Quality of Life Hospice & Palliative Care LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the patient’s current medications were included in the drug profile. Agency policy Medications-Profile, no date, stated in part, “A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy.” Clinical Record 1: The patient elected the hospice benefit on 04/18/2024 with diagnoses of congestive heart failure and cerebral vascular accident. The plan of care dated 04/18/2024 to 06/16/2024 included an order for “Oxygen at 2 liters via nasal cannula.” The medication profile dated 04/18/2024 did not include Oxygen. During an interview and record review on 07/30/2024, the Clinical Director reviewed the record and confirmed that Oxygen was not included in the medication profile.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed with aide services provided, the agency did not ensure the Registered Nurse developed patient specific care instructions for the Hospice Aide. Clinical Record 1: The patient elected the hospice benefit on 04/18/2024 with diagnoses of congestive heart failure and cerebral vascular accident. The plan of care dated 04/18/2024 to 06/16/2024 included an order for “Oxygen at 2 liters via nasal cannula.” The aide care plan assignment completed by the RN and dated 04/18/2024 did not include information to the aide related to the patient’s Oxygen use and if the patient would need to remain on oxygen during cares, such as a bath. The aide visits dated 06/20/2024, 06/22/2024, and 06/27/2024 included documentation that “hair care completed.” The RN did not include hair care instructions on the aide care plan assignment. During an interview and record review on 07/30/2024, the Clinical Director reviewed the record and stated, “Hair care and oxygen instructions are not on the aide care plan, but they should have been.””

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure physician orders were included in the patient’s clinical record. Clinical Record 1: The patient elected the hospice benefit on 04/18/2024 with diagnoses of congestive heart failure and cerebral vascular accident. The nursing note dated 07/10/2024 included documentation that “The patient’s G-tube dressing was changed.” Clinical record review revealed no documented evidence of a physician order to change the G-tube dressing. During an interview on 07/30/2024, the Clinical Director reviewed the record and stated, “There is not a physician’s order in the chart for the G-tube split gauze dressing.””