Every finding on record at Woodland Hospice Care, Inc

Upon patient record review, 2 of 14 (Patient #4,#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 #4-Medication profile listed bisacodyl, docusate, milk of magnesia, mineral oil and miralax all prn as treatment options for constipation. There was no evidence of when to use which prn medication. Patient#12 -Medication profile listed senna, milk of magnesia, and bisacodyl - all prn as treatment options for constipation. There was no evidence of when to use which prn medication.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #1 - The nursing comprehensive dated 06/29/25, noted the patient had a gastrostomy tube and it was being utilized for all medication and nourishment consumption. There was no evidence of education related to the tube feeding and its care provided to the patient/caregiver. This was corrected onsite.

Upon patient record review, 2 of 14 (Patient #10,11) 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 #10 - The medical record showed patient was receiving continuous care for uncontrolled symptoms from 03/20/25 - 03/24/25. There was no evidence of problems, goals or interventions for the continuous care.

Upon patient record review, 3 of 14 (Patient #1,4,12) 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#1- Patient's comprehensive assessment listed patients diet at "liquid". There was also documentation which noted that all medications were provided via g-tube. There was no evidence of the kind of tube feeding on the POC orders. Patient #4-POC orders listed bisacodyl, docusate, milk of magnesia, mineral oil and miralax all prn as treatment options for constipation. There was no evidence of when to use which prn medication. Patient#12 -POC orders listed senna, milk of magnesia, and bisacodyl - all prn as treatment options for constipation. There was no evidence of when to use which prn medication.

Upon patient record review, 1 of 14 (Patient #1) 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 medical record showed patient is receiving feeding and medication via g-tube. There was no evidence that the supplies needed for g-tube care were listed on the plan of care.

Upon patient record review, 1 of 14 (Patient #11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #11 - The medical record showed patient was receiving continuous care for uncontrolled symptoms from 02/11/25 - 02/17/25. There was no evidence of problems, goals or interventions for the continuous care.

Upon patient 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 IDG note dated 06/24/25, it was noted that an order was placed by the hospice physician to obtain a CBC. Nursing LVN notes dated 06/30/25 and 07/08/25 and RN notes dated for 06/26/25 and 07/10/25, showed no evidence of that the CBC was obtained. There was also no evidence of the results of that lab work in the medical record.

Upon patient record review, 1 of 14 (Patient #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#5 - The medical record showed evidence of a signed POLST form dated 4/18/25 which outlined patient wishes to be a full code. The social worker plan of care upon admission documented patient to be a DNR and resolved that problem on 6/28/25. There was no evidence that patient/POA's wishes change regarding resuscitation wishes and no change of code status order was noted.