Every finding on record at Caring Seasons Health, LLC

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 and 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 document review, clinical record review, and interview. In 2 of 10 (20%) clinical records reviewed, the agency did not ensure the Registered Nurse (RN) followed agency policy when documenting the patient’s current medications as part of the comprehensive assessment. Agency policy CO1.046 Medication Profile and Medication Reconciliation, dated 01/10/2023, required in part, “At the time of initial assessment, the RN [Registered Nurse] will create and document a complete list of medications that the patient is taking, including dose, indication, route, and frequency. Any discrepancies will be reconciled by an RN with the patient's physician. Discrepancies include duplications, omissions, changes, contraindications and/or unclear information." Clinical Record 3: This patient elected the hospice benefit on 10/28/2024 with diagnoses of congestive heart failure and insulin dependent diabetes mellitus. The medication profile listed Insulin Lispro 100 units/ml with directions per sliding scale three times daily. The comprehensive assessment medication profile did not include the sliding scale for Insulin Lispro. Clinical Record 7: The patient elected the hospice benefit on 10/28/2024 with diagnoses of malignant neoplasm of the right bronchus and lung, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, type 2 diabetes mellitus, and anxiety. The referral dated 10/27/2024 included physician orders for Alprazolam 1mg PO [by mouth] three times a day as needed for anxiety and Gabapentin 600 mg PO three times daily. The comprehensive assessment medication profile dated 10/28/2024 included documentation that Alprazolam 1mg and Gabapentin 600mg administer three times weekly. During an interview and review of records on 11/26/2024, the Director of Clinical Operations stated the sliding scale for clinical record three should have been part of the order and for clinical record seven, there may have been a computer glitch as the medications were ordered three times daily and not weekly.

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 3 of 10 (30%) clinical record reviews, the agency did not ensure that each patient's individualized plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected the hospice benefit on 10/13/2024 with a primary diagnosis of protein calorie malnutrition. The plan of care for the certification period from 10/13/2024 to 01/10/2025 included a physician order for Aspirin [antiplatelet medication with side effect of increased risk of bleeding] 81mg PO daily. The plan of care did not include interventions for bleeding precaution safety measures for this antiplatelet medication prescribed for the patient. Clinical Record 7: The patient elected the hospice benefit on 10/28/2024 with diagnoses of malignant neoplasm of the right bronchus and lung, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure and type 2 diabetes mellitus. The plan of care for the certification period from 10/28/2024 to 01/25/2025 did not include goals and interventions for the patient’s diagnosis of diabetes mellitus. Clinical Record 9: The patient elected the hospice benefit on 11/03/2024 with diagnoses of chronic kidney disease, heart failure, and comorbidity of type 2 diabetes mellitus. The plan of care for the certification period from 11/03/2024 to 01/31/2025 did not include goals and interventions for the patient’s diagnosis of diabetes mellitus. During an interview and review of records on 11/26/2024, the Director of Clinical Operations confirmed the plans of care did not include interventions associated with the patient's diagnoses and safety measures associated with medications prescribed.

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 following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 10 (30%) clinical records reviewed, the agency did not ensure that each patient's individualized plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 6: The patient elected the hospice benefit on 11/06/2024 with a diagnosis of chronic obstructive pulmonary disease. The plan of care for the certification period from 11/06/2024 to 01/04/2025 included a physician order for breathing treatments every four hours for shortness of breath. The plan of care did not include a nebulizer, the medical equipment that would be needed to administer the breathing treatments. Clinical Record 7: The patient elected the hospice benefit on 10/28/2024 with a diagnosis of malignant neoplasm of the right bronchus and lung. The plan of care for the certification period from 10/28/2024 to 01/25/2025 included a physician order for inhalation (breathing) treatments. The plan of care did not include a nebulizer, the medical equipment that would be needed to administer the breathing treatments. Clinical Record 8: The patient elected the hospice benefit on 07/05/2024 with a diagnosis of chronic respiratory failure. The plan of care for the certification period from 07/05/2024 to 10/02/2024 included a physician order for breathing treatments every four hours for shortness of breath. The plan of care did not include a nebulizer, the medical equipment that would be needed to administer the breathing treatments. During an interview and review of records on 11/26/2024, the Director of Clinical Operations confirmed that the patient's would need the nebulizers to administer the breathing treatments, but they were not included in the list of equipment needed for the patient.