Every finding on record at Dogwood Hospice, 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 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 measures 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. Agency policy " Drugs and Biologicals" (dated 06/17/2024) stated in part, "Medication records are established at time of admission and updated as needed. The medical record will contain a current medication list." In 1 of 7 (14%) clinical records reviewed and home visits observed, the agency did not ensure that the initial comprehensive assessment included documentation of a drug profile that contained the patient's current prescription and over-the-counter medications that could affect drug therapy. Clinical Record 1/Home Visit 1: The patient elected hospice care on 03/27/2025 with the diagnosis of chronic obstructive pulmonary disease (COPD). During a home visit with the Registered Nurse (RN) [Personnel Record 3] on 04/21/2025, a review of the patient's medications with the patient's daughter revealed the patient was using Xyzal 5mg, one (1) by mouth (PO) every night (hs), Prevagen, one (1) tab po daily, docusate 100mg, one (1) cap po 3 times a week, vitamin B 12, one (1) po daily, Areds, two (2) soft gels po AM and PM. The patient's daughter stated in part that the patient is new to Xyzal, but had been taking the Prevagen, Areds, and vitamin B12 since before the hospice admission. The patient was seen weekly by the RN since admission to hospice services on 03/27/2025. The medication profile was not updated in accordance with the agency's policy. There was no documented evidence that these medications were reviewed with the patient's medication regimen. The Clinical Services Director, who was present during the home visit, confirmed that the medications were not on the medication profile and had not been reviewed as part of the patient's medication regimen.