Welby Way Home, LLC

“Upon patient record review, 2 of 14 records reviewed (Patient #2,3) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The record indicated the following medication was ordered: Acetaminophen ES 500mg po 2 tabs as needed for mild/moderate pain every 4 hours. There was no evidence in the record not exceed 4 grams in a 24 hour period. COS. Patient #3: The medication profile had Oxygen 2-5 lpm via NC continuous, there was no evidence this matched the physician order. COS.”

“Upon patient record review, 2 of 14 records reviewed (Patient #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 #2: The record indicated the following medication was ordered: Acetaminophen ES 500mg po 2 tabs as needed for mild/moderate pain every 4 hours. There was no evidence in the order to not exceed 4 grams in a 24 hour period. COS. Patient #3: The record indicated a physician order on 12/07/24 for Oxygen 2LPM as needed for shortness of breath, there was no route of administration on the physician order. COS”

“Upon patient record review, 3 of 14 records reviewed (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 equipment and supply needs. Patient #1: The plan of care summary indicated the patient had a CADD Pump in the home and the medication profile had no medication listed for the CADD Pump. The Administrator confirmed there was no CADD Pump in the home. COS. In addition, the record indicated the patient had the following DME and medical supplies ordered on 12/02/24: ensure, wipes, incontinent pads, diapers, sterile gloves, oxygen regulator, wheel chair, foot rest, suction machine, bed rails, oxygen cart, nebulizer and oxygen concentrator. There was no evidence of these items in the care plan. COS. Patient #2: The record indicated the patient had oxygen, oxygen tank, nebulizer, bariatric bed and air pressure mattress ordered on 12/06/24. There was no evidence of these items in the care plan. COS. Patient #3: The record indicated the patient had the following DME ordered on 9/9/24: wheel chair, breathing tubing, suction machine, overbed table, oxygen cannula, humidifiers, oxygen, oxygen concentrator, mattress, electric hospital bed, bed side rails. There was no evidence of these items in the care plan. COS.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,6,8,9) 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 #1: The record indicated the IDG was scheduled on 11/20/24 and 12/04/24. There was no evidence of notes and or signatures from the Nurse, MD, Social Worker and/or Chaplain on these IDG dates and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #2: The record indicated the patient was admitted on 12/06/24. There was no evidence of an IDG meeting at the time of the survey. COS. Patient #3: The record indicated the IDG was scheduled on 11/06/24, 11/20/24 and 12/04/24. There was no evidence of notes and or signatures from the Nurse, MD, Social Worker and/or Chaplain on these IDG dates and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #4: The record indicated the IDG was scheduled on 08/21/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #6: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the MD, Nurse, Chaplain and/or Social Worker. In addition the attending physician was not updated and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #8: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS. Patient #9: The record indicated the IDG was scheduled on 11/20/24. There was no evidence of participation by the Social Worker and/or Chaplain and no evidence the IDG POC was updated with progress towards goals being met. COS.”