Every finding on record at Loving Arms 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 This standard was not met as evidenced by clinical records, observations, and interviews. In 1 of 6 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the drug profile included all the patient's prescriptions and over-the-counter drugs to be included in the medication review for effectiveness of drug therapy. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 09/09/2025. During a home visit conducted on 10/01/2025, with a Registered Nurse (Personnel Record 1), medication reconciliation revealed that the patient was currently taking Baby Aspirin 81 mg daily, Gas Relief (2 tablets daily as needed), Bisacodyl 5 mg tabs 1 tab (daily as needed), and Acetaminophen 500 mg (every 4 hours as needed). These medications are not listed on the agency’s current drug profile. Additionally, Glipizide, which the patient reported they had discontinued back in July 2025 remained listed on the agency’s drug profile. The medication review process did not include all the medications was currently taking. Following the joint record review and observation during the home visit on 09/30/2025, the Director of Nursing agreed that all of the patient's medications were not included on the agency's medication list.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by interview and personnel record review. In 1 of 8 (12%) personnel records reviewed it was revealed that the agency did not ensure that all employees and contracted staff, with patient and family contact, where oriented to the hospice philosophy. PERSONNEL RECORD 8: The Medical Director was hired on 09/04/2024 as a contracted employee. The personnel record lacked evidence of orientation to the hospice philosophy. Following joint personnel record review and interview with the Director of Nursing on 10/02/2025, she agreed that his personnel file does not include all the required information.