American Veterans Hospice

“Upon patient record review, 7 of 14 (Patients #1,#2,#3,#5,#6,#8,#9) 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: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. The medication profile also contained duplicative listings of bisocodyl, levsin, lorazepam, morphine, and phenergan. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. The medication profile also contained duplicative listings of Miralax and polythethylene. Corrected on site. Patient 5: The medication profile also contained oxygen with no frequency and a lidocaine patch with no area defined for administration. Corrected on site. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen included in the medication profile. Corrected on site. Patient 8: The medication profile contained oxygen with no defined delivery method. Corrected on site. Patient 9: The medication profile contained Miralax oral powder with no instructions for a diluent.”

“Upon patient record review, 1 of 14 (Patient #3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 3: There was no evidence of a comprehensive physical assessment by the RN between 11/17/23 and 12/16/23.”

“Upon patient record review, 1 of 14 (Patient #6) 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 6: The medical record contained nursing documentation upon admission identifying patient issue with dysphagia. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site.”

“Upon patient record review, 6 of 14 (Patients #1,#3,#5,#6,#8,#9) 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: There was no evidence of an order for oxygen dose, frequency, and delivery method. Corrected on site. Patient 3: The medical record contained an order for oxygen with no frequency. Corrected on site. Patient 5: The medical record contained an order for oxygen with no frequency and a lidocaine patch with no area defined for administration. Corrected on site. Patient 6: The medical record contained an order for oxygen with no frequency. Corrected on site. Patient 8: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 9: The medical record contained an order for Miralax oral powder with no instructions for a diluent.”

“Upon patient record review, 6 of 14 (Patients #1,#2,#3,#4,#7,#8) 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 contained nursing documentation upon admission identifying patient use of a wheelchair, commode, and oxygen equipment. There was no evidence of orders for the listed DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, walker, wheelchair, shower chair, and commode. There was no evidence of orders for the listed DME included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a walker and oxygen equipment. There was no evidence of orders for the listed DME included in the plan of care. Corrected on site. Patient 4: The aide care plan identifies patient use of a shower chair. There was no evidence of an order for the shower chair included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation 1/4/24 identifying patient use of a shower bench and toilet riser. There was no evidence of orders for the listed DME included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation 12/9/23 identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected on site.”

“Upon client record review, 4 of 14 (Patients #1, #3,#8, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: There was no evidence of frequency orders for nursing visits. Corrected on site. Patient 3: The medical record contained an order for nursing frequency of twice weekly effective 12/11/23. There were 4 visits completed the week of 12/10/23, and 3 visits completed the week of 12/24/23. Patient 8: The medical record contained an ordered nursing frequency of once weekly. There were 2 visits completed the weeks of 12/3/23 and 12/17/23. Patient 10: There was no evidence of a frequency order for nursing visits.”

“Upon patient record review 2 of 14 (Patients #4,#8) 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 4: The medical record contained an ordered aide frequency of three times weekly. The record shows aide visits twice weekly for December to current. Patient 8: The medical record contained an ordered aide frequency of three times weekly. There was no evidence of a third visit completed the week of 12/31/23.”

“Upon patient client record review, 1 of 14 (Patient #3) 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 3: The medical record identified the patient transferred from another hospice agency upon admission in benefit period 11/9/23-2/8/24. The chart contained a signed CTI for benefit period 1/10/24-4/8/24. There should not be a new benefit period starting until 2/9/24. Corrected on site.”