Every finding on record at Aperture Hospice 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; 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 and interview. In 4 of 5 (80%) clinical records reviewed, the agency did not ensure that the medication profiles contained the patient's current prescription drugs. Clinical Record 2: The patient elected hospice care on 06/14/2023. The medication profile was documented as reviewed and reconciled upon admission at the 6/16/2023 interdisciplinary team meeting. The medication profile documented "Tylenol #3 po q6hr prn severe pain"; however, the dosage of Tylenol was not documented. Clinical Record 3: The patient elected hospice care on 06/13/2023. The medication profile was documented as reviewed and reconciled upon admission at the 6/16/2023 interdisciplinary team meeting. The medication profile documented "Tylenol #3 po q6hr prn severe pain"; however, the dosage of Tylenol was not documented. Clinical Record 4: The patient elected hospice care on 06/13/2023. The physician's order dated 06/13/2023 documented "O2@2L via NC prn shortness of breath." The medication profile was documented as reviewed and reconciled upon admission at the 6/16/2023 interdisciplinary team meeting; however, oxygen was not included in the medication profile at the time of the review. Clinical Record 5: The patient elected hospice care on 06/15/2023. The physician's order dated 06/15/2023 documented "O2@2L via NC prn shortness of breath." The medication profile was documented as reviewed and reconciled upon admission at the 6/16/2023 interdisciplinary team meeting; however, oxygen was not included in the medication profile at the time of the review. During an interview and a joint review of the records on 06/28/2023, the Administrator stated medication profiles are reviewed at admission, plan of care development, and team meetings; however, the discrepancy was inadvertently not captured at that time and that the medication profiles had since been corrected.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by clinical record review, personnel record review, and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that entries in the patient record were appropriately authenticated by the person performing the care/service. Clinical Record 1: The home safety evaluation, consent (election of benefits), initial orders, verbal certification, caregiver agreement, photograph consent, COVID 10 screening, Medicare Secondary Payor (MSP) screening agency forms dated 06/14/2023, completed by the Registered Nurse (RN) [Personnel1], contained the first initial and last name of the RN with the associated credentials and date. According to the signature attestation in the employee file [Personnel1], the signature must include a complete first and last name. The spiritual assessment visit note completed by the chaplain on 06/15/2023 contained no credentials with the associated signature and date. Clinical Record 2: The home safety evaluation, consent (election of benefits), initial orders, verbal certification, caregiver agreement, photograph consent, COVID 10 screening, and MSP screening agency forms dated 06/14/2023 completed by the RN [Personnel1] contained the first initial and last name of the RN with the associated credentials and date. According to the signature attestation in the employee file [Personnel1], the signature must include a complete first and last name. Clinical Record 3: The home safety evaluation, consent (election of benefits), initial orders, verbal certification, caregiver agreement, photograph consent, COVID 10 screening, and MSP screening agency forms dated 06/13/2023 completed by the RN [Personnel1] contained the first initial and last name of the RN with the associated credentials and date. According to the signature attestation in the employee file [Personnel1], the signature must include a complete first and last name. Clinical Record 4: The home safety evaluation, consent (election of benefits), initial orders, verbal certification, caregiver agreement, photograph consent, COVID 10 screening, and MSP screening agency forms dated 06/13/2023 completed by the RN [Personnel1] contained the first initial and last name of the RN with the associated credentials and date. According to the signature attestation in the employee file [Personnel1], the signature must include a complete first and last name. Clinical Record 5: The home safety evaluation, consent (election of benefits), initial orders, verbal certification, caregiver agreement, photograph consent, COVID 10 screening, and MSP screening agency forms dated 06/15/2023 completed by the RN [Personnel1] contained the first initial and last name of the RN with the associated credentials and date. According to the signature attestation in the employee file [Personnel1], the signature must include a complete first and last name. The spiritual assessment visit note completed by the chaplain on 06/16/2023 contained no credentials with the associated signature and date. During an interview and a joint review of the records on 06/28/2023, the Administrator stated the RN signature attestation does not match the signature in the patient record and has since been amended. The Administrator also stated that the missing chaplain credentials had been corrected on the associated chaplain visits.