Interim Healthcare of the Twin Cities, Inc.

“Based on observation, interview, and document review, the facility failed to include all medications received in the patients’ plans of care for 3 of 4 patients (P3, P4, P5) observed during home visits. Findings Include:P3’s Plan of Care (POC), signed 6/2/26, identified P3 was admitted to hospice services on 5/8/26, and included diagnoses of senile degeneration of brain, Parkinson’s disease, and chronic kidney disease. P3’s Medication Profile dated 7/27/26, included the following:-Celoxib (a nonsteroidal anti-inflammatory medication used to treat pain) 100 milligram (mg) oral (by mouth) capsule. Take one capsule orally two times a day for mild pain.During a home visit on 7/27/26, at 3:31 p.m., P3’s medications were reviewed with family member (FM)-A. FM-A and surveyor went through all scheduled and as needed medications, including emergency medications not yet initiated, that were provided by hospice. Celoxib was not included in P3’s current medications found in the home.P4’s POC, signed 7/23/26, identified P4 was admitted to hospice services on 7/13/26, and included diagnoses of senile degeneration of brain, legal blindness, and adjustment disorder with mixed anxiety and depressed mood.P4’s Medication Profile dated 7/27/26, included the following: -hydrocortisone-Aloe 0.5% topical cream, apply one gram topically daily for hemorrhoids-Senna Lax (laxative medication) 8.6 mg oral tablet, take one tab orally once a day at bedtime as needed for constipationDuring a home visit on 7/28/26 at 11:34 a.m., P4’s current Medication List was provided from the nurse at the assisted living facility. P4’s assisted living facility Medication List dated 7/28/26, included the following:-Senna S (laxative and stool softener medication) 8.6-50 mg tablet, take one tablet by mouth twice daily-fluticasone SPR (Flonase allergy relief) 50 microgram (MCG) daily 1 gram -instill one spray in each nostril once daily for chronic rhinitis (inflammation of the nasal lining)-ipratropium SPR (nasal spray for runny nose) 0.06% four times a day, one milliliter (ml) spray one spray in each nostril four times a day for chronic rhinitis-levothyroxine (medication to treat low thyroid hormone levels) 50 MCG take one tablet by mouth once daily-raloxifene (medication to treat osteoporosis) 60 mg take one tablet by mouth once daily-vitamin B12 1000 MCG tablet, take to tablet by mouth once daily for B12 deficiency-estradiol cream (medication to treat vaginal symptoms caused by menopause) 0.01% place two grams vaginally twice weekly on Tuesday and Friday for postmenopausal atrophic vaginitis-acetaminophen 325 mg tablet, take two tablets by mouth three times a day as needed for sciatica (sciatic nerve pain) unspecifiedP4’s facility medication list contained multiple medications not listed on P4’s hospice Medication Profile list. P4’s hospice Medication Profile list contained two medications not on P4’s current assisted living Medication List. P5’s POC signed 6/5/26, identified P5 was admitted to hospice services on 12/5/24, and included diagnoses of Parkinson’s disease, chronic pain, and seizures.P5’s Medication Profile dated 7/27/26, included the following; -carbidopa -levodopa (combination medication to treat Parkinson’s disease) 25 mg-100 mg oral tablet, administer one tablet oral four times a day for Parkinson’s-polyethylene glycol (MiraLAX-laxative) 3340 oral powder for reconstitution; administer 17 grams orally once a day for constipation-morphine Solu tab 5 mg tablet; administer one tablet sublingually (under the tongue) two times a day for air or shortness of breathDuring a home visit on 7/28/26 at 12:39 p.m., P5’s current Medication List was provided from the nurse at the assisted living facility. P5’s assisted living facility Medication List dated 7/28/26, included the following:-morphine Solu tab 5 mg, take one tablet by mouth as bedtime (HS) for pain/shortness of breath-carbidopa-levodopa 25-100 mg tablet, take one half (12.5 mg/50 mg) by mouth twice a day for Parkinson’s-nystatin 100,00 unit/gram powder, apply to affected area one gram topically two times a day for rash/itching to abdominal folds on left side-MiraLAX powder 17 grams, mix 17 gram in water as directed by mouth three times per week, Monday, Wednesday, Friday (MWF) hold for loose stools, for constipationP5’s hospice Medication Profile did not match P5’s assisted living Medication List for carbidopa-levodopa, morphine and MiraLAX dosage and/or administration times, and did not contain all medications found on P5’s current assisted living Medication List. During interview on 7/29/26 at 11:51 a.m. hospice director (HD) reviewed the above findings and confirmed P3, P4 and P5’s Medication Profiles did not match their current medications received. HD stated her expectation was that medications would be reconciled during admission assessment and at every visit. HD indicated the nurses should ask at every visit if any changes were made in medications and the patient’s Medication Profile would be updated. HD stated medication reconciliation was important to ensure patients were receiving the correct dosages and at correct times. The agency policy titled Drug Regimen Review dated 1Q(first quarter)/2026, identified all patients would have a review of their drug regimen or profile, which would include all prescription drugs, over-the-counter medications, herbal remedies and other alternative treatments which could affect their drug therapy. To be completed during the patient specific initial and comprehensive assessment. A written notification would be forwarded to the attending physician regarding any need for change in orders.”