Every finding on record at Clm Enterprises 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; [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 clinical record review, document review, observation, and interview. Agency policy "Drugs and Biologics-Administration, Use and Disposal" (revised 6/8/2021) stated in part, "The designated Registered Nurse is responsible for maintaining a current medication profile that includes prescription drugs and biologics, over-the-counter drugs, herbal remedies and alternative treatments used by each patient, as well as the current dosage, frequency, and route of administration." In 2 of 4 (50%) home visits observed, the hospice agency did not ensure the patient's medication profile contained the patient's current medication regimen. Home Visit 1/Clinical Record 1: The patient elected hospice hospice care on 9/8/2023 and resided in a Skilled Nursing Facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 10/24/2023, the patient's SNF medication profile and medication administration record documented in part, "Tamsulosin HCL oral capsule 0.4 mg, take one (1) capsule by mouth one (1) time a day." The hospice agency's medication profile did not contain the medication Tamsulosin. During a joint record review and interview on 10/24/2023, the Director of Health Care Services (DHCS), present during the visit, confirmed the hospice agency medication profile did not match the SNF profile. The DCHCS reported the hospice agency discontinued the Tamsulosin on September 15, 2023. However, the patient was still taking the Tamsulosin. Home Visit 2/Clinical Record 4: The patient elected hospice hospice care on 2/3/2023 and resided in an Assisted Living Facility (ALF). During the home visit with the Registered Nurse (RN) Personnel Record 5] on 10/24/2023, the hospice agency's medication profile dated 10/24/2023 documented, "Melatonin 3mg., take one (1) tab at bedtime. The ALF medication profile documented, "Melatonin 3mg., take one half (0.5) tablets at bedtime." The DHCS confirmed the hospice agency's medication profile did not match the patient's current medication regimen.

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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy "Drugs and Biologics-Administration, Use and Disposal" (revised 6/8/2021) stated in part, "Each patient's drugs, biologics, over-the-counter, herbal remedies, and alternative treatments are identified on the medication profile as part of the interdisciplinary Group (IDG) plan of care." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure all drugs needed for the palliation and management of the patient were included in the plan of care. Clinical Record 1/Home Visit 1: The patient elected hospice hospice care on 9/8/2023 and resided in a Skilled Nursing Facility (SNF). During the home visit with the Registered Nurse (RN) Personnel Record 4] on 10/24/2023, the patient's SNF medication profile and medication administration record documented in part, "Tamsulosin HCL oral capsule 0.4 mg, take one (1) capsule by mouth one (1) time a day." The hospice agency's medication profile did not contain the medication Tamsulosin. The plan of care dated 10/24/2023 did not include documentation of the Tamsulosin. During a joint record review and interview on 10/24/2023, the Director of Health Care Services (DHCS), present during the visit, confirmed the patient's plan of care did not contain the medication Tamsulosin.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure the hospice aide documented changes in the plan of care to the Registered Nurse. Clinical Record 7: The patient elected hospice care on 9/27/2023.The plan of care ordered hospice aide services two (2) times a week for the benefit period dated 9/27/2023 through 11/25/2023. The week of 10/8/2023 through 10/14/2023, the patient received a hospice aide visit on 10/11/2023. One (1) documented missed hospice aide visit dated 10/9/2023 documented, "Family-Caregiver able to assist the patient." The hospice aide visit note did not contain evidence the Registered Nurse (RN) was notified of the missed visit. In addition, the patient had previously elected hospice care on 8/30/2022. The plan of care ordered hospice aide services two (2) times a week for the benefit period dated 8/25/2023-9/25/2023. The week of 9/10/2023 through 9/16/2023, the patient received a hospice aide visit on 9/13/2023. There was one (1) documented missed hospice aide visit dated 9/11/2023. The hospice aide visit note did not contain evidence that the RN was notified of the missed visit. During a joint record review and interview on 10/24/2023, the Director of Clinical Health Care Services confirmed the record did not contain evidence the RN was notified of the missed hospice aide visits on 10/9/2023 or 9/11/2023.

