Tribute Hospice and Palliative Care

“Upon patient record review, 12 of 19 (Patient #1,#2,#3,#4,#5,#10,#13,#14,#16,#17,#18,#19) 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. Patient #1: During home visit medication profile reconciliation found: Pt taking D3 1,000 IU one PO Q day, not on medication profile. Medication profile included Atorvastin Calcium 10 mg one PO Q HS, none in home and pt. is not taking. Corrected on site. Patient #2: Medication profile dated 2/2/2024 included Morphine sulfate 100mg/5ml, admin 0.25-1ml SL Q 2 hr. PRN pain or SOB, dated 3/11/2024 included Tylenol #3 one PO Q 4-6 hrs. PRN pain, dated 3/20/2024 included Hydrocodone 7.5/325mg 1-2 tabs PO Q 6 hrs. PRN pain. No evidence of parameters of which medication to administer and when. Corrected on site. Patient #3: During home visit medication profile reconciliation found: Pt taking Meloxicam 15mg one PO QD, not on medication profile, On profile two duplicate orders for Zofran/Ondansetron 4mg one tab PO PRN N/V Q 6 hrs.- none in home and pt. is not taking per caregiver, On profile Imodium AD-2mg take two tabs PO after 1st loose stool the one tab with each subsequent loose BM not to exceed 8 tabs in 24 hrs.-none in home pt. not taking, on profile Atorvastin 10mg one PO QD HS- none in home pt. is not taking. Medication profile dated 5/29/2024 included O2 2-5 LPM via NC for SOB, pt. resides in ALF, no parameters for what dose to give and when. Corrected on site. Patient #4: During home visit medication profile reconciliation found: Pt taking Magnesium liq. drops one dropperful 1,000mg PO QD and Ducolax soft chews 1200mg two chews PO PRN constipation, not on medication profile. On profile and not taking are Donepezil HCL 5mg one PO QD and Metoprolol succinate ER 25mg one PO QD. Corrected on site. Patient #5: medication profile dated 3/29/2024 included Tylenol #3 one PO Q 6 hrs. PRN pain, dated 5/2/2024 include Morphine sulfate 100mg/5ml 0.25-1 ml PO Q 2-4 Hrs. PRN pain. No evidence of parameters for which medication to give and when. Corrected on site. In addition, Order dated 4/16/2024 includes O2 2-4 LPM via NC as needed for SOB. On nurses notes dated 5/13/2024 and 5/31/2024 “O2 at 8LPM continuous”, no evidence of an order for this. Patient #10: Medication profile dated 5/24/2024 included O2 2-5LPM via NC as needed. No evidence of an indication for O2, and 3/13/2024 Bio freeze roll on external gel 4% one dose as directed topically to affected area. No evidence of a frequency or an area to apply the ointment. Corrected on site. Patient #13: SOC 11/14/2022, first evidence of a medication profile occurred on 5/3/2023. Patient #14: Medication profile dated 3/14/2024 included Morphine sulfate 100mg/5ml, admin 0.25ml SL Q 2-4 hr. PRN pain or SOB, dated 3/18/2024 included Tylenol #3 one PO Q 6 hrs. PRN pain. No evidence of parameters for which medication to give and when. Corrected on site. Patient #16: Order dated 11/18/2023 for O2 2LPM via NC PRN, no evidence of a route or indication for use. Patient #17: Medication profile dated 10/24/2023 included Morphine sulfate 100mg/5ml, admin 0.25ml SL Q 2 hr. PRN pain or SOB, dated 10/24/2023 included Tylenol #3 one PO Q 4 hrs. PRN pain. No evidence of parameters for which medication to give and when. Patient #18: Medication profile dated 8/31/2022 included the following meds: Hydrocodone 5-325 mg one PO Q 8 hrs. PRN pain, Tylenol 650MG one PO Q 8 hrs. PRN pain, and Tramadol 50mg one PO Q 6 hrs. PRN pain. No parameters for which medication to give and when. Patient #19: Medication profile dated 10/30/2022 included Morphine sulfate 20mg/5ml, admin 0.25-1 ml SL Q 2-4 hr. PRN pain or SOB, dated 11/4/2022 included Tramadol 50mg two tabs PO Q 4 hrs. PRN pain. No evidence of parameters for which medication to give and when. Dated 10/30/2023 included O2 2-10 LPM NC PRN, No evidence of parameters for dosing or indications for use.”

