Every finding on record at Lg Palliative and 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, 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 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 a review of clinical records, document reviews and interviews. 2 of 5 (40%) records reviewed revealed the agency did not follow it's own policy regarding documentation of the patient's medication regimen on a drug profile and did not ensure a complete drug profile review was performed. Record 1: Patient elected hospice benefit on 12/26/22. The medication profile included a list of medications documenting the patient's medication regimen but did not include a date to indicate when the medication profile was initiated. Record 3: Patient elected hospice benefit on 2/3/23. A hospice nursing clinical note dated 2/14/23 documented “O2 (oxygen) at 2-4 liters, O2 saturation 92% on 2L (liters)" and a hospice IDG (interdisciplinary) meeting/care plan update” on 2/16/23 documented “Assess/perform nebulizer inhalation treatments Ipratropium/Albuterol 94% PRN." Oxygen and Ipratropium/Albuterol were not listed on the patient's medication profile. There was no documented evidence that a drug regimen review included all medications. Policy No. 4-050.1 Medication Profile, Revised April 2017 stated in relevant part, "Upon admission to hospice the admitting nurse will initiate a medication profile to document the current medication regimen," and "a drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment." During an interview on 2/23/23, the Administrator agreed the medication profile did not contain all of the medications the patient was taking, and did not include dated evidence of when review occurred.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised Plan of Care (POC) includes a record of the patient’s progress toward the outcomes and goals specified in the POC. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 5 (20%) records reviewed revealed the agency did not ensure documented evidence of the patient's progress toward the goals and outcomes as part of the revised POC. Record 1: Patient with election of benefit on 12/26/22. The "Hospice IDG (interdisciplinary) Meeting/Care Plan Update" dated 1/5/23 indicated pain was an active care plan problem with a goal of “patient’s pain will remain at a comfortable level during care within cert period of time." The care plan update also indicated "cardio/respiratory" was an active care plan problem with goals “patient/caregiver will receive optimal teaching and support as cardiac and pulmonary functions change during the care” and “patient/caregiver will demonstrate proper and safe use of oxygen set up”. There was no progress toward goals/outcomes documented for the pain and cardio/respiratory goals. During an interview on 2/23/23, the Administrator confirmed the findings and stated, "that section where it says progress towards goals/outcomes is blank."