Based on record review and interview, it was determined that the hospice failed to ensure that skilled nursing coordinated and implemented the plan of care to meet the patient's continuous needs in 1 of 3 records reviewed (MR# 1) resulting in the potential for poor patient outcomes for all hospice patients. Findings include: **Agency policy "Chapter 6 - Care Delivery: Nursing Services" (6/21/13) stated, "2. A hospice RN (Registered Nurse) performs the initial and comprehensive assessment, as well as ongoing assessments of the patient's physical status and the psychosocial status of the patient/family. 3. A hospice RN is designated to provide coordination of care and to ensure the continuous assessment of each patient's/family's needs, as well as the implementation of the IDG (Interdisciplinary Group Services) plan of care to guide the delivery of services and achieve the goals of hospice care." MR#1: The Start of Care (SOC) was dated 1/5/22. The Plan of Care (POC) identified terminal diagnoses of Nutritional Deficiency, Major Depressive Disorder and Other Symptoms and Signs Involving Cognitive Functions and Awareness. During record review on 6/13/22, the patients wound was noted on the "RN Initial Assessment" dated 1/5/22 as "Location: Coccyx ...Odor: Foul ...Treatment: No treatment initiated prior to Hospice admission - cleaned with wound cleanser, patted dry and applied Optifoam per VO (Verbal Order) from NP#1 ...Wound Pain: 3." The following Skilled Nursing (SN) visit dated 1/7/22, documented the wound as "Location: Coccyx ...Odor: not assessed this visit. Treatment: Per POC by staff prior to SN visit ...Wound Pain: None." Additionally, on 1/7/22 a "Physicians Order" was written that stated, "SN/CG (Care Giver) to perform wound care to coccyx 3x/week and PRN (as needed) for soiling/deadhesion of dressing if dressing present.... Problems: Skin. Problem name: Risk for skin breakdown. Interventions: Assess for changes in skin integrity. Educate and/or assess for signs and/or symptoms of infection..." On 1/8/22, the SN documented the patients wound as "...Odor: Foul...Treatment: Dressing dry and intact this visit - ALF (assisted living facility) staff changed prior to SN visit". On the following SN visit dated 1/10/22, the wound was documented as "...Odor: Foul. Treatment: Per POC..." Additionally, the SN documented under "Assessment/Instruction/Performance...a foul odor coming from pressure ulcer was noted but odor resolved some after cleansing wound. Conferenced with RN#2 and NP#1 regarding wound and concerns for the foul smell. We will reevaluate on Wednesday's (1/12/22) visit..." Furthermore, a "Plan of Care Order" dated 1/10/22 stated, "...Problems: Name: Pressure ulcer to buttocks. Description: Pressure ulcer to buttocks. Goal: ....Wound(s) will remain free of infection ..." On 1/12/22, the following SN visit, the wound was documented as " ...Odor: Foul. Treatment: Per POC..." Additionally, the SN documented under "Assessment/Instruction/Performance ...When viewing the wound, we determined a new POC which has been updated. RN#2 conferenced with NP#1 regarding the need for flagyl x3 a sprinkled to wound bed NP#1 reports she will look into the treatment and notify with further orders. Patient denies any pain, but if you watch patient for any period of time he is constantly noted moving back and forth and trying to lift buttocks off the bed. We discussed me talking with his wife about scheduling pain meds and he was on board with plan." On 1/14/22, the following SN visit, the wound was documented as "...Odor: Foul. Treatment: Per POC. Patient Response to Treatment: Patient denies pain but cried out and yelled with intervention. Morphine given..." Furthermore, the SN documented under "Assessment/Instruction/Performance...cleansed and changed his coccyx wound dressing per POC but patient was crying out and very painful with intervention despite saying he didn't have any pain. I educated patient on pain meds available and encouraged him to be honest with staff when he is painful, so pain is better controlled. Med Tech administered morphine per my request for patients' painful response with dressing change and reposition." Following the SN visit, a "Physician Order" was completed by RN#1 stating, "Orders:...Flagyl Oral Tablet 250 MG... Instructions: Skilled nursing to sprinkle crushed medicine to coccyx wound bed 3x/week with dressing change..." The following SN visit was on 1/17/22 after the patient had passed. The agency failed to timely address the POC goals to meet the patient's needs, which could have potential negative outcomes.