Every finding on record at Allegiant Hospice and Home 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; 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 review of clinical records, and interview. 4 of 12 (33%) of records reviewed revelaed the hospice did not ensure a drug regime review was completed for all current medications the pateint was taking at the time of the comprehensive assessment. Record #74264 the nurse documented on 02/03/2021 "lanolin based ointment with zinc place thin layer on patient's skin to help protect area from tape. Medication profile was reviewed on 04/05/2022 and revealed no order for Zinc Oxide was noted and Zinc Oxide was not listed on the medication profile. Record #45876 the nurse documented on 03/04/2021 "lanolin based ointment with zinc place thin layer on patient's skin to help protect area from tape". Medication profile was reviewed 04/05/2022 and revealed no order for Zinc Oxide was noted and Zinc Oxide was not listed on the medication profile. Record #13499 the nurse documented on 03/13/2021 "lanolin based ointment with zinc place thin layer on patient's skin to help protect area from tape. Medication profile was reviewed 04/05/2022 and revealed no order for Zinc Oxide and Zinc Oxide was listed on the medication profile. Record #48787 the nurse documented on 11/27/2021 "lanolin based ointment with zinc place thin layer on patient's skin to help protect area from tape. Medication profile was reviewed 04/05/2022 and revealed no order for Zinc Oxide was noted and Zinc Oxide was listed on the medication profile. The Administrator was interviewed on 04/05/2022. She reviewed and confirmed that there was no order for Zinc Oxide and that this was an error because of a template in their EMR. The oganization began working with thier software company to make a correction within the system's initial assessment.

It is required that each patient’s individualized written plan of care:reflects patient and family goals; identifiesplanned interventions based on problems identified in the initial and updated comprehensive assessments; includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care; the documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by review of clinical records, 3 of 13 (23%) of records reviewed revealed that the plans of care (POC) lacked measurable goals and outcomes. Record #21003- The Social Worker documented 07/26/2021 that the patient needed a DNR signed. No documentation of interventions or measurable goals documented. Record #36162 - The Social Worker documented on 12/26/21 that her assessment was completed for a life alert and for meals on wheels that the patient needed. No measurable goals documented. Record #13499- The Social Worker documented on 03/15/2021 that she provided emotional support, encouragement and continued referrals for the patient. No measurable goals were documented. Interview with the administrator on 04/05/2022 she reviewed and confirmed that this had been self identified and they were developing a plan of correction.