Bay Hospice Care, Inc.

“Upon patient record review, 4 of 5 (Patient #1,#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 Patient #1: The medication list indicated Miralax powder 17g 1 pack po daily PRN constipation; however, instructions for reconstitution of this powdered medication were not included on the medication list. (corrected onsite) Patient #3: The patient’s allergies have not been reviewed since the time of hospice admission; therefore, actual or potential interactions cannot be assessed. Additionally, the medication list indicated Miralax powder 17g 1 pack po daily PRN constipation; however, instructions for reconstitution of this powdered medication were not included on the medication list. Finally, the medication list also indicated Nystatin powder 100,000 units/g apply daily PRN redness; however, the location ordered for use does not appear on the medication list. (corrected onsite) Patient #4: The medication list indicated Miralax powder 17g 1 pack po daily PRN constipation; however, instructions for reconstitution of this powdered medication were not included on the medication list. (corrected onsite) Patient #5: The medication list indicated Miralax powder 17g 1 pack po daily PRN constipation; however, instructions for reconstitution of this powdered medication were not included on the medication list. (corrected onsite)”

“Upon patient record review, 1 of 5 (Patient #2) 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 #2: The RN made a visit to complete the comprehensive initial assessment on 07.06.2024; the next update to the comprehensive assessment was completed by the RN on 09.04.2024, which exceeds the 15 day allowable limit.”

“Upon patient record review 2 of 5 (Patient #1, #3) 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 #1: On 08.13.2024, the plan of care was updated with orders for the aide to visit the patient 2 x weekly. However, since the week of 08.25.2024, the aide has only seen the patient 1 x weekly. The DPCS verified that the patient’s POA requested the change to 1 x weekly visits and the plan of care has failed to be updated; the plan of care was updated accordingly during the survey. Patient #3: The plan of care indicates the aide is to visit the patient 2 x weekly. However, the aide has been seeing the patient 3 x weekly on an ongoing basis. The RN updated the plan of care accordingly.”

“Upon patient client record review, 3 of 5 (Patient #1,#2,#3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: The patient was admitted for hospice services onc7/29/24; however, the election form did not indicate the date the date hospice services were initiated. Patient #2: The patient was admitted for hospice services on 7/6/24; however, the election form did not indicate the date the date hospice services were initiated. Patient #3: The patient was admitted for hospice services on _6/18/24; however, the election form did not indicate the date the date hospice services were initiated.”