Unitypoint Hospice

“Upon patient record review, 5 of 19 (Patient #2,#3,#4,#7,#12) 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 medication profile contained Acetaminophen 500mg; however, the instructions for administration was 650mg TID PRN. Also, during medication reconciliation, the facility and hospice medications did not match. The facility medication profile contained Acetaminophen 325mg 2 tabs TID PRN, Acetaminophen 325mg 2 tabs TID scheduled, and ASA 81mg QD; however, there was no evidence of the medications on the hospice medication profile. Patient 3: The medication profile contained cholestyramine oral powder with no instructions to mix with a diluent. Patient 4: The medication profile contained ophthalmic solution eye drops with no instructions for one or both eyes. Patient 7: The medication profile contained Silvadene for contact dermatitis. However, the contact dermatitis was documented as resolved in the plan of care effective 7/19/2026. Patient 12: The medication profile contained Calmoseptine ointment but did not indicate specific area for administration.”

“Upon patient record review, 1 of 19 (Patient #8) 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 8: The patient is a risk for bleeding due to use of ASA and Clopidogrel since admission. There was no evidence of problems, interventions and goals related to the issue included in the plan of care.”

“Upon patient record review, 5 of 19 (Patient #2,#3,#4,#7,#12) 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 medical record contained order for Acetaminophen 500mg; however, instructions to administer 650mg TID PRN. Also, during medication reconciliation, the facility and hospice medications did not match. The facility medical record contained orders for Acetaminophen 325mg 2 tabs TID PRN, Acetaminophen 325mg 2 tabs TID scheduled, and ASA 81mg QD; however, there was no evidence of the medications in the hospice medical record. Patient 3: The medical record contained order for cholestyramine oral powder with no instructions to mix with a diluent. Patient 4: The medical record contained order for ophthalmic solution eye drops with no instructions for one or both eyes. Patient 7: The medical record contained order to apply Silvadene to contact dermatitis. However, the contact dermatitis was documented as resolved in the plan of care effective 7/19/2026. Patient 12: The medical record contained order to apply Calmoseptine ointment to affected area but did not indicate specific area for administration.”

“Upon patient record review, 4 of 19 (Patient #1,#5,#13,#14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1,14: The medical record indicates patient has dysphagia; however, there was no evidence the aide care plan contained instructions for swallowing difficulty or risk of aspiration. Patient 5: Aid care plan contains instructions for wound to right buttock; however, the wound was resolved in the plan of care effective 7/30/2026. Patient 13: The medical record indicates patient taking an anticoagulant; however, there was no evidence the aide care plan contained instructions for bleeding risk.”

“Upon patient client record review, 1 of 19 (Patient #7) 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 7: Wound care order with instructions to change dressing every 3 days; however, care is delineated for RN to change once weekly and CG to change daily when RN doesn’t provide a visit. Also, RN documented TAO applied; however, there was no evidence of this abbreviation on the approved abbreviation policy.”