Coxhealth at Home

“Upon patient record review, 5 of 19 (Patient #3, #4, #5, #7, #10) 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 #3: There is evidence on the medication record that the route for Atropine drops was ophthalmic rather than oral. In addition, there was no reason indicated for PRN medication Atropine. corrected on site Patient #4: There is evidence on the medication record that Sustain eye drops every 4 hours as needed did not indicate which eye or eye(s). corrected on site Patient #5: There is evidence in the medication record that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. corrected on site Patient #7: There is evidence in the medication record that Acetaminophen suppository PRN, did not include a reason for use. In Addition, Carvedilol hold for hypotension did not identify a blood pressure reading for hold. corrected on site Patient #10: There is evidence in the medication record that Acetaminophen suppository PRN one every 6 months as needed, this PRN did not include a reason for use. In addition, Atropine 1% eye was written as ointment rather than drops and the route was ophthalmic rather than oral.”

“Upon patient record review, 6 of 19 (Patient #3, #4, #5, #7, #10, #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 #3: There is evidence on the plan of care that the route for Atropine drops was ophthalmic rather than oral. In addition, there was no reason indicated for PRN medication Atropine. corrected on site Patient #4: There is evidence on the plan of care that Sustain eye drops every 4 hours as needed did not indicate which eye or eye(s). corrected on site Patient #5: There is evidence in the plan of care that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. corrected on site Patient #7: There is evidence in the plan of care that Acetaminophen suppository PRN, Haldol, PRN and Bisacodyl suppository PRN did not include a reason for use. In Addition, Carvedilol hold for hypotension did not identify a blood pressure reading for hole. corrected on site Patient #10: There is evidence in the medication record that Acetaminophen suppository PRN one every 6 months as needed. In addition, this PRN did not include a reason for use. In addition, Atropine 1% eye was written as ointment rather than drops and the route was ophthalmic rather than oral. corrected on site Patient #12: There is evidence in the medication record that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. In addition, Nitroglycerine 0.4 mg SL q 5 min as needed for chest pain, did not include a total dose. In addition, Oxygen indicated the route was oral. corrected on site”

“Upon patient record review, 3 of 19 (Patient #1, #6, #7) 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: There is evidence in the Plan of Care that the patient is at risk for bleeding. The HHA plan of care did not include bleeding precautions. corrected on site Patient #6: There is evidence in the Plan of Care that the patient is using Oxygen. The HHA plan of care did not include Oxygen precautions. corrected on site Patient #7: There is evidence in the Plan of Care that the patient had a foley catheter inserted on 6/30/24. On 7/8/24, the HHA plan of care continued to state incontinence care and was not updated to foley care. corrected on site”

“Upon patient record review 2 of 19 (Patient #3, #7) 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 #3: There is evidence in the record that the HHA plan of care ordered shampoo 1Xweek. The week of 7/14/24, the HHA completed a shampoo 2X. Patient #7: There is evidence in the record that the HHA plan of care ordered 2 visits per week. The week of 6/30/24 there was one HHA visit.”

“Upon patient client record review, 14 of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #16, #17, #18, #19) 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-#10 and #16-#19: There is evidence in the record that when agency staff sign the Election of Benefits, credentials are not included.”