Every finding on record at Hospice Preferred Choice, Inc.

Based on review of clinical records (CRs), policy/procedures, and interview with staff, the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed (CR#1); and agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1). --- Cross Reference: 418.54(c)(6) Drug Profile Tag L530 -- the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed (CR#1). 418.54(d) Update of the comprehensive assessment Tag L533 -- the agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1).

Based on review of clinical records (CRs), agency policies, and interview with the agency director, the agency failed to ensure the current comprehensive assessment included an accurate/updated review and documentation of the patient's medications including identification of duplicate drug and dose therapy for one (1) of three (3) CRs reviewed. --- Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed: CR#1 start of care (soc) 6/17/2023: -Patients blood pressure medication prescribed by primary care physician, Lisinopril 40 milligrams (MG) by mouth, daily; documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications. -10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication change to supervisory registered nurse (RN). -10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient. -10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; verbal order obtained by RN from Medical Director physician at 12:04 PM; new lower dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN, [Medication Transcription Error]. -10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; assigned RN for CR#1 documented ";Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described ";MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT." -SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented ";Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication. -SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented ";Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication. -11/7/23, 11/21/23, 12/5/23, 12/19/23, and 1/2/24 IDG meeting minutes document review of medication list with two duplicate doses of Lisinopril listed. -SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented ";Medications reviewed"; and no documented observation of two duplicate doses of Lisinopril medication. -1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 duplicate doses of lisinopril (total 60 MG by mouth daily at 9:00 AM for 5-day respite stay. -1/18/24 Agency Clinical Manager RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patients medication profile. Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1 and 2 of 13 ";Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 118/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74; 1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission. Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents 1/17/24 – ";Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list. Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, ";(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the clients medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ...."; policy Guide for Medication Orders, revised 11/203, ";the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... 6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines – RN/LPN, Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN." Review conducted on March 13, 2024, at approximately 3:00 PM, of agency job titles revealed: HSP Registered Nurse ";Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physicians orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse revealed: ";Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physicians orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff." Interview conducted on March 13, 2024, at approximately 3:15 PM, with agency administrator revealed confirmation of lack of coordination, supervision, and accurate communication between agency RNs/LPN, Clinical Manager, physicians, and SNF staff; nursing medication transcription error continued from 10/18/23 to 1/18/24 despite many healthcare staff medication reviews and resulted in SNF staff administering duplicate Lisinopril doses (20 MG and 40 MG) to patient for the five respite care days.

Based on a review of clinical records, agency policies/procedures, and interview with agency administrator, the agency failed to ensure the interdisciplinary group updated the patient comprehensive assessment with an accurate and complete review of all the patient's prescription medications which could affect drug therapy and patient outcomes for one (1) of three (3) clinical records reviewed (CR#1). --- Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed: CR#1 start of care (soc) 6/17/2023: -Patients blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily, documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications. -10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication change to supervisory registered nurse (RN). -10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient. -10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; verbal order obtained by RN from Medical Director physician at 12:04 PM; new dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error]. -10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patients care documented ";Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described ";MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT." -SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented ";Medications reviewed"; and no documented observation of two doses of Lisinopril medication. -11/7/23 IDG meeting note: Medical Director (MD) notes (page 3 of 6) described ";MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."; and Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification. -11/18/23 Nurse Practitioner Face-to-Face Encounter Note: No documentation of medications review. -11/21/23 IDG meeting note: Page 5 of 6, Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification. -12/5/23 IDG meeting note: RN documented ";Patient had decrease in his lisinopril to 20 mg from 40 mg daily." (Page. 3 of 7); and page 7 of 7 medication list documented Lisinopril 40 MG and 20 MG, oral daily. -12/5/23 Hospice Recertification Plan of Care Update (12/14/23 to 2/11/24 period) document: Page 5 of 6, Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification. -SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented ";Medications reviewed"; and no documented observation of two doses of Lisinopril medication. -12/19/23 IDG meeting note: Page 6 of 6, medication list documented Lisinopril 40 MG and 20 MG, oral daily. 1/02/24 IDG meeting note: MD notes (page 3 of 6) described ";MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT."; and page 5 of 6, medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification. -1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 doses of lisinopril (total 60 MG at 9:00 AM for a 5-day respite stay. -1/18/24 Agency Clinical Supervisor RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patients medication profile. -1/22/24 SN narrative note: Patient was discharged from SNF. -1/24/24 SN visit note: BP 86/42; documentation described evidence of patients functional physical decline. Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003Assessments: Page 1 of 6, ";Updates to the comprehensive assessment are completed by the IDT (in collaboration with the patients attending physician (if any) and considers changes that have taken place since the initial or last comprehensive assessment."; page 6 of 6, ";(2) The comprehensive assessment must include: ... (B) a review, repeated as necessary, of the clients medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; Policy AA-005 Hospice Plan of Care: Page 2, ";The POC is reviewed and revised as often as necessary, but no less frequently than every 15 day calendar days.; ... Review of the POC shall include but is not limited to: ... 8. Medications the patient is receiving including ... e. Duplicative therapies ...."; and Policy MA-005, Medication Errors: Page 1 of 1, ";1. A medication error is defined as an error in delivery of any medication by an employee of the agency. Examples of medication errors include, but are not limited to, the wrong dose, route, frequency, patient, patient, medication, or incorrect patient education. Interview conducted on March 13, 2024, at approximately 3:30 PM, with agency administrator confirming the above findings.

Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to ensure the interdisciplinary group maintains responsibility for coordination, supervision, and communication of provided care and services to one (1) of three (3) patients reviewed (CR#1); and agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1). --- Cross Reference: 418.56(e) Coordination of service Tag L554 -- the agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1). 418.56(e)(5) Provide for an ongoing sharing of information between all disciplines providing care/services in all settings Tag L557 -- the agency failed to communicate accurate patient information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1).

Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to ensure the interdisciplinary group maintains responsibility for coordination, supervision, and communication of provided care and services to one (1) of three (3) patients reviewed (CR#1). --- Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed: CR#1 start of care (soc) 6/17/2023: -Patients blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily; documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications. -10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication dosage change to supervisory registered nurse (RN). -10/10/23 Interdisciplinary Group (IDG) meeting notes documented Lisinopril dosage as 40 MG continues for patient. -10/18/2023 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by RN; RN did not document any verification of new medication dose communication with PCP; verbal order obtained by RN from Medical Director physician at 12:04 PM; new dosage order added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error]. -10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patients care documented ";Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification; and Medical Director (MD) notes (page 5 of 8) described ";MD was present throughout the IDT discussion, reviewed medications for interactions, side effects, and appropriateness. ... Reviewed and agreed with POC and changes made at this IDT." -SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented ";Medications reviewed"; and no documented observation of two doses of Lisinopril medication. -SN visit notes for 10/25/23, 11/2/23, 11/8/23, 11/15/23, 11/22/23, and 11/29/23: RNs/LPN documented ";Medications reviewed"; and no documented observation of two doses of Lisinopril medication. -11/7/23, 11/21/23, 12/5/23, 12/19/23, and 1/2/24 IDG meeting minutes document review of medication list with continued list of two doses of Lisinopril 20 MG and 40 MG, by mouth, daily. -SN visit notes for 12/6/23, 12/13/23, 12/20/23, 12/27/23, 1/3/24, and 1/10/24: RNs/LPN documented ";Medications reviewed"; and no documented observation of two doses of Lisinopril medication. -1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF care orders with 2 doses of lisinopril (total 60 MG at 9:00 AM for 5-day respite stay. -1/18/24 Agency Clinical Manager RN initiated and obtained verbal order from agency MD to discontinue Lisinopril 40 MG dose order (6/17/23) and 20 MG dose order (10/18/23). RN added Lisinopril 20 MG tablet, oral, daily order into patients medication profile. Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1-2 of 13 ";Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 11/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74;1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission. Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents ";Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list. Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, ";(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the clients medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; policy Guide for Medication Orders, revised 11/203, ";the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... 6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines – RN/LPN, Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN." Review conducted on March 13, 2024, at approximately 3:10 PM, of agency job title positions revealed: HSP Registered Nurse ";Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physicians orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse: ";Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physicians orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff." Interview conducted on March 13, 2024, at approximately 3:15 PM, with agency administrator revealed confirmation of lack of coordination, supervision, and accurate communication between agency RNs/LPN, Clinical Manager, physicians, and SNF staff; nursing medication transcription error continued from 10/18/23 to 1/18/24 despite many healthcare staff medication reviews and resulted in SNF staff administering duplicate Lisinopril doses (20 MG and 40 MG) to patient for the five respite care days.

Based on review of clinical records (CRs), agency policy, skilled nursing facility (SNF) documents, and interviews with agency administrators, the agency failed to communicate accurate patient medication information to SNF respite care staff in one (1) of three (3) patients reviewed (CR#1). --- Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed: CR#1 start of care (soc) 6/17/2023: -1/17/24 RN/SN narrative note: Patient admitted to skilled nursing facility (SNF) for five-day respite stay; hospice RN performed review of Plan of Care (POC) with SNF RN which contained duplicate orders and doses for lisinopril medication; transfer POC documents given to facility and SNF Medical Director initiated SNF admission care orders with 2 doses of lisinopril (total 60 MG)at 9:00 AM for 5-day respite stay. Review conducted on March 13, 2024, at approximately 2:00 PM, of Respite SNF documents revealed: Pages 1 and 2 of 13 ";Lisinopril 20 MG by mouth x1/day 9:00 AM and Lisinopril 40 MG by mouth x1/day 9:00 AM, documented as administered on 1/18/24 to 1/22/24; and blood pressure measurement were 1/17/24 3:19 PM 136/72; 1/18/24 6:25 AM 118/58; 1/18/24 11:19 AM 120/68; 1/18/24 7:30 PM 122/72; 1/19/2024 10:42 AM 128/76; 1/19/24 7:48 PM 130/74; 1/20/24 12:56 AM 124/67; 1/20/24 10:16 AM 128/66; and 1/20/24 3:53 PM 122/72"; and patient only received Lisinopril 60 MG doses for five days during SNF admission. Review conducted on March 13, 2024, at approximately 2:15 PM, of hospice agency patient transfer documents – ";Client Medication Report" revealed: Page 2 of 3, both Lisinopril 20 MG and 40 MG listed on current medication list. Review conducted on March 13, 2024, at approximately 2:30 PM, of agency policy TX-010 Inpatient Respite Care revealed: ";Services provided in the inpatient setting must conform to the hospices Plan Of Care (POC). The hospice is the professional manager of the patients care." Interview conducted on March 13, 2024, at approximately 3:00 PM, with agency administrator revealed confirmation of above findings.

