Every finding on record at Alora Hospice and Palliative Care, 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/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) medication profiles for active hospice patients reviewed revealed that the hospice agency did not ensure that the patient's drug profile contained the patient's current prescription and over-the-counter drugs. The hospice agency did not ensure the patient's drug profile was updated per the hospice policy and procedure. Agency Policy PC.85, stated in part, the hospice will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient. (Medication Profile) Home Visit 1: During the home visit (Home Visit 1) with the hospice aide (Personnel Record 3), a review of the patient’s medication was reviewed. The pharmacy prescription label on the patient's medication bottle read cyclobenzaprine HCL 10 mg by mouth daily as needed. The patient's caregiver stated she administered the medication twice a day. The hospice agency's medication profile listed the medication, cyclobenzaprine HCL, 10 mg oral every eight (8) hours as needed. The patient's caregiver provided another medication bottle that had been delivered by the hospice agency's contract pharmacy for trazodone 50 mg oral every morning. This medication was not on the hospice agency's medication profile. Home Visit 3: During the home visit (Home Visit 3) with the registered nurse (RN) (Personnel Record 2), the hospice agency's contract pharmacy delivered guaifenesin 400mg orally every 12 hours. The hospice agency's medication profile listed guaifenesin extended-release oral 600 mg twice a day as needed for cough. During an interview on 05/17/2024, the Director of Nursing agreed the medication profiles were not reconciled.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed for patients receiving services revealed that the hospice did not ensure a registered nurse provided coordination of care, continuous assessment of each patient's and family's needs, and ensure the implementation of the interdisciplinary plan of care. Agency Policy PC.8 CH, stated in part, a registered nurse, who is a member of the IDT, will be designated to provide coordination of care and will ensure continuous assessments of each patient's/family's needs, and implementation of the IDT plans of care. Clinical Record 3: The plan of care dated 01/13/2023 ordered the social worker and chaplain to visit twice a month. The social worker made one visit on 01/16/2023. There was no documented evidence of a chaplain visit made. The plan of care dated 02/15/2023 ordered the chaplain to visit once a month. There was no documented evidence of a chaplain visit made during February. Clinical Record 4: The plan of care dated 03/27/2024 ordered skilled nursing visits two to three times a week, a social worker one time a month, and chaplain visits one time a month. The skilled nurse made one visit a week on 03/23/2024, 03/30/2024, 04/06/2024, and 04/20/2024. The social worker and chaplain had no documented evidence of visits made or reason for missed visits. During an interview on 05/15/2024, the Alternate Administrator/Alternate Director of Nursing agreed that the frequencies ordered by the IDG had not been bet. The Alternative Administrator/Alternate Director of Nursing stated the frequencies on the plan of care orders were incorrect.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) volunteer program binder reviewed revealed that the hospice agency did not ensure that the Volunteer Coordinator documented viable and ongoing efforts to recruit and retain volunteers. During an interview on 05/17/2024, the Administrator/Volunteer Coordinator stated she was aware of the requirements for documenting viable recruitment and retention of volunteers. The Administrator/Volunteer Coordinator stated that she had fallen behind and had not maintained the documentation of volunteer recruitment and retention.