Every finding on record at Your Dream Hospice Care, Inc

Upon patient record review 2 of 14 (Patient #7,#8) 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 7 and 8:The medical record includes documentation from SCC that phone contact was made with caregivers and per their request, a visit and assessment would be completed within the month. There is no documentation of a completed spiritual assessment within the patient record from admission through 04/08/25, greater than 5 days and outside of the documented time frame for follow up.

Upon patient record review, 1 of 14 (Patient #6) 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 6:The medication profile includes entries for both Prozac and Fluoxetine Hydrocholoride 10 mg twice daily for depression. , Prozac is brand name and Fluoxetine Hydrocholoride is generic name of the same medication, duplicate entries.

Upon patient record review, 2 of 14 (Patient #2,#5) 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:The medical record includes an ordered diet of NSA, diabetic, low cholesterol and nursing documentation of fair appetite and instruction provided on small frequent meals. There is no evidence that the plan of care includes problems, goals and interventions for management of the altered diet and decrease intake. Patient 5:The medical record includes CVA as the Primary diagnosis. There is no evidence that the plan of care includes problems, goals and interventions for the management of the primary diagnosis.

Upon patient record review 1 of 14 (Patient #9) 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 9:The medical record includes a visit frequency for the aide of 1 visit weekly starting 3/4/25. There is no evidence of visits noted in record after visit on 3/4/25 and no documentation of reason frequency is not met.

Upon patient record review, 1 of 1 applicable record (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide must include indicated precautions and be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #5; The record indicated that the patient was on Brilinta 90mg BID. There was not evidence of bleeding precautions on the aide plan of care.