Preferred Peaceful Transitions Home Health Care Inc.

“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 and 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 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, document review and interview. In 3 of 14 (21%) clinical records reviewed the agency did not ensure that the drug profile included the patient’s current prescription and over-the-counter drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The agency’s policy (PC.M55) (2023) required in part, “ 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. The medication profile must include all current patient medications, date prescribed or taken, name of medication, dose, frequency, drug classification, date discontinued, drug and/or food allergies.” Clinical Record 2: The Plan of Care (POC) for the benefit period of 05/02/2024 to 07/30/2024, included an order for oxygen. The comprehensive assessment drug profile dated 05/02/2024 did not include oxygen. Clinical Record 3: The POC for the benefit period of 08/22/2024 to 11/19/2024, included an order for oxygen. The comprehensive assessment drug profile dated 08/22/2024 did not include oxygen. Clinical Record 5: The POC for the benefit period of 10/03/2024 to 12/31/2024, included an order for oxygen. The comprehensive assessment drug profile dated 10/03/2024 did not include oxygen. During a joint record review and interview on 10/16/2024, the Administrator and Director of Clinical Services confirmed the comprehensive assessment drug profiles did not include oxygen as ordered on the plan of care.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse 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 7 of 10 (70%) clinical records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the registered nurse (RN) provided the aides with specific patient care instructions. Clinical Record 2: A review of the Plan of Care (POC) for the episode 07/31/2024 to 10/28/2024 revealed the patient had a diagnosis of chronic combined systolic and diastolic heart failure. The orders on the POC included oxygen and Aspirin 81 mg by mouth daily. The aide care plan did not include oxygen safety or bleeding precautions. Clinical Record 3: A review of the Plan of Care (POC) for episode 08/22/2024 to 11/19/2024 revealed the patient had a diagnosis of malignant lung cancer and was on continuous oxygen, required a walker or wheelchair for transfers, and had a history of falls. The aide care plan did not include oxygen safety or fall precautions. Clinical Record 8: A review of the Plan of Care (POC) for episode 07/25/2024 to 10/22/2024 revealed the patient had a diagnosis of heart failure and atrial fibrillation and was on the anticoagulant, Warfarin. The Aide care plan did not include bleeding precautions. Clinical Record 9: A review of the Plan of Care (POC) for the episode 09/24/2024 to 12/22/2024 revealed the patient had a diagnosis of esophageal cancer and was admitted with wounds to the medial buttocks, coccyx, and right shin. The aide care plan did not include aspiration precautions or instructions for the aide if the dressings came off during the bath. Clinical Record 10: A review of the Plan of Care (POC) for episode 07/19/2024 to 10/16/2024 included a diagnosis of atrial fibrillation and the medication, Eliquis (anticoagulant). The aide care plan did not include bleeding precautions. The POC included fall precautions, however, fall precautions were not included in the aide care plan. Clinical Record 11: The Plan of Care (POC) for episode 06/06/2024 to 09/03/2024 included a diagnosis of breast cancer. Safety measures on the POC included “Transfer Precautions”. The Aide care plan did not include fall precautions. Clinical Record 12: The Plan of Care (POC) for episode 08/05/2024 to 11/02/2024 included a diagnosis of Alzheimer’s Disease with aspiration precautions. The aide care plan did not include aspiration precautions. During a joint record review and interview on 10/16/2024, the Administrator and the Director of Clinical Services confirmed the aide care plans were missing the identified patient care instructions.”