Every finding on record at Cura-Hpc Eastok, 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; and 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, interview, and observation. In 4 of 6 (67%) clinical records reviewed revealed that the agency did not ensure that all medications were included in the patient's drug profile Clinical Record 1/ Home Visit 1: The patient elected the hospice benefit on 09/14/2023. The most recent comprehensive nursing assessment was dated 03/01/2024. The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Basaglar Kwikpen (100 units/ml) give 10 units subcutaneously daily, Active 02/10/2024. Novolin R give subcutaneously as per sliding scale before each meal, Active 02/10/2024." Upon review of the current medication from the hospice was dated 03/01/2024, the Basaglar and Novolin R were not documented on the medication profile. Clinical Record 2/ Home Visit 2: The patient elected the hospice benefit on 09/14/2023. The most recent comprehensive assessment was dated 03/01/2024. The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Chloraseptic Throat Lozenge 6mg-10mg Give one every 2 hours as needed for sore throat, Active 02/24/2024. Milk of Magnesia 30ml daily as needed for constipation, Active 02/01/2024". Upon review of the current medication profile from the hospice dated 03/01/2024, the Chloraseptic Throat Lozenge and Milk of Magnesia were not documented on the medication profile. Clinical Record 3/ Home Visit 3: The patient elected the hospice benefit on 02/28/2024. The initial comprehensive assessment was dated 02/28/2024. The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Citalopram 40mg daily, Active 02/21/2024. Metoprolol 25mg daily, Active 02/21/2024. Imodium 4mg every hour as needed for diarrhea, Active 02/21/2024. Milk of Magnesia (1200mg/15ml) Give 30ml daily as needed for constipation, Active 02/21/2024.". Upon review of the current medication profile for Clinical Record #3 from the hospice dated 02/28/2024, the Citalopram, Metoprolol, Imodium, and Milk of Magnesia were not documented on the medication profile. Clinical Record 5: The election of hospice benefits was 09/11/2023. The initial nursing assessment dated 09/11/2023 read in part "O2 on at 5L per simple mask". The initial plan of care dated 09/11/2023 read in part "Administer supplemental oxygen as ordered". There were no orders for oxygen on the medication profile. In an interview on 03/06/2024, the administrator reviewed the records and stated, "I do not see any orders for these medications.".

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. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed revealed that the agency did not ensure that all services necessary for the palliation and management of the terminal illness were included in the patient's plan of care. Clinical Record 1: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Basaglar Kwikpen (100 units/ml) give 10 units subcutaneously daily, Active 02/10/2024. Novolin R give subcutaneously as per sliding scale before each meal, Active 02/10/2024.". The plan of care lacked orders for Basaglar and Novolin R. Clinical Record 2: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Chloraseptic Throat Lozenge 6mg-10mg Give one every 2 hours as needed for sore throat, Active 02/24/2024. Milk of Magnesia 30ml daily as needed for constipation, Active 02/01/2024". The plan of care lacked orders for Chloraseptic Throat Lozenge and Milk of Magnesia. Clinical Record 3: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Citalopram 40mg daily, Active 02/21/2024. Metoprolol 25mg daily, Active 02/21/2024. Imodium 4mg every hour as needed for diarrhea, Active 02/21/2024. Milk of Magnesia (1200mg/15ml) Give 30ml daily as needed for constipation, Active 02/21/2024.". The plan of care lacked orders for Citalopram, Metoprolol, Imodium, and Milk of Magnesia. Clinical Record 5: The nursing assessment dated 09/11/2023 read in part "O2 on at 5L per simple mask". The initial plan of care dated 09/11/2023 read in part "Administer supplemental oxygen as ordered". The plan of care lacked specific orders for oxygen. Clinical Record 6: The election of hospice benefits was on 09/14/2023. The patient went to the hospital ER early morning of 11/14/2023 and was sent home later that same day and care was resumed. A review of clinical documentation revealed that a resumption of care nursing visit note dated 11/14/2023 confirmed the presence of a foley catheter, documenting "Patient had a Foley placed in the ER. Foley remains intact.". The revised plan of care lacked specific catheter orders, size of catheter, and maintenance of catheter. In an interview on 03/06/2024, the administrator reviewed the records and stated, "I don't see these medication and catheter orders on the plan of care, but they should have been.".

