Divine Palliative Hospice 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 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 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, interview, and observation. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that the drug profile included the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy, which resulted in the medication reconciliation being incomplete. DOCUMENT 1: Agency policy Medication Profile, Policy No. 4-050.1, stated, in part: “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.” CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit 03/31/2025 with a terminal diagnosis of senile degeneration of the brain. A review of the clinical record, the drug profile dated 03/31/2025, which was the most current drug profile, included the following medications: Lisinopril 10 mg by mouth daily, Oxycarbazine 300 mg by mouth twice a day, Potassium Chloride 10 MEq by mouth Monday-Wednesday-Friday, Ferrous Sulphate 325 mg by mouth twice a day, and Oxygen 2-4 L/NC prn for shortness of breath. During the home visit with the hospice aide (Personnel Record 1) on 04/15/2025, the home drug profile was reviewed with the Caregiver. The following medications were included in the home drug profile: Potassium Chloride 10 MEq 1/2 tablet every other day, Lisinopril 10 mg by mouth every day, Senna by mouth every other day, Oxycarbazine 300 mg 1 tablet by mouth daily, and Memantine 5 mg 2 tablets by mouth daily. The Caregiver verified these were the current medications that were administered to the patient. The following medications did not match with the hospice drug profile: Potassium Chloride 10 MEq by mouth was to be administered every other day by the home drug profile and Potassium Chloride 10 MEq 1/2 tablet Monday-Wednesday-Friday by the hospice drug profile, Oxycarbazine 300 mg by mouth was to be given once a day per the home drug profile and Oxycarbazine 300 mg twice a day per the hospice drug profile. The home drug profile did not include Ferrous Sulphate 325 mg by mouth twice a day or Oxygen 2-4 L/NC prn as per the hospice drug profile, and the hospice drug profile did not include Senna by mouth every day or Memantine 5 mg 2 tablets by mouth daily as per the home drug profile. There was no documented evidence that the medication review was completed at the time of the comprehensive assessment. In an interview conducted with the Registered Nurse on 04/16/2025, it was stated that the agency did not ensure that the hospice policy for the drug profile was followed. The Registered Nurse called the Caregiver at the patient’s home to reconcile the patient’s medications.”