Gateway Hospice

“Upon patient record review, 4 of 17 (Patient #4,14,15,16) 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 #4, 3/27/24 Nursing visit documentation states continue with antibiotic. No evidence of antibiotic added to medication profile. Patient #14, Medication order on 6/26/23 states morphine 5mg Q4 PRN, Lorazepam 0.5mg Q6 PRN, d/c Lasix 40mg; add Lasix 80mg. No evidence of time/frequency or route documented and reason for PRN. No documentation of liquid concentration. Medication documented with time, route and morphine concentration of 100mg/5ml on medication profile. Patient #15, Medication order on 12/29/23 states New order obtained. Add oxygen 2l cont. No evidence of route for oxygen. Patient #16, Order on 10/13/23, states O2 order. Medication Profile states oxygen 2-4l as needed hypoxia. No evidence of route.”

“Upon patient record review, 3 of 17 (Patient #1,10,17) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1, Order on 3/1/24 MSW effective 3/1/24, 4 PRN. No evidence of scheduled frequency with PRN visits. Patient #10, SC frequency order on 8/17/23 to 9 PRN. No evidence of scheduled frequency with PRN visits and 9 PRN is too high for an individualized plan of care. Patient #17, Upon recertification MSW frequency 2 PRN effective 4/1/24. No evidence of scheduled frequency with PRN visits.”

“Upon patient record review, 3 of 17 (Patient #4, 14, 16) 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 #4, No evidence of antibiotic order and patient wound orders state right lower leg, cleanse with wound cleanser, apply medi-honey to wound, cover with absorbent dressing, apply compression stockings, change 3x/week and as needed. Left lower leg, cleanse with wound cleanser, apply triple antibiotic to left lower leg, cover well. Apply compression stocking. Change 3x/week and PRN. No evidence of in the order of what wound application covering to be used prior to compression stocking being placed on left lower leg. Patient #14, Incomplete order for Lasix, missing the route and time. Patient #16, Incomplete order for Oxygen missing the route and frequency/duration.”

“Upon patient record review, 4 of 17 (Patient #4,6,7,11) 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 #4, Plan of care documents DME as incontinence, skin care. Initial RN visit documents bed rails, hospital bed, overbed table. No evidence of these items on POC. Patient #6, Plan of care documents DME as incontinence. Initial RN visit documents alternate pressure pad/pump, bed rails, hospital bed, overbed table. No evidence of these items on the POC. Patient #7, Plan of care documents DME as incontinence, urology. Initial RN visit documents alternate pressure pad/pump, commode, hospital bed, IV pole. No evidence of these items on the POC. Patient #11, Plan of care documents DME as incontinence. Initial RN visit documents alternate pressure pad/pump, hospital bed, overbed table, oxygen concentrator, wheelchair. No evidence of these items on the POC.”

“Upon patient record review 9 of 17 (Patient #2,4,9,10,12,13,14,16,17) 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 #2, Care plan states shampoo weekly. Aide completed shampoo on 3/18, 3/19, 3/20. Patient #4, Care plan states change linens weekly, Aide completed 1/22 and 1/26. Patient #9, No evidence Aide completed care as directed on care plan. On 10/16/23, Aide documented shampoo No, shaving No, oral care No, shower No, not required this visit. No evidence aide notified RN of task that were not completed. Patient #10, Care plan states nail care 1x/week, shave 2x/week. Aide completed these tasks on 8/14, 8/16, 8/18/23. Patient #12, Care plan states shampoo; weekly, shaving; weekly. On 12/19 and 12/22/23, Aide documented shampoo as yes, shower as no; already completed and shaving as yes. Patient #13, No evidence Aide completed care as directed on care plan. 6/26 and 6/30 date of last BM documented as no; no BM this shift. 6/26 and 6/30, documented stand by assist no; patient is bedbound. Patient #14, Care plan states nail care 1x/week. Nail care completed on 8/22 and 8/25. Patient #16, Care plan states nail care 1x/week. Nail care completed on 12/12, 12/13, 12/14. Patient #17, No evidence Aide completed care as directed on care plan. On 3/29, Aide documented oral care No, not required, turn and reposition, No, not required.”

“Upon patient client record review, 4 of 17 (Patient #1,4,6,8) 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, No evidence of SC and MSW signature on IDG note on 12/29/23 and 2/23/24. Patient #4,Visit on 3/29/24 documents wound care provided per order and tolerated without pain. Documentation not specific for wound care being provided. Patient #6, No evidence of MSW signature on IDG note on 12/29/23 and 1/16/24. Patient #8, No evidence of SC signature on IDG note on 11/3/23. No evidence of MSW and SC signature on IDG note on 12/29/23.”