West River Hospice

“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, 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, observation, and interview. 1 of 19 (5%) clinical records reviewed and an observed home visitrevealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 4/CLINICAL RECORD 7: The patient’s date of hospice election was 10/22/2024. The patient resides in a skilled nursing facility (SNF). The patient’s hospice clinical record medication profile, printed on 03/03/3036, included the following: - haloperidol 2 mg/ml oral concentrate, administer 1 milliliter orally every 6 hours as needed for terminal agitation or nausea, dated 10/22/2024; - hyoscyamine 0.125 mg/ml oral solution, take 1 milliliter orally every 4 hours as needed for terminal secretions, dated 10/22/2024; - Morphine 20 mg/ml oral concentrate, administer 0.25-1 milliliter(s) orally every 2 hours as needed for pain or SOB [shortness of breath], dated 10/22/2024; - Aspi-Cor 81 mg oral delayed release tablet, take 1 tab orally once a day for 731 day(s), dated 10/22/2024 - End Date 10/22/2026; and - Pantoprazole 40 mg oral delayed release tablet, take 1 tab orally once a day for 731 day(s), dated 10/22/2024 - End Date: 10/22/2026. During the observed home visit on 03/04/2026 with the Registered Nurse (RN - Personnel Record 5), the hospice record’s medication profile was compared to the medication list at the facility. Discrepancies were noted between the hospice medication profile and the SNF medication list. The SNF medication list included the following: - Atropine Sulfate 1% opthalmic solution, give 4 drops sublingually every 4 hours as needed for secretions, dated 10/22/2024; - Fleet Enema, give one per rectum prn constipation if no BM [bowel movement] after dulcolax suppository, dated 08/14/2025; - Geri-Tussin oral liquid 100 mg/5 ml, give 10 ml by mouth every 6 hours as needed for cough, dated 03/17/2025; - Imodium A-D oral tab 2 mg; give one tablet by mouth every 4 hours as needed for diarrhea, dated 08/02/2024; - Magnesium Citrate solution lemon, give one application by mouth as needed for constipation, dated 11/22/2021; - Geri-Lanta suspension 200-200-20 mg/5 ml (Alum & Mag Hydroxide - Simethicone), give 30 ml by mouth as needed for indigestion, give 30 ml by mouth every 4 hours as needed for indigestion/nausea, dated 08/14/2025; - Mirtazepine oral tablet 7.5 mg, give one tablet at bedtime, dated 10/22/2024; - Morphine Sulfate 20 mg/ml, give 0.25 ml by mouth every 1 hour as needed for shortness of breath [SOB] or pain, dated 10/25/2024; - Morphine Sulfate 20 mg/ml, give 0.25 ml by mouth every 6 hours for SOB or pain, dated 02/01/2025; - Neurontin capsule 100 mg, give one capsule by mouth twice a day, dated 11/22/2021; and - Zofran 4 mg, give one tablet by mouth every 8 hours as needed for nausea, dated 09/19/2024. The haloperidol, hyoscyamine, Aspi-Cor, and pantoprazole were not listed on the facility’s medication list. The Atropine Sulfate, Fleet Enema, Geri Tussin, Immodium A-D, Magnesium Citrate, Geri-Lanta, Mirtazepine, Neurontin, and Zofran were not listed on the hospice medication profile. Additionally, the morphine sulfate frequencies did not match between the facility’s list and the hospice medication profile. The record lacked evidence that complete, accurate medication reconciliation occurred when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 03/04/2026, the Executive Director/Administrator confirmed that there was no documented evidence that medications were accurately reconciled when new medications were added or when changes were made to existing medications.”

“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: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure the patients’ signed consents included the date of hospice election. CLINICAL RECORD 8: The patient was admitted to services on 04/01/2025. The Election of Benefit Statement was signed and dated 04/01/2025. There was a space for the election date, but it was left blank. CLINICAL RECORD 19: The patient was admitted to services on 07/28/2025. The Election of Benefit Statement was signed and dated 07/28/2025. There was a space for the election date, but it was left blank.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records of discharged patients reviewed revealed that the agency did not ensure the discharge summary, inclusive of all required elements, was forwarded to a facility receiving a hospice patient for care, or to the patient’s community attending physician upon hospice discharge. CLINICAL RECORD 15: The patient resided in a skilled nursing facility and elected the hospice benefit on 04/25/2023. The patient’s date of revocation was 10/09/2025. The discharge summary lacked evidence of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 03/05/2026, the Executive Director/Administrator confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.”