Every finding on record at Cfhc No4 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 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, interview, and observation. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile during the comprehensive assessment. HOME VISIT 3: The patient's (Clinical Record 7) date of election was 05/29/2024. The Medication Profile printed on 04/22/2025 was reviewed during the Home Visit. The medication bottles in the home revealed Senna Plus 8.6/50 mg tablet, one to two tablets twice a day as needed for constipation, filled on 03/17/2025 and 04/15/2025; and Phenytoin Sodium Extended 100 mg capsule, one capsule three times a day for seizures. The son and caregiver stated that the patient has been taking the Phenytoin Sodium Extended for over thirty years. The Registered Nurse Visit dated 03/01/2025 documented, "Refills for today visit for Monday delivery are Phenytoin 100 mg Er capsule..." The most recent RN visit note was dated 04/15/2025, which documented, "Refills: Phenytoin 100 mg Er capsule..." The Senna Plus 8.6/50 mg tablet, one to two tablets twice a day as needed for constipation and the Phenytoin Sodium Extended 100 mg capsule, one capsule three times a day for seizures were not on the medication profile dated 04/22/2025. There was no documented evidence that a medication reconciliation was completed during the most recent comprehensive assessment dated 04/15/2025. During a joint record review and interview on 04/23/2025, the Administrator/Director of Nursing confirmed that there was no documented evidence of medication reconciliation at the time of each comprehensive assessment and updated to the drug profile. On 04/24/2025, the Administrator/Director of Nursing stated that the assigned nurses have reconciled the medication records.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. A review of the volunteer program documents revealed the agency did not ensure to document efforts to recruit and retain volunteers for 04/23/2024 to 04/22/2025. During a joint review of the volunteer program records and interview on 04/24/2025, the Administrator/Director of Nursing confirmed that the documentation lacked efforts to recruit and retain volunteers from 04/23/2024 to 04/22/2025. The Administrator/Director of Nursing stated that the Volunteer Program was loosely monitored over the last several months but has hired an experienced Volunteer Coordinator in April 2025. The Volunteer Coordinator confirmed on 04/24/2025 that the documentation lacked efforts to recruit and retain volunteers from 04/23/2024 to 04/22/2025. The Volunteer Coordinator communicated that the current plans are to recruit volunteers through community outreaches, social media platforms, and at local universities and colleges. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to recruit and retain volunteers for 04/23/2024 to 04/22/2025.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed that the agency did not ensure volunteer percentage the hospice would have incurred if paid employees occupied the positions from 04/23/2024 to 04/22/2025 did not reach the required 5%. The total percentage for this timeframe was 2.67%. During a joint review of the volunteer program records and interview on 04/24/2025, the Administrator/Director of Nursing confirmed that the documented volunteer hours and direct care staff hours did not meet 5% from 04/23/2024 to 04/22/2025. The Administrator/Director of Nursing stated that the Volunteer Program was loosely monitored over the last several months but has hired an experienced Volunteer Coordinator in April 2025. During a joint review of the volunteer program records and interview on 04/24/2025, the Volunteer Coordinator confirmed acknowledgement that the documented volunteer hours and direct care staff hours did not meet 5% from 04/23/2024 to 04/22/2025. The Volunteer Coordinator verbalized efforts that have been implemented within the last few days to a week and future efforts that will be set in place. Upon reviewing the volunteer program, the documentation lacked evidence of the volunteer percentage the hospice would have incurred if paid employees occupied the positions from 04/23/2024 to 04/22/2025. The total percentage for this timeframe was 2.67%.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by clinical record reviews and interview. 1of 5 (20%) records reviewed revealed the hospice did not ensure that care and services provided to the patient followed the individualized care plan. Record # 43518 was reviewed and identified the patient elected hospice care on 5/04/2022. The physician order dated 5/10/2022 documented "Chaplain 1 time per month effective 5/15/2022." The record included no evidence of completed chaplain visits between 5/15/2022 and 6/15/2022. An interview with the Alternate Supervising Nurse (#27324), confirmed that there were no chaplain visits provided 5/15/2022 – 6/15/2022 as ordered.