With Love Hospice Inc.

“Upon patient record review, 3 of 5 (Patient #1, #2,#3) 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 #1: Medication profile dated 3/23/2024- SOC includes Clindamycin topical cream, apply to affected areas once daily for skin irritation, no evidence of an area to apply. On HV medication reconciliation the following meds were found without no evidence of being included on medication profile: Trazadone 50mg one PO at HS, Torsemide 100mg one PO BID dated 1/16/2024, Digoxin 0.125mg One PO QD, Gabapentin One PO TID dated 1/16/2024, Vitamin D3 50,000IU one PO Q month, Folate 1,333mcq One PO QD, Zinc 50 mg on PO QD, Omega 3-Acid 1 GM cap 2 PO QD, Multi vitamin one PO QD, and Humulin Insulin to sliding scale. Patient #2: On HV medication reconciliation the following meds were found without evidence of being included on the medication profile: Omega3 1 GM cap 2 PO BID, Benadryl 25mg one PO HS, Multivitamin one PO QD, and B-Complex one PO QD. Patient #3:On HV medication reconciliation the following med were found without evidence of being included on the medication profile: Epleronone 25mg PO QD. For Home visits #1, #2, #3 patient/care giver denied any recent changes, all three patients had meds older than last SN visit that were not included on the current medication profile.”

“Upon patient record review, 2 of 5 (Patient #1, #2) 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 #1: SOC SN assessment identifies pt as fall risk. No evidence of problem/goals/interventions for fall risk on POC. Patient #2: SOC SN assessment identifies pt as fall risk. No evidence of problem/goals/interventions for fall risk on POC.”

“Upon patient record review, 2 of 5 (Patient #4, #5) 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 #4: SOC POC/IDG included orders for visits: MSW 1 PRN and SC 1 PRN. Patient #5: SOC POC/IDG included orders for visits: MSW 1 PRN and SC 1 PRN.”

“Upon patient record review, 3 of 5 (Patient #1,#2,#3) 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: Order dated 3/23/2024- SOC includes Clindamycin topical cream, apply to affected areas once daily for skin irritation, no evidence of an area to apply. On HV medication reconciliation the following meds were found without no evidence of an order: Trazadone 50mg one PO at HS, Torsemide 100mg one PO BID dated 1/16/2024, Digoxin 0.125mg One PO QD, Gabapentin One PO TID dated 1/16/2024, Vitamin D3 50,000IU one PO Q month, Folate 1,333mcq One PO QD, Zinc 50 mg on PO QD, Omega 3-Acid 1 GM cap 2 PO QD, Multi Vitamin one PO QD and Humulin Insulin to sliding scale. Patient #2: On HV medication reconciliation the following meds were found without evidence of an order: Omega3 1 GM cap 2 PO BID, Benadryl 25mg one PO HS, Multivitamin one PO QD, and B-Complex one PO QD. Patient #3:On HV medication reconciliation the following med were found without evidence of an order: Eplerenone 25mg PO QD.”

“Upon patient client record review, 1 of 5 (Patient #4) 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 #4: Live DC occurred 3/29/2024. Discharge Live note includes: Discharge summary along with med profile and POC sent to physician 7/28/2023. IDG members and physician notified 11/28/2023. Note has pt. DOB as 3/21/1969. (pts actual DOB is 3/21/1987)”