Every finding on record at Comfort Hospice of Texas, 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, supplements, herbal remedies, other alternative treatments that could affect drug therapy. 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 2 of 19 (10%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a medication profile that contained the patient's current medications. Clinical Record 2/Home Visit 2: The patient elected hospice care on 6/20/2023. During the home visit with the hospice aide (HA) [Personnel Record 11] on 12/13/2023, a joint review of medications with the patient revealed the patient was taking Baby Aspirin 81 mg daily, Clonidine HCL 0.2mg as needed, Senna S 2 tablets as needed, and Ibuprofen 2 tablets as needed for headaches. The medications were not documented in the agency's medication profile. There was no evidence that Baby Aspirin, Clonidine, Senna, and Ibuprofen were included in the patient's medication regimen review. Clinical Record 4/Home Visit 1: The patient elected hospice care on 11/2/2023. During the home visit with the registered nurse (RN) [Personnel Record 2] on 12/13/2023, a review of the patient's medications revealed the patient was taking Bayer 81 mg daily, D3 125 mcg daily, and B6 100mg daily. The patient confirmed taking the medications. The medications were not documented in the agency's medication profile. There was no evidence Bayer, D3, and B6 were included in the patient's medication regimen review.

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, observation, and interview. 2 of 19 (10%) clinical records reviewed, the hospice did not ensure the patient's plan of care included all drugs and treatments necessary to meet the needs of the patient. Clinical Record 2/Home Visit 2: The patient elected hospice care on 6/20/2023. During the home visit with the hospice aide (HA) [Personnel Record 11] on 12/13/2023, a joint review of medications with the patient revealed the patient was taking Baby Aspirin 81 mg daily, Clonidine HCL 0.2mg as needed, Senna S 2 tablets as needed, and Ibuprofen 2 tablets as needed for headaches. The plan of care did not include documentation of the medications. Clinical Record 4/Home Visit 1: The patient elected hospice care on 11/2/2023. During the home visit with the registered nurse (RN) [Personnel Record 2] on 12/13/2023, a review of the patient's medications revealed the patient was taking Bayer 81 mg daily, D3 125 mcg daily, and B6 100mg daily. During an interview, the patient confirmed taking the medications. The plan of care did not include documentation of the medications.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure the clinical record contained physician orders for treatments or level of care changes. Clinical Record 2: The patient elected the hospice benefit on 6/20/2023 with a diagnosis of Senile Degeneration of the Brain. The recertification assessment dated 11/3/2023 for the benefit period of 11/17/2023 through 1/17/2024 the registered nurse (RN) documented "mild hip pain, pain is managed with Tylenol." Additionally, the RN documented "Patient has new orders for antibiotic for 7 days for a UTI and boil on her vaginal area that is having pus and bloody discharge." A review of the clinical record revealed no evidence of a physician's order for the antibiotic medication. Clinical Record 19: The patient elected the hospice benefit on 8/8/2023 with a diagnosis of Alzheimer's Disease. The patient was discharged from this hospice agency on 10/23/2023 due to being medically stable. A review of the clinical record revealed no evidence of a physician's order for the discharge. During an interview and a joint review of the clinical record, the Administrator and Quality Manager agreed that there was no documented evidence of physician orders for the medications and the discharge.