Every finding on record at Acg Kansas, LLC

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, interview and observation. In 1 of 3 (33%) home visit observations it was revealed that the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 2: The date of election of benefits was 03/19/2024. The medication profile dated 05/22/2024 documented Senna Plus 8.6mg-50mg capsule two capsules daily. During the home visit, the patient's wife stated that the patient was taking Docusate Sodium 100mg capsules three capsules once daily. The wife stated that the patient has been taking this for approximately four years. The medication profile did not include documentation of the use of Docusate Sodium. During a joint review of the record and an interview on 05/22/2024, the Director of Accreditation and Compliance agreed that a medication reconciliation was not completed, and medications updated to the medication profile.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations it was revealed that the agency did not ensure the staff followed the hand hygiene policy. Document 1: Agency policy, Hand Hygiene Policy No. 7-011 stated in part, "Hand decontamination using an alcohol-based hand rub should be performed when moving from a contaminated body site to a clean body site during patient care, and after removing gloves." Home Visit 2: During the home visit (Clinical Record 9) on 05/22/2024 with the Hospice Aide (HA) (Personnel Record 9), the HA bathed the patient, washed the hair, and dressed the patient without changing their gloves. During the process, the HA scratched their own arm with the same pair of gloves that were donned prior to the patient being bathed. The HA did not change the gloves when moving from a contaminated body site to a clean body site during patient care. The HA did not remove the gloves and decontaminate the hands prior to scratching their arm. During an interview on 05/22/2024, the Director of Accreditation and Compliance agreed the staff did not follow the hand hygiene policy.