Every finding on record at Tranquility Health Care

Upon patient record review, 1 of 14 (Patient #7) 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 #7: Polyethylene Glycol powder order (8/23/23) with no diluent on the medication profile. Corrected on Site.

Upon patient record review, 3 of 14 (Patients #3, 4 & 9) 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. Patients #3 The record reflected that this patient had a Duoneb inhalation order. Patient had a BST. The DME (nebulizer machine and BST) were not listed on Plan of Care. Patient #4: The record reflected that this patient had a Duoneb inhalation order. The DME (nebulizer machine) was not listed on Plan of Care. Corrected on site. Patient #9: The record reflected that this patient had a oxygen PRN order. The DME (02 Concentrator machine) was not listed on Plan of Care. Corrected on site.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: The POC listed Skilled Nursing visit frequency of, 2 X's per week. For Benefit Week 8/20/23 SN visits occurred on 8/24/23, and 8/26/23 x2 (had two SN visits for this day). The total SN Visits was 3x not 2x. This visit frequency was not met.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Per Policy PC.M60 Medication Use and Disposal of Controlled Substances (Procedures 1b) a copy of this policy is to be provided to patient or patient representative and family. An abbreviated version was provided in patient handbook not Policy PC.M60 as indicated.

Upon client record review, 14 of 14 (Patients #1 through 14) did not have evidence that the written policies and procedures for managing controlled drugs was provided. Per Policy PC.M60 Medication Use and Disposal of Controlled Substances (Procedures 1b) a copy of this policy is to be provided to patient or patient representative and family. An abbreviated version was provided in patient handbook not Policy PC.M60 as indicated.