Ennoble Care

“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 following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and 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 clinical record review, interview, and observation. In 2 of 6 (33%) clinical records reviewed, the agency did not ensure that the drug administration record was updated, which resulted in the medication reconciliation being incomplete. CLINICAL RECORD 1/Home Visit 1: This patient elected the hospice benefit on 11/29/2024 with a terminal diagnosis of senile degeneration of the brain and a secondary diagnosis of Diabetes Type II. This patient resided in an Assisted Living Facility (ALF). A review of the clinical record, the Hospice Medication Administration Record (MAR) dated 01/07/2025 did not include Metformin as noted in the ALF MAR during a home visit conducted on 01/08/2024. During Home Visit 1 (Clinical Record #1) on 01/08/2025 to observe the Registered Nurse (RN) (Personnel Record #2), a review of the Assisted Living Facility (ALF) Medication Administration Record (MAR) included Metformin HCL 500 mg give 1 tablet by mouth in the morning. The ALF Certified Medication Aide (CMA) verified that the patient received this medication. The Hospice MAR as reviewed in the hospice Electronic Medical Record (EMR) did not include Metformin. The RN stated that he did not know the patient was receiving this medication and it was not in the MAR in his EMR. CLINICAL RECORD 2/Home Visit 2: This patient elected the hospice benefit on 11/27/2024 with a hospice diagnosis of unspecified severe protein-calorie malnutrition. A review of the clinical record, the Medication Administration Record (MAR) in the Electronic Medical Record (EMR) reviewed 01/08/2025 included Iron 325 mg 1 tablet every day, Potassium 10 Meq every other day, Metoprolol Tartrate 25 mg 1 tablet 2 times a day by mouth. These medications were marked as discontinued on the MAR in the patient home (printed 09/23/2024). Digoxin 125 mcg 1 tablet by mouth every other day was listed on the MAR in the home but was not listed in the hospice MAR as noted by review of the EMR. Glipizide 10 mg 1 tablet by mouth once a day was started on 09/17/2024 but was marked discontinued in the Hospice MAR as reviewed in the EMR. The home MAR documented Glipizide 10 mg orally by mouth once a day was re-started on 12/04/2024. The Hospice EMR MAR on 01/09/2025 and it did not include Glipizide. During Home Visit 2 (Clinical Record #2) to observe the Certified Nursing Assistant (Personnel Record 3) on 01/08/2025, a review of the patient’s medications was conducted with the Licensed Practical Nurse (LPN) (Personnel Record 11) who was also present during the home visit. It was verified that the following drugs had been discontinued but the Hospice MAR had not been updated: Iron, Potassium, and Metoprolol. It was also verified that the patient was currently taking Glipizide once a day, but the Hospice MAR was not updated to include this change. The Executive Director was interviewed on 01/08/2024 and confirmed that the drug administration records had not been updated which resulted in the medication reconciliation being incomplete.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that include the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records in which bereavement services were to be made available after the death of the patient, the agency did not ensure that bereavement services were made available to the family and other individuals in a written bereavement plan of care. CLINICAL RECORD 5: This patient elected the hospice benefit on 11/22/2024 with a terminal diagnosis of severe protein-calorie malnutrition. This patient expired 12/12/2024. A review of the clinical record revealed there was no documented evidence that a bereavement plan of care was developed to provide for bereavement services to be offered which reflected the needs of the bereaved and the frequency of service delivery. There was no evidence in the clinical record that the bereaved family declined bereavement services. The Bereavement Coordinator was interviewed on 01/09/2025 by phone with the Executive Director present. It was confirmed by the Bereavement Coordinator that the agency did not ensure that a bereavement plan of care was developed to meet the needs of the bereaved family and other individuals.”

“It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) clinical records reviewed that required recertification, there was no documentation that a hospice physician or nurse practitioner (NP) completed a face-to-face encounter with every hospice patient to determine the continued eligibility of that patient prior to the 180th day recertification, and prior to each subsequent recertification as per hospice policy. DOCUMENT 1: Hospice Policy No. 1-007.A stated in part; A face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods. (Revised 05/2024) CLINICAL RECORD 1: This patient elected the hospice benefit on 11/29/2024 with a terminal diagnosis of senile degeneration of the brain. He was admitted to this hospice in the fourth certification period. In review of the clinical record, there was no documented evidence that a face-to-face encounter was conducted prior to admission or recertification. CLINICAL RECORD 3: This patient elected the hospice benefit 11/29/2024 with a terminal diagnosis of hypertensive heart disease with chronic kidney disease stage 4. This admission occurred during the fourth benefit period. A CTI was signed by the Hospice Medical Director on 12/06/2024, but there was no documented evidence that a face-to-face encounter was completed prior to the admission or recertification. The Executive Director was interviewed on 01/08/2025 and confirmed that a face-to-face encounter was not conducted for patients entering the third and all subsequent benefit periods as per hospice policy.”