Every finding on record at Falling Stars Palliative & 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. 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 the medication profile included the patient's current over the counter drugs. Clinical Record 4: The patient elected the hospice benefit on 10/11/2022, with a terminal diagnosis of Breast Cancer. The hospice plan of care (POC) dated 10/11/2022 included an order for the skilled nurse to, “instruct the patient to use over the counter muscle rub as tolerated.” The “muscle rub” medication was not listed on the patient’s medication profile. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record dated 10/13/2022, 10/27/2022 and 11/10/2022. Clinical Record 5: The patient elected the hospice benefit on 12/19/2022, with a terminal diagnosis of Congestive Heart Failure. The hospice POC dated 12/19/2022 included an order for the skilled nurse to “instruct the patient to use over the counter muscle rub as tolerated.” The “muscle rub” medication was not listed on the patient’s medication profile. Medication review documentation was noted as completed at each comprehensive assessment update and at the interdisciplinary group meetings in the clinical record dated 12/28/2022 and 01/11/2023. During an interview dated 08/11/2023, the Administrator reviewed the associated clinical records and stated that the medication had inadvertently been omitted from the medication profile and had since been corrected.

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 drugs and treatment necessary to meet the needs of the patient. 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 each patient’s individualized written plan of care included complete orders specific to the drugs and treatments necessary to meet the needs of the patient. Clinical Record 4: The patient elected the hospice benefit on 10/11/2022, with a terminal diagnosis of Breast Cancer. The hospice plan of care (POC) dated 10/11/2022 included an order for the skilled nurse to, “instruct the patient to use over the counter muscle rub as tolerated.” The order on the POC did not include the name of the “muscle rub,” the type of medication ointment, cream or lotion, the application location or the specific frequency for application. The POC also included an order that stated “ice/heat therapy as tolerated.” The POC order did not include the application location or the specific frequency for application. Clinical Record 5: The patient elected the hospice benefit on 12/19/2022, with a terminal diagnosis of Congestive Heart Failure. The hospice POC dated 12/19/2022 included an order for the skilled nurse to “instruct the patient to use over the counter muscle rub as tolerated.” The POC order did not include the name of the “muscle rub,” the type of medication ointment, cream or lotion, the application location or the specific frequency for application. The POC also included an order that stated “ice/heat therapy as tolerated.” The order on the POC did not include the application location or the specific frequency for application. During an interview dated 08/11/2023, the Administrator reviewed the associated clinical records and stated that the referenced items were considered nonpharmacological measures to control discomfort and had inadvertently been left incomplete and had since been corrected.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that all entries in the clinical record were appropriately authenticated and dated by the person performing the care/service. Clinical Record 1: The patient elected the hospice benefit on 07/03/2023, with a terminal diagnosis of Multiple Sclerosis. The bereavement risk assessment dated 07/06/2023 was signed by the Chaplain but did not include the date and credentials with the associated signature. Clinical Record 2: The patient elected the hospice benefit on 07/12/2023, with a terminal diagnosis of Cerebral Vascular Accident. The bereavement risk assessment dated 07/14/2023 was signed by the Chaplain but did not include a date with the associated signature. Clinical Record 3: The patient elected the hospice benefit on 07/11/2023, with a terminal diagnosis of Chronic Obstructive Pulmonary Disease. The bereavement risk assessment dated 07/14/2023 was signed by the Chaplain but did not include the date and credentials with the associated signature. Clinical Record 4: The patient elected the hospice benefit on 10/11/2022, with a terminal diagnosis of Breast Cancer. The bereavement risk assessment dated 10/14/2022 did not include a signature, date or credentials of the person that completed the assessment. Clinical Record 5: The patient elected the hospice benefit on 12/19/2022, with a terminal diagnosis of Congestive Heart Failure. The bereavement risk assessment dated 12/22/2022 was signed by the Chaplain but did not include a date with the associated signature. During an interview dated 08/11/2023, the Administrator reviewed the associated records and stated that the signatures were missing name of clinician, dates and credentials and had since been corrected.