Every finding on record at Holistic Hospice 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, 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, 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 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 review of clinical records, document review, and interview. 4 of 10 (40%) records reviewed revealed the hospice failed to update the drug profile at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. Record: 39587: The registered nurse documented in the visit note dated 8/17/2021, "Respiratory... O2 at 2LPM via NC.... O2 started as per MD orders." The "Hospice Initial Plan of Care/Physician Orders" dated 8/9/2021 documented, "O2@ 2 LPM PRN...." The clinical record was missing documented evidence that the medication profile was updated to include the oxygen. Record: 58959: The registered nurse documented in the visit note dated 10/12/2021, "Patient started on oxygen via NC at 2LPM." The physician’s order dated 10/12/2021 documented, "As per MD orders the patient started on oxygen via NC at 2 LPM." The clinical record was missing documented evidence that the medication profile was updated to include the oxygen. Record: #82707: The registered nurse (RN) documented in the visit note dated 5/13/2021,"O2 started on patient at 2 LPM as per MD orders via NC." The RN documented in the visit note dated 5/21/2021,"Respiratory... O2 at 2LPM continuous..." The "Hospice Initial Plan of Care/Physician Orders" dated 5/7/2021 documented,"O2 @2 LPM...." The clinical record was missing documented evidence that the medication profile was updated to include the oxygen. Record: # 13986: The RN documented in the visit note dated 3/29/2021,"The patient has O2 as needed for SOB." The RN documented in the visit note dated 4/6/2021, "The patient was using his O2 at 2LPM." The "Hospice Initial Plan of Care/Physician Orders" dated 5/7/2021 documented,"O2 @2-5 LPM...." The clinical record was missing documented evidence that the medication profile was updated to include the oxygen. Agency policy #PC.17 "Medication List and Monitoring" documented, "Agency will maintain a current, accurate list of all prescription and over -the -counter (OTC) medications taken by the patient... (Medication Profile) ... Changes in the medication regimen will be updated as frequently as necessary to keep the profile accurate." The findings were validated by the Supervising Nurse on 4/12/2022 at 4:30p during an interview and a joint review of the records.

It is required that each patient’s individualized written plan of care including all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 10 (10%) records reviewed revealed the hospice did not ensure that the plan of care provided measurable outcomes anticipated from implementing and coordinating the plan of care. Record: #58959: The RN comprehensive assessment dated 9/18/2021 documented "Primary Pain... Abdomen... Intensity 5 Medium.... Target pain goal... 0 None." The Plan of Care (POC) dated 9/18/2021 documented, "Problems...Pain... Goal.... Patient will be free on pain during certification period." This goal did not reflect the patient/family goals and was not measurable. The finding was validated during an interview with the Supervising Nurse on 4/12/2022 at 4:30 PM.