5 Star Hospice

“Upon patient record review, 3 of 14 (Patient #3,4,5) 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 #3-Medication profile dated 02/25/25 includes Diclofenac Sodium 1% topical gel, apply topically to affected area twice daily. The order does not include an amount or a location. #4-Medication profile dated 01/10/25 includes Triamcinolone Acetonide 0.1% apply topically to affected area twice daily. The order does not include an amount or a location. #5-Medication profile dated 11/08/24 includes Diclofenac Sodium 3% topical gel 2 grams topically to affected area twice daily as needed. The order does not include a location or an indicator.”

“Upon patient record review, 2 of 14 (Patient #3,7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. #3-Patient reported on 03/03/25 that pain was not managed on current regimen and Tramadol 50 mg daily as needed was ordered. There is no evidence in the chart that follow-up took place to determine if the new medication was effective. #7-Patient reported on admission that pain was a 5/10 and controlled “fairly well.” There is no evidence that the nurse followed up to determine if the patient was satisfied with the current regimen or if the patient felt a 5/10 was an acceptable pain level.”

“Upon patient record review, 3 of 14 (Patient #3,4,5) 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. #3-Plan of care dated 02/25/25 includes Diclofenac Sodium 1% topical gel, apply topically to affected area twice daily. The order does not include an amount or a location. #4-Plan of care dated 01/10/25 includes Triamcinolone Acetonide 0.1% apply topically to affected area twice daily. The order does not include an amount or a location. #5-Plan of care dated 11/08/24 includes Diclofenac Sodium 3% topical gel 2 grams topically to affected area twice daily as needed. The order does not include a location or an indicator.”

“Upon patient record review, 11 of 14 (Patient #1,2,4,5,6,7,8,9,10,13) 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. #1-Plan of care dated 02/18/25 does not include DME and patient requires a walker. #2-Plan of care dated 02/10/25 does not include DME and patient requires walker and shower chair. #4-Plan of care dated 01/10/25 does not include DME and patient requires a walker. #5-Plan of care dated 11/08/24 does not include DME and patient requires a walker, shower chair, nebulizer, oxygen concentrator, portable E tank and a bedside commode. #6-Plan of care dated 02/19/25 does not include DME and patient requires a cane, shower chair and walker. #7-Plan of care dated 02/08/25 does not include DME and patient requires a cane, walker and shower chair. #8-Plan of care dated 02/08/25 does not include DME and patient requires a walker and shower chair. #9-Plan of care dated 01/26/25 does not include DME and patient requires a cane, walker and geri-chair. #10-Plan of care dated 01/25/25 does not include DME and patient requires a cane. #13-Plan of care dated 02/04/25 does not include DME and patient requires a cane, walker and shower chair.”