Every finding on record at Acg Missouri East, 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. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and when new medication is added or changes are made to existing medication. This standard was not met as evidenced by document review and observation. Agency policy # 2-004 stated in part, "A drug regimen review will be performed at the time of initial and comprehensive assessments when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication." In 2 of 5 (40%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Clinical Record 1/ Home Visit 1: The patient elected hospice care on 05/22/2024 and resided in a Skilled Nursing Facility (SNF). During the home visit with the Certified Nursing Assistant (CNA) [Personnel Record 6] on 06/04/2024, the hospice medication profile documented, Metamucil oral capsule 0.36 GM; give two capsules by mouth once daily. The facility medication profile documented, Metamucil 0.4 GRAM capsule; give two capsules by mouth daily. The hospice agency corrected the medication profile and presented the reconciled medication profile on 06/06/2024. Clinical Record 3/Home Visit 3: The patient elected hospice care on 04/30/2024 and resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 06/04/2024, the hospice medication profile documented, prednisone 2.5 mg one tablet by mouth daily. The facility medication profile documented, prednisone oral 2.5 mg; give 2 tablets by mouth two times a day for inflammation. The hospice agency corrected the medication profile and presented the reconciled medication profile on 06/05/2024