Bexar 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 and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 1: The patient elected that hospice benefit on 12/03/2024. During the home visit observation on 10/21/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the patient’s home medications to the hospice medication profile printed on 10/21/2025. The hospice medication profile included Atorvastatin Calcium Oral Tablet 10 mg, one tablet by mouth daily, started on 12/03/2024, Levothyroxine Sodium Oral Tablet 50 MCG, one tablet by mouth every day before breakfast, started 12/03/2024 and Restoril Oral Capsule 15 MG, one capsule by mouth every night before bedtime, started 12/03/2024. The patient’s current home medications did not include Atorvastatin, Levothyroxine, and Restoril. The paid caregiver, who manages the patient’s medications, reported that Atorvastatin and Levothyroxine were discontinued approximately 10 months ago, and Restoril was discontinued about 4 or 5 months ago. The paid caregiver stated that the patient would refuse to take medications. The RN verified that the medications were on the printed medication profile dated 10/21/2025. The hospice medication profile also included orders for Cyanocobalamin (Vitamin B12) Injection Solution 1000 MCG/ ML, inject 1 ML every month on the 29th, started 06/05/2025, Vitamin B-12 Sublingual Tablet Sublingual Tablet 2500 MCG, one tablet by mouth daily, started 06/05/2025, Furosemide Oral Tablet 20 MG, one by mouth daily, started 06/05/2025, and Furosemide Oral Tablet 20 MG, take one tablet by mouth once a day for edema, started 09/16/2025. The family reported that when the “Vitamin B-12 shots started, (the patient) stopped taking the ones by mouth.” There was no documented evidence that the patient’s medications were reviewed for duplicate drug therapy at the time of the comprehensive assessment and drug profile updated. The last comprehensive assessment was dated 10/14/2025. During a joint record review and interview on 10/22/2025, the Director of Nursing/Alternate Administrator/Bereavement Coordinator confirmed that there was no documented evidence the patient’s medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“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 and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 1: The patient elected that hospice benefit on 12/03/2024. During the home visit observation on 10/21/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the patient’s home medications to the hospice medication profile printed on 10/21/2025. The hospice medication profile included Atorvastatin Calcium Oral Tablet 10 mg, one tablet by mouth daily, started on 12/03/2024, Levothyroxine Sodium Oral Tablet 50 MCG, one tablet by mouth every day before breakfast, started 12/03/2024 and Restoril Oral Capsule 15 MG, one capsule by mouth every night before bedtime, started 12/03/2024. The patient’s current home medications did not include Atorvastatin, Levothyroxine, and Restoril. The paid caregiver, who manages the patient’s medications, reported that Atorvastatin and Levothyroxine were discontinued approximately 10 months ago, and Restoril was discontinued about 4 or 5 months ago. The paid caregiver stated that the patient would refuse to take medications. The RN verified that the medications were on the printed medication profile dated 10/21/2025. The hospice medication profile also included orders for Cyanocobalamin (Vitamin B12) Injection Solution 1000 MCG/ ML, inject 1 ML every month on the 29th, started 06/05/2025, Vitamin B-12 Sublingual Tablet Sublingual Tablet 2500 MCG, one tablet by mouth daily, started 06/05/2025, Furosemide Oral Tablet 20 MG, one by mouth daily, started 06/05/2025, and Furosemide Oral Tablet 20 MG, take one tablet by mouth once a day for edema, started 09/16/2025. The family reported that when the “Vitamin B-12 shots started, (the patient) stopped taking the ones by mouth.” There was no documented evidence that the patient’s medications were reviewed for duplicate drug therapy at the time of the comprehensive assessment and drug profile updated. The last comprehensive assessment was dated 10/14/2025. During a joint record review and interview on 10/22/2025, the Director of Nursing/Alternate Administrator/Bereavement Coordinator confirmed that there was no documented evidence the patient’s medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”