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 an 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 2 of 6 (33%) clinical records where aide services were ordered reviewed revealed that the agency did not ensure that all instructions were included in the aide care plan. Clinical Record 1: Physician orders dated 02/29/2024 included wound care and dressing orders for a wound on the coccyx. The aide care plan dated 03/01/2024 did not include specific instructions to the aide related to the wounds. Clinical Record 2: Physician orders dated 11/10/2023 included wound care and dressing orders for wounds on both feet. The aide care plan dated 11/13/2023 did not include specific instructions to the aide related to the wounds. In an interview on 03/05/2024, the administrator reviewed the record and stated, "I did not realize that there had to be instructions on the aide care plan regarding wounds".

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 5 of 6 (83%) clinical records reviewed revealed that the agency did not ensure that all physician's orders were included in the patient's clinical record. Clinical Record 1: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Basaglar Kwikpen (100 units/ml) give 10 units subcutaneously daily, Active 02/10/2024. Novolin R give subcutaneously as per sliding scale before each meal, Active 02/10/2024.". The record lacked evidence of orders for Basaglar Kwikpen or Novolin R. Clinical Record 2: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Chloraseptic Throat Lozenge 6mg-10mg Give one every 2 hours as needed for sore throat, Active 02/24/2024. Milk of Magnesia 30ml daily as needed for constipation, Active 02/01/2024". The clinical record lacked orders for Chloraseptic Throat Lozenge or Milk of Magnesia. Clinical Record 3: The medication profile from the skilled nursing facility dated 03/05/2024 read in part "Citalopram 40mg daily, Active 02/21/2024. Metoprolol 25mg daily, Active 02/21/2024. Imodium 4mg every hour as needed for diarrhea, Active 02/21/2024. Milk of Magnesia (1200mg/15ml) Give 30ml daily as needed for constipation, Active 02/21/2024.". The clinical record lacked orders for the Citalopram, Metoprolol, Imodium, and Milk of Magnesia. Clinical Record 5: The election of hospice benefits was 09/11/2023. The nursing assessment dated 09/11/2023 read in part "O2 on at 5L per simple mask". The initial plan of care dated 09/11/2023 read in part "Administer supplemental oxygen as ordered". The clinical record lacked specific orders for oxygen. Clinical Record 6: The election of hospice benefits was on 09/14/2023. The patient was hospitalized on 11/14/2023 and care resumed later on 11/14/2023. A review of clinical documentation revealed that a resumption of care nursing visit note dated 11/14/2023 confirmed the presence of a foley catheter, documenting "Patient had a Foley placed in the ER. Foley remains intact.". The clinical record lacked specific catheter orders, size of catheter, and maintenance of catheter. In an interview on 03/06/2024, the administrator reviewed the records and stated, "There are no orders for these medications or foley catheter for these patients".

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the most recent hospice plan of care for each patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home visits at a skilled nursing facility reviewed revealed that the agency did not ensure that the most recent hospice plan of care was provided for each patient. Home Visit 1: The patient elected the hospice benefit on 09/14/2023 with a diagnosis of End State Renal Disease. The patient resided in a facility. During the home visit with the Administrator (Personnel Record 1) a review of the hospice agency's binder at the facility, the current benefit period was 01/12/2024-03/11/2024. The most recent plan of care was dated 11/13/2023-01/11/2024. There were no other plans of care in the record at the skilled nursing facility. In an interview on 03/06/2024, the administrator stated "We make sure that the current plan of care is at the nursing facility for each patient. I am not sure why that plan of care was not at the facility."