/Levodopa 10-100mg 2 tablets oral four times per day. Patient verbalized he takes four times a day. Entacapone 200mg 1 tablet oral, directions read take 1 tablet by mouth with each Carbidopa/Levodopa dose. No evidence the correct dose was updated on the plan of care for the Carbidopa/Levodopa.

Upon patient record review, 2 of 3 (Patient #1,2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, Upon chart review, MSW frequency order is 1x/month. Patient seen 3/1/25 and 3/25/25. No evidence of MSW visit the month of May. Patient #2, Upon chart review SC frequency order is every certification period. Patient seen 10/25/24 and 1/17/25. New certification period starts on 1/21/25.

Upon observation, there was no evidence of retention of patient records and information. The agency only had 3 records and could not find records from prior CHOW on 5/25.