Every finding on record at Blue Bonnet Hospice 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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. 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, observation, and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the drug profile contained the patient's current prescription and over the counter drugs. Clinical Record 2/Home Visit 2: During home visit observation with the social worker (staff 7), the patient was observed taking two extra strength Tylenol for complaints of knee pain. Review of the patient’s medication profile reveled it did not include Tylenol. Clinical Record 5: The Registered Nurse documented on the skilled nurse visit note dated 06/07/2023 the patient had taken “Tylenol 1000mg taken status post patient fall for pain.” Tylenol was not included on the medication profile in the plan of care dated 05/02/2023. During an interview on 11/21/2023, the Director of Patient Care Services reviewed the associated records and stated that the medication profiles were incomplete and had since been corrected.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure the hospice plan of care included interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 10/14/2023. The hospice plan of care dated 10/14/2023 and the updated hospice plans of care dated 10/30/2023 and 11/13/2023 included an aide frequency of three times per week but did not include interventions and goals for aide service provisions based on self-care deficits identified on the 10/14/2023 Registered Nurse start of care comprehensive assessment and the 10/30/2023 and 11/13/2023 updated comprehensive assessments. During an interview on 11/21/2023, the Director of Patient Care Services reviewed the associated record and stated the self-care deficit goals and interventions had inadvertently been omitted from the hospice plans of care and had since been corrected.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with aide services provided, the agency did not ensure aide services were provided as ordered in the hospice plan of care. Clinical Record 2: The hospice plan of care dated 10/14/2023 included an order for aide visits three times per week. The clinical record contained no documented evidence the aide provided visits the week of 10/14/2023. The clinical record contained no documentation to explanation why aide services were not provided as ordered. During an interview on 11/21/2023, the Director of Patient Care Services reviewed the associated record and stated the incorrect aide frequency had been placed on the hospice plan of care and had since been corrected.