Every finding on record at Jefferson Hospice, 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; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, 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 clinical record review, observation, and interview. In 3 of 3 (100%) home visit observations, the hospice did not ensure the hospice medication profile was updated, at the time of each comprehensive assessment, and when new medication is added, or changes are made in existing medication. CLINICAL RECORD 4/HOME VISIT 1: The patient elected the hospice benefit on 08/09/2024 and resided in an Assisted Living Facility (ALF). During the home visit observation on 05/15/2025 with the Registered Nurse (RN) (Personnel Record 5), a medication review was completed by comparing the hospice medication profile, dated 05/14/2025, to the ALF medication profile. The ALF medication profile included Clopidogrel 75mg take one daily (12/12/2024) and Acetaminophen 325mg take two tablets every 6 hours as needed for fever greater than 99.6 and/or mild pain (08/09/2024). The hospice medication profile did not include Clopidogrel and Acetaminophen 325mg. The Hospice medication profile included Acetaminophen 500mg take two tablets daily as needed for mild pain. The facility confirmed that the patient has been taking the Clopidogrel and Acetaminophen 325mg tablets. During the home visit observation, the RN stated, "I should have reviewed these during my visits, I missed these." CLINICAL RECORD 6/HOME VISIT 2: The patient elected the hospice benefit on 04/10/2025. During the home visit observation on 05/15/2025 with the Social Worker (SW) (Personnel Record 6), a medication review was completed by comparing the hospice medication profile, dated 05/14/2025, to the patient’s current home medications. The patient and sister confirmed an inhaler found at the patient’s bedside was a current medication, Breztri 160mcg/9mcg/4.8mg inhaled two puffs by mouth twice daily. The patient and sister confirmed the patient was using the Breztri inhaler twice daily "for at least the last few years." The hospice medication profile did not include the Breztri inhaler. CLINICAL RECORD 9/HOME VISIT 3: The patient elected the hospice benefit on 08/15/2024 and resided in a Skilled Nursing Facility (SNF). During the home visit observation on 05/16/2025 with the Hospice Aide (HA) (Personnel Record 8), a medication review was completed by comparing the hospice medication profile, dated 05/15/2025, to the SNF medication profile. The hospice medication profile listed Lorazepam 1mg take one tablet every 4 hours as needed for anxiety (08/15/2024). The SNF medication profile included documentation that Lorazepam was discontinued on 03/11/2025 and not listed as a current medication. During joint record review and interview on 05/16/2025, the Director of Clinical Services agreed the hospice medication profiles were not updated and stated, "we need to provide more education and identify a person in the facility to review medications with."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. Review of the agency’s Volunteer Hours/Cost Savings Report for the period dated 01/01/2024 to 12/31/2024 revealed a cost savings of 1%. The report revealed cost savings of 1.1% for the period dated 05/01/2024 to 05/15/2025. During a joint review of the Volunteer Hours/Cost Savings Report and interview on 05/16/2025, the Administrator and the Volunteer Coordinator agreed that the agency did not meet the minimum five percent cost savings requirement for the periods 01/01/2024 to 12/31/2024 and 05/01/2024 to 05/15/2025. The Administrator stated, "We need to work on our recruiting efforts and get more volunteers in the home." The Volunteer Coordinator stated, "Recruitment has been challenging. We need to focus on more recruitment efforts outside of colleges."