Every finding on record at Z & B Healthcare Inc

Upon patient record review, 3 of 14 (Patient #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 medications and treatments. Patient #1: POC denoted Zolmitiptan 5 mg/1 tab as needed- no prn indicator listed. Patient #2: POC denoted fleet enema rectal as needed- no prn indicator listed. Biscadyl 10 mg 1 supp rectally as needed- no prn indicator listed Patient #3: POC denoted Ducolax 100 mg 1 as needed, Nitroglycerin 0.4 mg 1 as needed, Tylenol 650 mg q 8 hours as needed- all without prn indicator listed.

Upon observation and home visit, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2, Agency policy not followed as evidenced by the SN failed to place barrier between nursing bag and floor. SN failed to create a clean versus dirty area for placement and cleaning of equipment.

Upon patient record review, 3 of 6 (Patient #1, #3, #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 #1: Orders for Guaifenesin on 10/11/21 and Senna S on 9/16/21 were not transcribed to the med profile. COS Patient #3: Orders for Methylprednisone 11/11/21, Augmentin 11/4/21 and Clindamycin 11/6/21 were not transcribed to the medication profile. COS Patient #6: Order for phenergan 8-4-21 was not transcribed to the medication profile COS

Upon patient record review 2 of 2 applicable patients (Patient #1, #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Included in the plan of care Patient #1: On aide care plan dated 12-2-21 there were no specified duties for linens. The aide performed a linen change 3 x week from 12/3/21 to 1/7/22. Additionally, the aide care plan ordered I/O to be recorded and from 12/3/21 to 1/7/22, the aide either checked I/O without recording, or documented the date of last BM without an order, or both. Patient #4: On aide care plan dated 7-19-21, there was no specification of whether to change or wash linens. On the aide note from 8-13-21 and 8-16-21, the aide documented that linens were changed.

Upon patient client record review, 1 of 6 (Patient #1) 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 #1: Informed consent incomplete- missing advance directive information, election date, reason patient unable to sign and date of transfer from previous hospice.

Upon patient record review, 1 of 6 (Patient # 2) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient#2: Ability of patient to administer medications was left blank. COS