MD Care Hospice

“Upon patient record review, 5 of 14 (Patient #1, 8, 9, 10 and 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: The comprehensive assessment on 10/22/25 does not show evidence of imminence of death assessed by SN. COS with updated visit note. Patient 8: The comprehensive assessment on 09/18/25 does not show evidence of imminence of death assessed by SN at SOC. COS with updated visit note. Patient 9: The comprehensive assessment on 08/04/25 does not show evidence of imminence of death assessed by SN at SOC. COS with updated visit note. Patient 10: The comprehensive assessment on 07/31/25 does not include evidence of imminence of death assessed by SN at SOC. COS with updated visit note. Patient 14: The comprehensive assessment on 8/22/2024 does not include evidence of imminence of death assessed by SN at SOC.”

“Upon patient record review, 2 of 14 (Patient #2 and 3) 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: Patient 2: Upon home visit, the medication profile contains multiple orders for Acetaminophen 500 mg tabs every 6 hours prn and Acetaminophen 650mg rectal suppository every 6 hour prn with no limit to not exceed in a 24 hours period. COS with updated physician order. Patient 3: Upon home visit, the medication profile contains multiple orders for Acetaminophen 500 mg tabs every 6 hours prn and Acetaminophen 650mg rectal suppository every 6 hour prn with no limit to not exceed in a 24 hours period. COS with updated physician order.”

“Upon patient record review, 1 of 14 (Patient # 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 5:The initial POC 10/23/25 contains an order for Xarelto with no evidence of risk for bleeding noted on POC. COS with update to POC to include risk for bleeding.”

“Upon patient record review, 3 of 14 (Patient # 2, 3 and 6) 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 updated POC on 11/3/25 contains multiple orders for Acetaminophen 500 mg tabs every 6 hours prn and Acetaminophen 650mg rectal suppository every 6 hour prn with no limit to not exceed in a 24 hours period. COS with updated physician order. Patient 3: The updated POC on 11/3/25 contains multiple orders for Acetaminophen 500 mg tabs every 6 hours prn and Acetaminophen 650mg rectal suppository every 6 hour prn with no limit to not exceed in a 24 hours period. COS with updated physician order. Patient 6: Initial POC on 10/18/25 contains wound care orders without frequency and who will provide wound care. Wound care instructions and care is being provided once weekly from Onmi wound care physicians and twice weekly by agency nurse. COS with updated orders for frequency and who will provide wound care and POC updated.”

“Upon patient record review, 4 of 14 (Patient # 7, 8, 9, and 10) 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 7: The initial POC on 10/14/25 contains problems/goals/interventions that have not been updated with target dates to meet by 10/28/25 for all issues including pain, edema, gastro, bowel elimination, genital-urinary and skin. COS with updated target dates to POC. Patient 8: The updated POC on 11/03/25 contains problems/goals/interventions that have not been updated with target dates to meet by 10/2/25 for all issues including pain, respiratory, and skin integrity. COS with updated target dates to POC. Patient 9: The updated POC on 11/03/25 contains problems/goals/interventions that have not been updated with target dates to meet by 08/18/25 for all issues including pain, respiratory, and skin integrity. COS with updated target dates to POC. Patient 10: The updated POC on 11/03/25 contains problems/goals/interventions that have not been updated with target dates to meet by 08/14/25 for all issues including pain, respiratory, and skin integrity. COS with updated target dates to POC.”

“Upon patient record review, 3 of 14 (Patient # 1, 2 and 9) 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: The comprehensive assessment on 10/22/25 and follow up visit on 11/2/25 do not show evidence of electronic date and signature by SN. COS with signature with approval of visit notes. Patient 2: The SN visit notes on 10/30/25 and 10/31/25 do not show evidence of electronic signature and date by SN. COS with signature with approval of visit notes. Patient 9: The medication list on 8/04/25 contains orders for NTE with Acetaminophen. NTE is not an agency accepted abbreviation per agency policy 6-023 for not to exceed. COS with update to medication list.”