Affinis Hospice, LLC

“Based on policies titled “Initial Assessment/ Comprehensive Assessment” and “Medication Profile,” record review, observations, and staff and family interviews, it was determined that the agency failed to update the comprehensive assessment with medication changes for one patient (P) (P#17) of four patient home observations (P#16, P#17, P#18, P#19). Findings include: Review of the policy titled “Initial Assessment/ Comprehensive Assessment,” dated 2020, revealed the following:Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc.) to identify:• Drug effectiveness• Side effects• Actual or potential drug interactions• Noncompliance with medications• Duplicate therapy• Ineffective therapy• Potential adverse effects• Medication reactions• Drug therapy associated with lab monitoring Review of the policy titled “Medication Profile,” dated 2020, revealed the following:• The nurse will add new/changed medications to the medication profile. Discontinued (“D/C”) medications will be documented and dated. The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the IDG. Clinical record review revealed P#17 was admitted to hospice on 5/16/2023. Review of the medication profile revealed:•Aspirin Low Dose (a medication primarily used to prevent blood clots): 81 mg oral delayed-release tablet; take 1 tab orally once a day. Start date: 5/16/2023•Carubinose (a dietary supplement used to promote urinary tract health and help prevent urinary tract infections): 500 mg tablet; administer 1 tab orally 2 times a day. Start date: 5/16/2023•Methenamine hippurate (a urinary antiseptic used to prevent recurring urinary tract infections): 1 g oral tablet; take 1 tab orally 2 times a day. Start date: 5/16/2023•Nystatin (an antifungal medication used to treat yeast and other fungal infections of the skin): 100,000 units/g topical ointment; apply 2 times a day (apply a thin layer to open, reddened areas on both legs twice a day as needed). Start date 5/30/2024•Vitamin D3 (a form of Vitamin D used in the treatment of specific medical conditions such as osteoporosis and chronic kidney disease): 25 mcg (1000 international units) oral tablet; take 2 tabs orally once a week. Start date 4/12/2024 Review of P#17’s medication profile failed to reveal medication changes made since patient was admitted to hospice services. On 10/28/2025 at 10:45 a.m., an interview was conducted during a home visit with the family member of P#17. Patient’s medications were reviewed with the family member and Registered Nurse (RN) AA and compared with the medication profile. The family member revealed that P#17 no longer takes aspirin, carubinose, methenamine, or Vitamin D3 and no longer uses nystatin on the patient’s legs. The family member explained it had been a while but could not give a specific timeframe when the medications were stopped. On 10/29/2025 at 9:45 a.m., an interview was conducted at the agency with RN AA, who verbalized she had updated the medication profile for P#17 to reflect current medications.”

“Based on record review, staff and family interviews, it was determined that the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, including updating the comprehensive assessment with medication changes and ensuring patients do not have outdated or unusable medications. The agency failed to ensure that the governing body is responsible for the day-to-day operations of the hospice. Findings include: Cross reference L0533 relating to the agency failed to update the comprehensive assessment with medication changes for one patient (P) (P#17). Cross reference L693 relating to the agency failed to ensure outdated or unusable medications ordered by the agency were not in the home for P#17.”

“Based on policy titled “Medication Profile,” record review, observations, and staff and family interviews, it was determined that the agency failed to ensure patients do not have outdated or unusable medications in the home that are ordered by the agency. Specifically, one patient (P) (P#17) of four patients observed had morphine (a powerful opioid medication used to treat severe pain) that expired 9/2024. Findings include: Review of the policy titled “Medication Profile,” dated 2020, revealed the following:• The RN or LPN reviews the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effects, storage, and administration of medications. Clinical record review revealed P#17 was admitted to hospice on 5/16/2023. The medication profile revealed:• Morphine (a powerful opioid medication used to treat severe pain): 20mg/ml oral concentrate; administer 0.25 milliliters orally every 4 hours as needed for moderate pain or dyspnea. Start date: 5/16/2023 During a home visit with P#17 on 10/28/2025 at 10:45 a.m., medications were reviewed with Registered Nurse (RN) AA and the family and compared with the agency’s medication profile. A family member produced a 30 ml bottle of morphine, revealing it was delivered at the time of P#17’s admission to hospice in 2023. Further observation revealed the unopened morphine had an expiration date of 9/2024. On 10/28/2025 at 10:45 a.m., during P#17’s home observation visit, an interview was conducted with RN AA, who acknowledged that the morphine had expired over a year ago, and that she had not checked the morphine during regular visits. On 10/29/2025 at 9:45 a.m., an office interview was conducted with RN AA, who verbalized she had instructed P#17’s family member to destroy the expired morphine and had ordered a new bottle for delivery. On 10/29/2025 at 9:45 a.m., an interview was conducted at the agency with the Administrator and Vice President (VP), who confirmed that nurses should be checking all medications on every visit.”