Every finding on record at Centurion Hospice & Palliative Care, Inc.

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; other alternative treatments that could affect drug therapy. The medication review process includes the identification of 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, document review and interview. In 1 of 5 (20%) clinical records reviewed it was revealed that the agency did not ensure that all current medications were included in the patient's drug profile. Document 1: Agency Policy PC.M55 "Medication - Profile" read in part "When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect the drug therapy. The patient's medication profile is reviewed by the IDG/Hospice Care Team whenever there is a significant change and, at a minimum, every fifteen days.". Clinical Record 5: A physician's order dated 04/20/2024 read in part "Give oxygen 3 liters through nasal cannula as needed if SpO2 is below 90%.". The initial nursing assessment dated 04/20/2024 read in part "Patient is on continuous oxygen.". The medication profile dated 04/20/2024 did not include oxygen. In an interview on 09/04/2024, the Director of Clinical Services reviewed the record, confirmed the finding and stated, "There is not oxygen on the medication profile.".

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records with aide services provided reviewed it was revealed that the agency did not ensure that all patient care instructions were included in the aide care plan. Clinical Record 2: The record revealed a physician's order dated 03/11/2024 for wound care with a wound dressing to a wound on the patient's left leg. The aide care plan dated 03/11/2024 lacked instructions related to the wound dressing on the left leg. In an interview on 09/04/2024, the Director of Clinical Services reviewed the record, confirmed the finding, and stated "There are no instructions for the wound dressing on the aide care plan."