Every finding on record at Well Care Hospice & Palliative Care Inc

Upon patient record review 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient#6:There is no evidence of a psychosocial initial assessment being completed within 5 days.

Upon patient record review, 2 of 14 (Patient #1,#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#1: During home visit it was noted and confirmed that patient was taking Eliquis 5mg 1 twice a day. However, the medication profile indicated Eliquis was 2.5mg 1 twice a day. Medication profile also showed Seroquel 25mg 1 at night and 50mg 1 at night. In the home it was noted and confirmed that patient bottle indicates patient takes Seroquel 25mg in the morning and 50mg at night. Corrected on site. Patient#2: During home visit patient had hydrocortisone topical cream 0.1%. Patient confirms to be currently using this medication. There is no evidence of an order. Corrected on site.

Upon patient record review, 4 of 14 (Patient #2,#3,#4,#9) 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#2: There is no evidence of goals or interventions related to skin precautions or bleeding precautions on plan of care as ordered by physician on 01/02/25. Also noted on plan of care is a problem listed as hard of hearing. However, there are no evidence of goals or interventions related to this problem on plan of care. Corrected on site. Patient#3: Physician order on 7/18/24 indicates aspiration precautions are needed. There is no evidence of goals or interventions related to aspirations precautions. Corrected on site. Patient#4: The record indicates patient was admitted with terminal illness of hypertensive heart disease. There is no evidence of problems, goals, or interventions related to this cardiovascular needs. Corrected on site. Patient#9: The record indicates patient taking Humulin 70/30 and Jardiance daily for diabetes. There is no evidence of problems, goals, or interventions related to these needs on plan of care. Corrected on site. The record indicated patient signed form indicating chose DNR. However, the POC/order indicates patient is full code. It was confirmed with patient that DNR was correct. 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: Upon review of the record, the plan of care indicated an intervention stating patient to receive dietary assessment by Hospice dietician. There is no evidence or documentation of this being completed or addressed.

Upon patient record review 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#14: Upon review of record, it indicated patient was a full code at time of death. However, there is no evidence or documentation that full code was upheld at death visit.

Upon patient record review, 2 of 14 (Patient #1,#9) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: Upon review of record, aide POC states feeding as tolerated NAS. There is no evidence of mechanical soft diet on aide POC. There is no evidence of bleeding precautions being indicated on aide POC. These patient needs are ordered by physician. Corrected on site. Patient#9: The record indicates patient takes Eliquis daily and requires bleeding precautions. There is no evidence of bleeding precautions indicated on aide POC. 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. Patient 2: The medication profile contains an order for Docusate/Senna 50/8.6mg 2 tabs bid prn. Upon home visit finding the prescription bottle is labeled docusate/Senna 50/8.6 two tabs daily. Caregiver confirms pt is taking the Docusate/Senna routinely and not PRN. 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: The POC contains an order for Docusate/Senna 50/8.6mg 2 tabs bid prn. Upon home visit finding the prescription bottle is labeled docusate/Senna 50/8.6 two tabs daily. The caregiver confirmed the pt is taking the Docusate/Senna routinely, not PRN. Corrected on site.

Upon patient record review, 5 of 5 (Patient #1,#2,#3,#4,#5) 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 1 and 2 The medical record contains a note from the RN stating pt is wearing heel protectors and is incontinent of bowel and bladder. There is no evidence of an order for heel protectors or incontinence supplies in the POC. Corrected on site. Patients 3, 4, and 5: The medical record contains a note from the RN stating pt is wearing heel protectors. There is no evidence of an order for heel protectors in the POC Corrected on site.