Every finding on record at Eureka Healthcare, 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, and 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 a review of clinical records, document reviews, and interviews. 2 of 3 (66%) home visits revealed the agency did not ensure that all medications including over-the-counter (OTC) medications were included on the medication profile. Home Visit #3: During the home visit conducted on 8/25/2022, a review of the patient's plan of care (POC) dated 7/27/22 through 9/24/22 and the patient’s medications in the home, revealed Clotrimazole AF 1% topical cream was being applied to both feet twice a day after the bath, and Loratadine 10 mg by mouth was being administered by the caregiver as needed with breakfast if patient exhibited allergy symptoms (watery eyes, runny nose). These medications were not included on the medication profile. The Director of Nursing (DON) (Staff 2) stated during an interview and a joint review of clinical record, neither of these medications were on the patient’s medication profile. Home Visit #2: During the home visit conducted on 8/25/2022, a review of the patient's medications revealed CBD extract pain cream was used by the patient at bedtime for her arthritic pain in both hands and Voltaren Arthritic pain cream was being used by the patient 2-3 times a day for her arthritic pain to both hands. These medications were not included on the medication profile. During an interview and a joint review of clinical record, the DON (Staff 2) confirmed that neither of these medications were on the patient’s medication profile. The agency's policy #H:2-055.1 "Medication Profile" stated in part, “The medication profiles will be updated to each change to reflect current medications, and new and/or discontinued medications.”

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 11 (36%) records reviewed revealed the agency did not ensure the medical social worker MSW) completed the initial bereavement risk assessment. Record #2 was reviewed and identified the patient elected hospice care on 6/29/22. The initial comprehensive assessment completed by the MSW on 7/1/22, documented, “Was Bereavement Assessment done...Yes....Please complete bereavement risk assessment via contact/assessment form.. ok." There was no documented evidence of the Bereavement Risk Assessment form in the patient’s medical record. The Director of Nursing (DON), stated in an interview and a joint review of the record on 8/25/22, the MSW did not complete the initial bereavement assessment. The DON presented a Bereavement assessment completed by the MSW dated 8/26/22. Record #0 was reviewed and identified the patient elected hospice care on 2/5/22. The initial comprehensive assessment completed by the MSW on 2/8/22, documented, “Was Bereavement Assessment done..... not appropriate at time of evaluation.” There was no documented evidence of the Bereavement Risk Assessment form in the patient’s medical record. The Director of Nursing (DON), stated in an interview and a joint review of the record on 8/25/22, the MSW did not complete the initial bereavement assessment. The DON presented a bereavement assessment completed by the MSW dated 8/26/22. Record #8 was reviewed and identified the patient elected hospice care on 12/6/2021. The initial comprehensive assessment completed by the MSW on 12/9/22, documented, “Was Bereavement Assessment done...Yes....Please complete bereavement risk assessment via contact/assessment form.. ok." There was no documented evidence of the Bereavement Risk Assessment form in the patient’s medical record. The Director of Nursing (DON), stated in an interview and a joint review of the record on 8/25/22, the MSW did not complete the initial bereavement assessment. The DON presented a Bereavement assessment completed by the MSW dated 8/26/22. Record #4 was reviewed and identified the patient elected hospice care on 3/10/22. The initial comprehensive assessment completed by the MSW on 3/10/22, “Was Bereavement Assessment done..... not appropriate at time of evaluation.” There was no documented evidence of the Bereavement Risk Assessment form in the patient’s medical record. The Director of Nursing (DON), stated in an interview and a joint review of the record on 8/25/22, the MSW did not complete the initial bereavement assessment. The DON presented a bereavement assessment completed by the MSW dated 8/26/22. The agency's policy stated in part, "the MSW is to complete the initial bereavement risk assessment."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review documents and interviews. 1 of 21 (5%) contracts reviewed revealed the hospice did not ensure that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. A review of the Durable Medical Equipment contract dated 8/13/2017, revealed the contract failed to include the clause, in writing, for the provision that requires criminal background checks for all contracted employees with direct patient contact or access to patient records. During a joint review of the contract and interview, the Administrator and the DON stated that the contract did not include the statement of provisions for the criminal background checks. The Administrator provided a new signed contract by both parties (contractor/contracted) dated 8/26/2022, which included the criminal background clause.