Heart to Heart Hospice of Tyler Ltd

“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 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 measures 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 19 (11%) clinical records reviewed and home visit observations, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Clinical Record 3 /Home Visit 3: The patient elected hospice care on 02/19/2025 with a diagnosis of cerebral infarction. During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 04/30/2025, the patient’s medications were reviewed with the patient’s daughter. The patient’s medications at home did not match the hospice medication profile. The hospice medication profile did not document Trazodone 50mg at bedtime, which the patient’s daughter stated in part, “She (the patient) started that about two (2) weeks after she came on hospice.” The plan of care, effective 02/19/2025, ordered twice weekly skilled nursing (SN) visits for two weeks, beginning the week of 02/19/2025, then once weekly beginning 03/03/2025. Skilled nursing visits were completed as ordered. The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report on 03/28/2025 documented “Trazodone QHS effectively manages insomnia...Medications reviewed to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, contraindications, significant drug and food interactions, duplicate therapy, and non-compliance.” The RN [Personnel Record 3] confirmed the findings and stated in part, “I didn’t have that medication on our list.” Trazodone was not documented in the patient’s hospice medication profile. Clinical Record 4/Home Visit 4: The patient elected hospice care on 02/15/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker [Personnel Record 4] on 05/01/2025, the hospice and SNF medication profiles were reviewed. The SNF medication profile documented: Multivitamin-Minerals Oral tablet, give one (1) tablet by mouth one time a day for supplement, order date 04/12/2025; Maalox Max Oral Suspension 400-400-40/5ml, give 30 ml by mouth every four hours as needed for indigestion, order date 11/01/2024; Loperamide HCl Tablet 2 mg, give two (2) caplet by mouth as needed for loose stool, not to exceed four (4) caplets per day, order date 11/01/2024; Ondansetron HCL Tablet 4 mg, give one (1) tablet by mouth every four (4) hours as needed for nausea and vomiting, order date 11/01/2024; MiraLAX Oral Powder 17 GM/Scoop, give 17 gram by mouth every twenty-four (24) hours as needed for constipation, order date 11/01/2024; and Milk of Magnesia Suspension 400MG/5ML, give 30 ml by mouth as needed for constipation daily, order date 11/01/2024. The hospice medication profile did not include the multivitamin-minerals, Maalox Max, Loperamide HCl, Ondansetron HCL, MiraLAX, and Milk of Magnesia. The hospice medication profile did not document the medications included in the SNF medication profile. During the joint record review and interview on 05/01/2025, the Patient Care Manager confirmed that the medication profile did not accurately represent the medications the patients received and stated, “The medication profiles have been updated.””

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s plan of care included drugs necessary to meet the needs of the patient. Clinical Record 3 /Home Visit 3: The patient elected hospice care on 02/19/2025 with a diagnosis of cerebral infarction. During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 04/30/2025, the patient’s medications included Trazodone 50mg at bedtime, which the patient’s daughter stated in part, “She (the patient) started that about two (2) weeks after she came on hospice.” The plan of care, effective 02/19/2025, ordered twice weekly skilled nursing (SN) visits for two weeks, beginning the week of 02/19/2025, then once weekly beginning 03/03/2025. Skilled nursing visits were completed as ordered. The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Reports (updated plans of care) dated 03/28/2025, 04/11/2025, and 04/25/2025 did not document Trazodone. The RN [Personnel Record 3] confirmed the findings and stated in part, “I didn’t have that medication on our list.” Clinical Record 4/Home Visit 4: The patient elected hospice care on 02/15/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker [Personnel Record 4] on 05/01/2025, the SNF medication profile documented: Multivitamin-Minerals Oral tablet, give one (1) tablet by mouth one time a day for supplement, order date 04/12/2025; Maalox Max Oral Suspension 400-400-40/5ml, give 30 ml by mouth every four hours as needed for indigestion, order date 11/01/2024; Loperamide HCl Tablet 2 mg, give two (2) caplet by mouth as needed for loose stool, not to exceed four (4) caplets per day, order date 11/01/2024; Ondansetron HCL Tablet 4 mg, give one (1) tablet by mouth every four (4) hours as needed for nausea and vomiting, order date 11/01/2024; Miralax Oral Powder 17 GM/Scoop, give 17 gram by mouth every twenty-four (24) hours as needed for constipation, order date 11/01/2024; and Milk of Magnesia Suspension 400MG/5ML, give 30 ml by mouth as needed for constipation daily, order date 11/01/2024. The hospice recertification plan of care dated 04/05/2025 through 06/03/2025, ordered weekly nursing visits beginning 04/05/2025. Skilled nursing visits were completed as ordered. The recertification plan of care dated 04/05/2025 through 06/03/2025, and the Hospice IDG Comprehensive Assessment and Plan of Care Update Reports (updated plans of care) dated 04/09/2025 and 04/23/2025 did not document the multivitamin-minerals, Maalox Max, Loperamide HCl, Ondansetron HCL, Miralax, and Milk of Magnesia. During a joint record review and interview on 05/01/2025, the Patient Care Manager [Personnel Record 4] confirmed the findings and stated in part, “Both records have been updated to reflect the current medications. We think that [clinical record 4] had stock medications added to the medication list at the facility.””