Every finding on record at Dogwood Hospice and Palliative Care 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 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, document review, and interview. In 2 of 5 (40%) clinical records reviewed the agency did not ensure an accurate review of medications the patient was currently using to identify any potential adverse effects and drug reactions. POLICY AND PROCEDURES: Agency Policy PC.17 "Medication List and Monitoring" read in part "The Hospice will maintain a current, accurate Medication Profile of all prescription and over-the-counter medications taken by the patient. Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order and in Plan of Care, as well as communicated to the patient and/or caregiver. Changes in medication regimen will be updated as frequently as necessary to keep the profile accurate". HOME VISIT 1: The patient’s election of benefit was 06/11/2025 with diagnosis of Hypertensive Heart Disease with Heart Failure. The patient resided in an assisted living facility (ALF). During the home visit on 08/26/2025 with the hospice aide (Personnel Record 1)and registered nurse (RN)(Personnel Record 2) ) , the patient (Clinical Record 1) had an oxygen concentrator at the bedside. The RN stated during interview "The oxygen is used on a PRN basis". A review of the agency provided medication profile dated 08/25/2025 did not include oxygen. There was no documented evidence that a medication review was completed during the comprehensive assessment dated 08/20/2025. HOME VISIT 2: During the home visit on 08/26/2025 with the RN (Personnel Record 2) the patient's medications in the home were reviewed. A prescription bottle labeled "Meclizine 25mg tablets, take one tablet three times daily" dated 07/15/2025 and a prescription bottle labeled "Senna 8.6mg tablets, take one tablet two times daily" dated 07/15/2025 were found in the patient's home. The Meclizine and Senna were not included in the agency provided medication profile dated 08/25/2025. The Registered Nurse stated during interview "I am not sure why the medication profile does not have Meclizine or Senna but they should be listed". There was no documented evidence that a medication review was completed during the comprehensive assessment dated 08/20/2025. During a joint record review with the Director of Nursing on 08/26/2025, the Director of Nursing confirmed the above findings that the patient's medication profiles did not include oxygen, Senna or Meclizine.

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 5 (20%) clinical records reviewed with hospice aide services provided revealed the agency did not ensure that all written patient care instructions were included in the hospice aide care plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/17/2025. The record included a physicians order dated 06/17/2025 for "Oxygen 4 liters via nasal cannula continuously". The plan of care dated 06/17/2025 through 09/14/2025 ordered "hospice aide 3 times per week". The hospice aide care plan dated 06/17/2025 included relevant instructions of "Shower at every visit". The hospice aide care plan did not include instructions regarding what the hospice aide should do with the oxygen during the shower. During a joint record review with the Director of Nursing on 08/26/2025, the Director of Nursing confirmed the above finding that oxygen instructions were not included in the hospice aide care plan.

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 5 (40%) clinical records reviewed the agency did not ensure that all physician's orders were included in the patient's clinical record. CLINICAL RECORD 1/HOME VISIT 1: The patient’s election of benefit was 06/11/2025 with diagnosis of Hypertensive Heart Disease with Heart Failure. The patient resided in an assisted living facility (ALF). During the home visit (Home Visit #1) on 08/26/2025 with the hospice aide (Personnel Record 1) and registered nurse (RN) (Personnel Record 2) it was noted that the patient had an oxygen concentrator at the bedside. The RN stated during interview "The oxygen is used on a PRN basis". A review of the clinical record benefit period 06/11/2025-09/08/2025 did not include physician's orders for oxygen. CLINICAL RECORD 2/HOME VISIT 2: The patient’s election of benefit was 04/29/2025 with diagnosis of Chronic Obstructive Pulmonary Disease. During the home visit (Home Visit #2) on 08/26/2025 with the registered nurse (RN) (Personnel Record 2), the patient's medications in the home were reviewed. A prescription bottle labeled "Meclizine 25mg tablets, take one tablet three times daily" dated 07/15/2025 and a prescription bottle labeled "Senna 8.6mg tablets, take one tablet two times daily" dated 07/15/2025 were found in the patient's home. There was no documented evidence in the clinical record for the Meclizine and Senna. During a joint record review with the Director of Nursing on 08/26/2025, the Director of Nursing confirmed the above findings that physician's orders for oxygen, Senna and Meclizine were not in the patient's clinical records.