Every finding on record at Wellness Proxy Resources LLC

Upon patient record review, 4 of 5 (Patients #2, 3, 4, 5) 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: The medication profile did not include frequency for PRN meds: Loperamide or Milk of Magnesium. Patient #3: Medication orders to discontinue were not updated on Medication List. There was yellow highlight only. The DC Date was not included in space provided on form "DC Date" column for the following meds: Bupropion, glipizide, lisinopril, metformin, Paxil, atorvastatin. The agency added an addendum to correct on site during survey. Patient #4: The medication profile did not include frequency for PRN meds: Firocet, Albuterol Nebulizer, Albuterol MDI, Elavil or Baclofen. Patient #5: The medication profile did not include frequency for PRN meds: Loperamide, Tylenol or Zofran.

Upon patient record review, 3 of 5 (Patients #1, 2, 3) 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. Patient #1: The record reflected that this patient had an APP Mattress. This was not included on the POC. Late Entry Addendum added during survey. COS. Patient #2: The record reflected that this patient had an Shower Chair. This was not included on the POC. Late Entry Addendum added during survey. COS. Patient #3: The record reflected that this patient had an HHN Treatments. This Nebulizer machine was not included on the POC. Late Entry Addendum added during survey. COS.

Upon patient client record review, 1 of 5 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #4: The Medical Director signed for Attending Physician in both places of the CTI. The Medical Director was not the patients chosen Attending Physician per EOB.

Upon patient client record review, 3 of 5 (Patient #2, 3, 5) 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 #2: Did not write "Daily" for scheduled meds. Used QD which is on the "do not use list" of policies and procedures. Patient #3: The nurse did not include her RN credential following her signature. Agency updated per policy with Late Entry Addendum. COS. Patient #5: Did not write "Every other Day" for a scheduled med. Used QOD which is on the "do not use list" of policies and procedures.