Every finding on record at Cardinal 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. 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, document review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure that the drug profile contained the patient's current prescription drugs. Medication Profile Policy No. 2-004 read in part, 1Upon admission to Hospice, the admitting nurse will initiate a medication profile to document the current medication regimen,' Clinical Record 11: The hospice election of benefit was dated 11/16/2023. The 11/16/2023 comprehensive assessment completed by the registered nurse and the 11/16/2023 hospice plan of care included documentation of the patient utilization of 'O2 @2lpm via nasal cannula.' At the time of the review on 03/05/2024, Oxygen was not included on the medication profile. During interview on 03/07/2024, the Director of Accreditation reviewed the associated record and stated Oxygen had inadvertently been omitted from the medication profile and had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed the agency did not ensure that the patient’s individualized written plan of care included complete treatment orders necessary to meet the needs of the patient. Clinical Record 13: The hospice election of benefit was dated 12/19/2023. The 01/04/2024 signed physician's order and the 01/10/2024 updated hospice plan of care read “skin tear right forearm and hand- using clean technique cleanse wound with NS, apply a thin layer of triple antibiotic, apply xeroform gauze, wrap with Kerlix and secure with ace bandage.” At the time of the review on 03/05/2024, the wound care order did not contain a frequency. During interview 03/07/2024, the Director of Accreditation reviewed the associated record and stated that the frequency had been inadvertently omitted and had since been corrected.