Every finding on record at V & M Hospice Care

Upon patient record review, 5 of 14 (Patient #2, #3, #4, #5, #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, #4, #5, #10 There are evidences that oxygen is being used for the patients but oxygen not listed under medication.

Upon patient record review, 3 of 14 (Patient #2, #4, #8) 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. Patients #2, #4, #8 Patients utilize oxygen at home, but there is no evidence of problems, goals and interventions concerning oxygen safety.

Upon patient record review, 5 of 14 (Patient #3, #6, #7, #8, #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 medications and treatments. Patient #3 Plan of Care of 6/6/24 states"Oxygen 2-5 liters daily as needed for shortness of breath" without directions for titration. Patients # 6, #7, #8, #9, Oxygen listed on medication list but no evidence of order.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 Volunteer service was provided on 6/10/24 and 7/8/24 but no frequency order.

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 HHA POC created by RN on 6/6/24 stated to provide shower instead of shower with shower chair. Per family member report, HHA has been utilizing shower chair during shower.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2 HHA service started on 6/26/24 twice a week but there is no evidence of RN supervisory visits completed on 7/9/24, 7/23/24, nor 8/6/24.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #8 EOB form did not contain a start of the care date.

Upon patient client record review, 1 of 14 (Patient #1) 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 #1 HHA frequency was listed in order as twice a week, but listed under plan of care and home health aide plan of care as once a week. HHA was visiting twice a week.