Every finding on record at Moments Hospice of Duluth, LLC

IIt 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; [and] 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 measures 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 medications. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency Policy #2-004 stated, in part: "A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, and with the addition of new medication." In 1 of 4 (25%) home visits observed, the agency did not ensure that the patient's drug profile was updated at the time of each comprehensive assessment or when new medications were added. HOME VISIT 2/CLINICAL RECORD 2: This patient elected the hospice benefit on 10/30/2025 with a terminal illness of Alzheimer's Disease. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse Case Manager (RNCM) [Personnel Record 2] on 11/11/2025, the patient's medications were reconciled with the hospice drug profile and the facility medication list. The facility's medication list dated 11/11/2025 documented "hyoscyamine 0.125 mg tablets sublingual every 4 hours 1 time a day as needed for secretions. The hospice drug profile dated 11/10/2025 did not document hyoscyamine. The RNCM found the hyoscyamine order in the facility chart and stated that it had been written but not added to the hospice drug profile. During an interview on 11/12/2025, the Clinical Leader confirmed the finding, stating that the drug profile should have included hyoscyamine.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #7-009 "Hand Hygiene" {revised 01/06/2025} stated in part, "Hand decontamination using an alcohol-based hand rub should be performed: Before having direct contact with patients. After contact with a patient's intact skin...After contact with body fluids or excretions, mucous membranes, non-intact skin..." In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed correctly when indicated per the agency's policy. HOME VISIT 1/CLINICAL RECORD 1: This patient elected the hospice benefit on 03/22/2024 with a terminal diagnosis of Alzheimer's Disease. The patient resided in a skilled nursing facility (SNF). During the home visit on 11/11/2025 with the Hospice Aide (HA) [Personnel Record 1], the HA was observed sanitizing their hands and applying gloves before initiating personal care. The HA cleansed the patient's perineal area and reached into the patient's drawer to obtain cream, without removing gloves and sanitizing hands. The HA then applied the cream to the patient's perineal area without changing gloves or sanitizing their hands. During an interview on 11/11/2025, the Clinical Leader confirmed the finding, stating that the Hospice Aide should have sanitized their hands before reaching into the patient's drawer as per the hospice policy.