Based on review of clinical records (CRs), agency policies, and interview with agency administrator, the agency failed to provide appropriate registered nurse supervision for assigned nursing staff to ensure patient medications are accurate in one (1) for three (3) reviewed patients (CR#1). --- Review conducted on March 13, 2024, at approximately 11:00 AM, of clinical records (CRs) revealed: CR#1 start of care (soc) 6/17/2023: -Patients blood pressure medication prescribed by primary care physician (PCP) Lisinopril 40 milligrams (MG)) by mouth, daily, documented on initial comprehensive assessment 6/17/2023; this same dosage is documented on weekly skilled nurse visit notes from June 16, 2023, until October 4, 2024. Daughter/caregiver administers all patient medications. -10/4/2023 skilled nurse (SN) visit note: Daughter/caregiver informed licensed practical nurse (LPN) that the lisinopril dosage had been decreased to 20 mg by mouth daily by patient's primary care physician; LPN did not document any communication of medication dosage change to supervisory registered nurse (RN). -10/10/23 Interdisciplinary Group meeting has no documentation of Lisinopril medication changes from clinical manager nurse or registered nurse associated to CR#1. -10/18/23 SN visit note: Documented lisinopril medication dosage decreased to 20 MG daily by assigned RN; RN did not perform a verification of medication dosage change with PCP; a verbal order obtained by assigned RN from Medical Director physician at 12:04 PM; new dosage Lisinopril order 20 MG, by mouth, daily added to patient medication profile; and no deletion of previous lisinopril medication order for 40 MG daily dose performed by RN [Medication Transcription Error]. -10/24/2023 IDG meeting note: New/added Lisinopril medication dose 20 MG documented; RN assigned to oversee patients care documented ";Med changes None"; Medication list documented Lisinopril 40 MG and 20 MG, oral daily ";Not Related to Terminal Diagnosis" classification. Review conducted on March 13, 2024, at approximately 3:00 PM, of agency policies revealed: Policy AA-003, revised 10/22 Assessments: Page 6 of 6, ";(2) The comprehensive assessment must include: (B) a review, repeated as necessary, of the clients medication list. The medication list must include all prescriptions and over-the counter drugs to assure that all drugs are indicated and to identify any potential problems including, ... (v) duplicate drug therapy ... ."; policy Guide for Medication Orders, revised 11/203, ";the medication POC will include all prescription and over the counter medications, oxygen, and herbal supplements both covered and not covered by the hospice benefit."; policy TX-002 Physician Verbal Orders, Operational Guidelines: ... ";6. In the event that a patient or family member relays information about changes in medications, treatments or any other changes in the plan of care, the clinician must call the prescriber back to verify the order including read-back."; and policy AA-015(a) Supervision of Disciplines – RN/LPN, ";Procedure: ... II. Registered Nurse (RN) ... **The Registered Nurse is supervised by the RN Clinical Manager. III. Licensed Practical Nurse (LPN/LVN) The LPN/LVN is supervised the RN." Review conducted on March 13, 2024, at approximately 3:10 PM, of agency job titles revealed: -HSP Registered Nurse, ";Reports to HSP Director of Operations/HSP Clinical Manager; Responsible for providing, coordinating, and directing the provision of hospice care according to physicians orders, through the competent application of the nursing process, and based on care center policies and procedures. ... 2. Coordinates the total Plan Of Care and maintains continuity of patient care by collaborating with appropriate staff. Revises plan of care as needed. Completes updated Plan Of Care according to state regulation and communicates changes to attending physician, hospice staff, and contractors providing care.; and ... 9. Assists in assigning LPN and Hospice Assistants to individual patients and supervises their care."; and HSP Licensed Practical Nurse, ";Works under the supervision of a Registered Nurse and performs skilled nursing services within scope as delegated by Registered Nurse according to physicians orders.; ... Essential Functions: ... 2. Communicates current health status and needs of patients to the Registered Nurse and other appropriate disciples/staff." Interview conducted on March 13, 2024, at approximately 3:15 PM, of agency administrator revealed confirmation for lack of appropriate registered nurse supervision of assigned nursing staff.