Every finding on record at Hospice Home Care, Inc

Based on clinical record review and staff interview, it was determined the Agency failed to ensure a process was in place for checking all medications for actual or potential drug interactions in 2 (#7 & #14) of 19 (#1-#19) clinical records reviewed. This failed practice by the Agency presented a risk to all patients on census as the failure to conduct a complete medication review potentially delayed decisions regarding the patient’s medication regimen. Findings follow: --- Review of clinical record #7 revealed a patient with a start of care of 03/22/25 and a diagnosis of Alzheimer’s Disease. On a document titled “Visit Note Report” and dated 04/10/25 the Registered Nurse documented “PATIENT WAS PRESCRIBED KEFLEX 500MG TID X7DAYS”. Review of a document titled “Client Medication Report” did not include Keflex. No documentation in the clinical record to indicate Keflex had been checked for potential side effects or interactions. Review of clinical record #14 revealed a patient with a start of care of 03/18/25 and a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Review of "Order Number: 379758" dated 03/18/25 revealed the Physician Narratives included "O2 (oxygen) is in the home to use as needed."  On a document titled “Visit Note Report” and dated 03/19/25 the Registered Nurse documented “DOES HAVE O2 IN THE HOME FOR PRN (as needed) USE”. On a document titled "Visit Note Report" and dated 03/19/25 the Medical Social Worker documented "OXYGEN CONCENTRATOR NEXT TO THE PT'S (patient's) BED" AND "PT ADMITTED TO HAVING TO USE THE OXYGEN THROUGHOUT THE DAY" Review of a document titled “Client Medication Report” did not include Oxygen. No documentation in the clinical record to indicate Oxygen had been checked for potential side effects or interactions. An interview on 05/22/25 at 4:00 PM, with Agency Personnel #2 confirmed the failure to check all medications for actual or potential drug side effects or interactions.

Based on Clinical Record review and staff interviews, it was determined the urinary catheter order was not complete in that the order did not include the size or type of catheter to be used in 5 of 5 (#4, #6, #8, #10 and #11) Clinical Records reviewed with urinary catheter orders. The failed practice did not ensure the appropriate type or sized catheter was used to prevent harm to the patient. The deficient practice could result in potential harm for all patients on census with orders for a urinary catheter. Findings follow: 1. Review of the document titled, "Hospice Certification and Plan of Care" in Clinical Records #4, #6, #8, #10 and #11 showed orders for a urinary catheter, "... PRN [As needed] insert Foley Catheter [urinary catheter]..." There was no evidence in the order of the type or size of catheter to be inserted. 2. Review of the document titled, "Visit Note Report" in Clinical Records #4, #6, #8, #10 and #11 showed patient assessments by the Registered Nurse which included the patient having an indwelling urinary catheter. 3. There was no evidence in Clinical Records #4, #6, #8, #10 and #11 the Agency obtained a complete order for urinary catheters to include the specific type and size. 4. On 07/7/22 at 4:00 PM, Agency Personnel #1 confirmed the lack of a complete order for urinary catheters.