Presbyterian Hospice of Northern NM

“Based on record review, observation and interview, the agency failed to ensure that the patient’s drug profile was current for 1 (P[patient]10) out of 4 (P6, P10, P17, and P18) patients. This deficient practice could lead to patients not having an accurate medication list and errors. The findings are:A. Record review of the agency’s policy titled, “Medication Management HH [home health] and Hospice” dated 07/31/2025 under “Procedure” it stated, “B. Hospice: A drug regimen review will be performed at the time of initial and comprehensive assessment. The drug regimen review will be completed by the interdisciplinary group in consultation with an individual with education and training in hospice and palliation drug management to ensure that drugs and biological meet each patient’s needs.4. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care.B. During an observation on 12/02/2025 at 9:25 am in P10’s home, the patient had one medication list in the home that included five (5) medications and the plan of care had a total of 16 medications. The medications on the home list for the caregiver to follow did not reflect her current plan of care and current drug profile. C. Record review of P10’s plan of care that was printed by facility on 12/01/2025 prior to home visit. The plan of care medication list had 16 medications, and the home list had 5 medications. C. During an interview on 12/02/2025 at 9:25 am with the caregiver of P10 confirmed the medication list was the only list that had been provided to them and was given on the start of care with the hospice on 06/09/2025. D. During an interview on 12/02/2025 at 9:35 am S(staff)6, clinical, it was explained that the medication list in the home should be updated.”

“Based on record review, the facility failed to have a policy in place regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government). This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. The findings are:A. Record review of the agency’s policy titled, “Medication Management HH [home health] and Hospice” dated 07/31/2025 revealed no evidence of content related to management and disposal of controlled drugs. B. Record request for policies related to management and disposal of medications resulted in the policy above being provided.”

“Based on record review and observation, the agency failed to provide the patient or caregivers with information regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government) for 1 (P[patient] 18) out of 4 (P6, P10, P17, and P18) patients observed. This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. The findings are:A. Record review of the agency’s undated document titled, “Hospice Admission Booklet” revealed no evidence of information regarding the management and disposal of controlled drugs.B. During an observation on 12/03/2025 at 2:57 pm in P18’s home there was no evidence of information regarding the management and disposal of controlled drugs.”

“Based on record review and interview, the agency failed to document that the patient or caregivers were provided information regarding the management and disposal of controlled drugs (drugs that are strictly regulated by the government) for 4 (P[patient]2, P3, P6, and P7) out of 19 (P1-P19) patient records reviewed. This deficient practice could place patients and caregivers at risk for medication misuse, diversion (when the drug is taken by someone other than who it is prescribed for) and unsafe disposal of controlled drugs. The findings are:A. Record review of P2’s record for start of care date 10/07/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.B. Record review of P3’s record for start of care date 02/01/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.C. Record review of P6’s record for start of care date 05/19/2024 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.D. Record review of P7’s record for start of care date 11/21/2025 there was no evidence that patient or caregiver were provided information regarding the management and disposal of controlled drugs.E. During an interview on 12/04/2025 on 2:15 pm with S(staff) 6, non-clinical, it was confirmed that there was no documentation of information provided to patient or caregivers regarding the management and disposal of controlled drugs.”

“Based on record review and interview, the agency failed to obtain a background check for 1 (S[staff] 2) out of 4 (S1, S2, S7, and S8) staff files reviewed. This deficient practice could put patients at risk when staff enter their homes if the agency is not aware of the staff’s background. The findings are:A. Record review of S2’s, clinical, employee file for hire date 02/06/2023 revealed that there was no background check on file.B. During an interview on 12/04/2025 at 1:15 pm with S6, non-clinical, it was confirmed that there was no background check on file for S2.”