Every finding on record at Victory Place Hospice Inc

Upon observation, there was no evidence the Emergency Plan communication plan included contact information for tribal emergency agencies along with a primary and alternate means for communicating with tribal emergency management agencies. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) 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 dated 9/26/2022 included Miralax 17GM package/pouch orally 2x day for BM>3 days. There was no evidence of a diluent. Corrected on site.

Upon patient record review, 1 of 5 (Patient #2) 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: An order dated 9/26/2022, on the care plan included Miralax 17GM package/pouch orally 2x day for BM>3 days. There was no evidence of a diluent. Corrected on site.

Upon review of policy and procedure, Policy Staff Competency Program 4.28.1 did not describe the method for assessment of competencies and procedure for maintaining a written description of the in-service training provided during the previous 12 months. The stated policy included competency at intervals defined: during orientation and at least every 3 years for patient care staff. No evidence of policy assessing competency annually. Policy corrected on site.