“Upon patient record review, 11 of 19 (Patient #2,#3,#6,#8,#9,#10,#11,#13,#15,#16,#18) 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 #2: On SOC SN assessment identified pt at moderate risk for pressure ulcers. The POC has no evidence of a problem/interventions/goals for skin integrity related to pressure ulcer prevention. Corrected on site. Patient #3: On SOC SN assessment identified Braden score 18 at risk for pressure ulcer, difficulty swallowing, fall risk of 7>4 at risk for falls. The POC has no evidence of problem/intervention/goals for skin integrity relation to prevention of pressure ulcers (added later on 5/14/2022), risk of aspiration (added 10/2/2022), fall risk (added 6/20/2022). Patient #6: MSW identified at SOC 5/1/2024 and 2nd visit on 5/31/2024 no DNR- per daughter pt. did not want to be resuscitated, and no advance directives in place. Notes include to f/u next visit with son. No evidence on POC of problem/intervention/goals for funeral planning or assisting with advance directives. Corrected on site. Patient #8: SN identified at SOC difficulty swallowing food, pt. is taking Plavix and Aspirin for blood thinning, MSW identified no funeral plans in place. There is no evidence on the POC for problem/interventions/goals for risk of aspiration, risk of bleeding or funeral planning. Corrected on site. Patient #9: SN identified at SOC difficulty chewing and swallowing food, and high risk for pressure ulcers. No evidence on the POC for problem/interventions/goals for skin integrity/risk of pressure ulcers, or aspiration risk. Corrected on site. Patient #10: SN identified at SOC moderate risk for pressure ulcers, MSW identified no funeral planning in place. No evidence on the POC for problem/interventions/goals for skin integrity/risk of pressure ulcers, or funeral planning. Corrected on site. Patient #11: SN identified at SOC 3/8/2024 high risk for pressure ulcers and risk for falls. No evidence on the POC for problem/interventions/goals for skin integrity/risk of pressure ulcers (added 3/27/2024), or risk of falls (Added 5/1/2024). Patient #13: SN identified at SOC difficulty chewing and swallowing food, and pt. on O2. No evidence on POC of problem/intervention/goals for risk of aspiration or respiratory/O2 use. Corrected on site. Patient #15: SN identified at SOC two pressure ulcers and high risk of same, Peg tube in place, Foley in place, seizure disorder,O2 use and MSW identified no funeral home plan in place. No evidence on the POC of problem/interventions/goals for skin integrity/wounds, peg tube, Foley, Seizure disorder, O2 use or funeral home planning. Patient #16: SN identified at SOC seizure disorder- takes two medications for seizures, is using O2, and has difficulty swallowing food. No evidence on POC of problem/intervention/goals for risk of aspiration, seizures or respiratory/O2 use. Patient #18: SN identified at SOC difficulty swallowing food, and moderate risk for pressure ulcers, and using O2. No evidence on the POC for problem/interventions/goals for skin integrity/risk of pressure ulcers, aspiration risk, or respiratory/O2 use.”

