Every finding on record at Universal Health Net Monterey, Inc

Upon patient record review, 6 of 14 (Patient 2, 4, 5, 7, 9 & 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 2 medication profile includes "Acetaminophen 500mg tab 2 tabs by mouth up to three times a day" with unclear frequency and "Voltaren 1% gel 2-4gms 3 times daily as needed" with no location identified. Patient 4 medication profile includes "Antifungal powder lightly coat affected area twice a day as needed for fungal rash" with no location identified. Patient 5 medication profile includes "Clonazepam 0.5mg tab 1-2 tabs by mouth every 8 hours as needed for agitation” with unclear dose Patient 7 medication profile includes "Nitroglycerin 0.3 mg tab 1 tab every 5 min x 3 for chest pain” with no evidence of directions if chest pain continues. Patient 9 medication profile includes "Benadryl 1% cream apply topically to affected area every 8 hours as needed for allergies/itching” with no location identified. Patient 12 medication profile includes "Diclofenac Sodium 1% gel, 2 gms four times a day as needed for arthritic pain” with no location identified. “Latanoprost 0.005% solution 1 drop every night for glaucoma” with no indication of which eye. “Miralax 17gm dose pack powder one packet by mouth daily” with no mixing instructions. "Oxycodone Hydrochloride 15 mg tab 1-2 tabs by mouth every 3 hours as needed for moderate pain" with unclear dose.

Upon patient record review, 6 of 14 (Patient 2, 4, 5, 7, 9 & 12) 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 plan of care includes "Acetaminophen 500mg tab 2 tabs by mouth up to three times a day" with unclear frequency and "Voltaren 1% gel 2-4gms 3 times daily as needed" with no location identified. Patient 4 plan of care includes "Antifungal powder lightly coat affected area twice a day as needed for fungal rash" with no location identified. Patient 5 plan of care includes "Clonazepam 0.5mg tab 1-2 tabs by mouth every 8 hours as needed for agitation” with unclear dose Patient 7 plan of care includes "Nitroglycerin 0.3 mg tab 1 tab every 5 min x 3 for chest pain” with unclear instructions and no route. Patient 9 plan of care includes "Benadryl 1% cream apply topically to affected area every 8 hours as needed for allergies/itching” with no location identified. Patient 12 plan of care includes "Diclofenac Sodium 1% gel, 2 gms four times a day as needed for arthritic pain” with no location identified. “Latanoprost 0.005% solution 1 drop every night for glaucoma” with no indication of which eye. “Miralax 17gm dose pack powder one packet by mouth daily” with no mixing instructions. "Oxycodone Hydrochloride 15 mg tab 1-2 tabs by mouth every 3 hours as needed for moderate pain" with unclear dose.

Upon patient record review 3 of 14 (Patient 1, 4 & 14) 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 1 plan of care/aide assignment ordered 2 x week however, only 1 visit noted weeks of 12/24/23 and 12/31 and 3 visits noted week of 1/7/24 and 1/14 Patient 4 plan of care/aide assignment ordered 2 x week however, 3 visits noted weeks of 1/7/24 and 1/14. Patient 14 plan of care/aide assignment ordered 2 x week however, only 1 visits week of 11/19/23.