Trinity Hospice

“Upon patient record review, 3 of 17 (Patient # 7, 8, and 11) 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: Patient 7: There is evidence on 02/01/24 the medication profile contains an order for MiraLAX with no diluent. Patient 8: There is evidence on the medication profile contains an order for MiraLAX with no diluent. Patient 11: The medication profile on 06/05/25 contains multiple orders for acetaminophen 650mg Rectally every 4 hours prn and Hydrocodone 5-325mg every 8 hours with no maximum daily limit for acetaminophen.”

“Upon patient record review, 2 of 17 (Patient # 6 and 13) 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 6: There is evidence on the POC 01/08/25 contains an order for Clopidogrel with no risk for bleeding on the POC. Patient 13: There is evidence on the POC on 01/18/25 contains an order for Eliquis with no risk for bleeding on the POC.”

“Upon patient record review, 5 of 17 (Patient #2, 6, 7, 8 and 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 medications and treatments. Patient 2: The POC on 04/26/25 contains an order for colostomy care with no directives of what type of care to provide and who is to provide the care and an additional order to change foley every 30 days with no evidence of directives of size, balloon and care of foley. Patient 6: The POC on 01/14/25 contains an order for foley care every 30 days with no evidence of directives of size, balloon and care of foley. Patient 7: There is evidence on 02/01/24 the POC contains an order for MiraLAX with no diluent. Patient 8: There is evidence the POC contains an order for MiraLAX with no diluent. The POC on 6/15/25 contains an order for foley care with no evidence of directives of size, balloon and care of foley. Patient 11: The POC on 06/05/25 contains multiple orders for acetaminophen 650mg every 4 hours and Hydrocodone 5-325 with no maximum daily limit for acetaminophen.”

“Upon patient record review, 4 of 17 (Patient # 5, 6, 11 and 13) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 5: The Aide POC on 12/28/24 contains orders with tasks written “as requested per patient or family request” for skin care, shampoo, nail, oral, and denture care. There is no evidence of patient’s cognitive or functional level to determine. Patient 6: The Aide POC on 01/15/25 contains orders with tasks written “as requested per patient or family request” for skin care, shampoo, nail, oral, and denture care. There is evidence of patient’s cognitive status unresponsive and functional level totally dependent. Patient 11: The Aide POC on 06/06/25 contains tasks including bathing, nail, oral, shampoo and shave per patient request. Options for both shower as tolerated per patient request and complete bed bath as requested by patient. Patient 13: The Aide POC on 01/18/25 includes tasks for nail, oral, shampoo and skin care per patient or family request. There is evidence of patient’s impaired cognitive status and functional limit is totally dependent.”

“Upon patient client record review, 2 of 17 (Patient # 6 and 10) 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 6: There is evidence of an unclear order on 01/08/25 for oxygen ordered 2-5 L continuous as needed PRN. Patient 10: There is evidence of an unclear order on 2/21/25 for oxygen ordered 2-5 L continuous as needed PRN.”