“Upon patient record review, 12 of 19 (Patient #1,#2,#3,#4,#5,#10,#14,#15,#16,#17,#18,#19) 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 #1: During home visit medication profile reconciliation found: Pt taking D3 1,000 IU one PO Q day, no order for this . Corrected on site. Patient #2: Order dated 2/2/2024 included Morphine sulfate 100mg/5ml, admin 0.25-1ml SL Q 2 hr. PRN pain or SOB, dated 3/11/2024 included Tylenol #3 one PO Q 4-6 hrs. PRN pain, dated 3/20/2024 included Hydrocodone 7.5/325mg 1-2 tabs PO Q 6 hrs. PRN pain. No evidence of parameters of which medication to administer and when. Corrected on site. Patient #3: Order dated 5/29/2024 included O2 2-5 LPM via NC for SOB, pt resides in ALF, no parameters for what dose to give and when. Corrected on site. During home visit medication profile reconciliation found: Pt taking Meloxicam 15mg one PO QD, no order, Corrected on site. Patient #4: During home visit medication profile reconciliation found: Pt taking Magnesium liq. drops one dropperful 1,000mg PO QD and Ducolax soft chews 1200mg two chews PO PRN constipation- no order. Patient #5: Order dated 3/29/2024 included Tylenol #3 one PO Q 6 hrs. PRN pain, dated 5/2/2024 include Morphine sulfate 100mg/5ml 0.25-1 ml PO Q 2-4 Hrs. PRN pain. No evidence of parameters for which medication to give and when. Corrected on site. Patient #10: Order dated 5/24/2024 included O2 2-5LPM via NC as needed. No evidence of an indication for O2, and 3/13/2024 Bio freeze roll on external gel 4% one dose as directed topically to affected area. No evidence of a frequency or an area to apply the ointment. Corrected on site. Patient #14:Order dated 3/14/2024 included Morphine sulfate 100mg/5ml, admin 0.25ml SL Q 2-4 hr. PRN pain or SOB, dated 3/18/2024 included Tylenol #3 one PO Q 6 hrs. PRN pain. No evidence of parameters for which medication to give and when. Corrected on site. Patient #15: Wound order in place with no frequency. Patient #16: Order dated 11/18/2023 for O2 2LPM via NC PRN, no evidence of a route or indication for use. Patient #17:Order dated 10/24/2023 included Morphine sulfate 100mg/5ml, admin 0.25ml SL Q 2 hr. PRN pain or SOB, dated 10/24/2023 included Tylenol #3 one PO Q 4 hrs. PRN pain. No evidence of parameters for which medication to give and when. Dated 10/24/2023 O2 2-5 LPM PRN. No evidence of an indication for use or route. Patient #18: Order dated 8/31/2022 included the following meds: Hydrocodone 5-325 mg one PO Q 8 hrs. PRN pain, Tylenol 650MG one PO Q 8 hrs. PRN pain, and Tramadol 50mg one PO Q 6 hrs. PRN pain. No parameters for which medication to give and when. Patient #19: Order dated 10/30/2022 included Morphine sulfate 20mg/5ml, admin 0.25-1 ml SL Q 2-4 hr. PRN pain or SOB, dated 11/4/2022 included Tramadol 50mg two tabs PO Q 4 hrs. PRN pain. No evidence of parameters for which medication to give and when. Dated 10/30/2023 included O2 2-10 LPM NC PRN, No evidence of parameters for dosing or indications for use.”

“Upon patient record review, 4 of 19 (Patient #3,#5,#10,#11) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #3: Pt SOC 6/1/2022, Oxygen order added 5/29/2024, no evidence on POC of problem/interventions/goals for respiratory status and oxygen. Corrected on site. Patient #5: Pt SOC 3/29/2024, O2 order added 4/16/2024, at risk for seizures. No evidence on POC of problem/interventions/goals for Seizure/neuro and respiratory status and oxygen (added O2 5/15/2024). Patient #10:Pt SOC 3/7/2024, O2 order added 5/24/2024/2024, no evidence on POC of problem/interventions/goals for respiratory status and oxygen. SN became aware 4/17/2024 pt. was driving independently and documenting risk of safety to pt. and others. There is no evidence on the POC for problem/interventions/goals for maintaining pt. and others safety related to pt. driving. Corrected on site. Patient #11:Pt SOC 3/8/2024, O2 order added 4/25/2024, no evidence on POC of problem/interventions/goals for respiratory status and oxygen. Corrected on site.”

“Upon patient record review, 8 of 19 (Patient #5,#8,#9,#13,#15,#16, #18, #19) 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 #5: SN identified pt. at risk of seizures on 5/8/2024, no evidence of seizure precautions on aides POC/Assignment sheet. Corrected on site. Patient #8: SN identified pt. at risk of aspiration, pt. on blood thinners. No evidence of aspiration or bleeding precautions on aide POC/Assignment sheet. Corrected on site. Patient #9: SN identified pt. at risk of aspiration, no evidence of aspiration precautions on on aide POC/Assignment sheet. Corrected on site. Patient #13: SN identified pt. at risk of aspiration, no evidence of aspiration precautions on on aide POC/Assignment sheet. Corrected on site. Patient #15: SN identified pt. at risk for seizures, no evidence seizure precautions on on aide POC/Assignment sheet. Patient #16: SN identified pt. at risk of aspiration and has seizure disorder. No evidence of aspiration precautions or seizure precautions on on aide POC/Assignment sheet. Patient #18: SN identified pt. at risk of aspiration and using O2. No evidence of aspiration precautions or oxygen precautions on on aide POC/Assignment sheet. Patient #19: SN identified O2 use, no evidence of oxygen precautions on aide POC/Assignment sheet.”