Every finding on record at Moments Hospice of Rochester, 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; [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 medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 14 (14%) clinical records reviewed and home visits observed, the hospice did not ensure the comprehensive assessment included a medication profile that contained the patient's current medications. Clinical Record 4/Home Visit 1: The patient elected hospice care on 01/03/2023 with a diagnosis of hypertensive heart disease with heart failure. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 6] on 05/21/2025, a medication review was completed comparing the hospice medication profile, dated 05/21/2025, to the SNF (Skilled Nursing Facility) medication profile. The SNF medication profile reviewed included current medications, MiraLAX 17 grams in 8 ounces daily as needed for constipation (09/26/2024), acetaminophen 500mg, take one (1) every 6 hours as needed for fever or pain (11/25/2024), and bisacodyl 10mg suppository rectally as needed for constipation (01/18/2025). Additionally, the SNF medication profile documented that the lorazepam tablet was a discontinued medication (03/21/2025-04/21/2025). The hospice medication profile reviewed on 05/21/2025 included an active order for lorazepam 0.5mg, take one (1) tablet every 4 hours as needed for agitation or anxiety (01/03/2023). The hospice medication profile did not document MiraLAX, acetaminophen, and bisacodyl, and was not updated to include the change to the lorazepam. There was no evidence that the MiraLAX, acetaminophen, and bisacodyl were reviewed with the patient's medication regimen. Clinical Record 6/Home Visit 2: The patient elected hospice care on 02/25/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 05/21/2025, a medication review was completed comparing the hospice medication profile, dated 05/21/2025, to the ALF (Assisted Living Facility) medication profile. The ALF medication profile documented naloxone 4mg, one (1) spray into one nostril as needed for reversal (09/26/24). The hospice medication profile did not document naloxone. There was no evidence that Naloxone was reviewed with the patient's medication regimen. During the joint record review and interview on 05/21/2025, the Team Director, who was present at the home visit, agreed there was no evidence that the hospice medication profile was updated with the medications identified. Additionally, the Team Director stated, "I will be providing more education to the nurses."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 12 (8%) clinical records reviewed of patients receiving Hospice Aide services, the hospice did not ensure that the Hospice Aide received written patient instructions to meet the needs of the patient. Clinical Record 1/Home Visit 3: The patient elected hospice care on 03/25/2024 with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The HA care plan dated 04/22/2025 assigned the HA the relevant tasks of skin care: cleanse under the abdominal fold and groin area with soapy water, dry well, and apply powder. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 05/21/2025, the patient's bedside table included Gold Bond Ultimate powder, Arm and Hammer Non-Talc powder, medicated over-the-counter powder, and Nystatin powder. A review of the HA care plans dated 04/01/2025 through 05/21/2025 did not specify which powder the HA should use. The HA documentation did not include the type of powder used. The RN [Personnel Record 5] stated during the interview, "I can see how this leaves it to the aide to decide, I will update the aide's plan of care." During the home visit, a joint record review, and interview on 05/21/2025, the Team Director stated, "The plan of care should have made it clear which powder to provide. The HA should not be making that decision. I will be providing education to the nurses."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed of patients who received Hospice Aide services, the hospice did not ensure that the Hospice Aide provided services included in the plan of care. Clinical Record 1: The patient elected hospice care on 03/25/2024 with a diagnosis of atherosclerotic heart disease of the native coronary artery without angina pectoris. The HA care plans dated 04/01/2025 through 05/21/2025 assigned the HA the relevant tasks: keep wound dressing dry during care, if dressing not in place or saturated, contact Registered Nurse Case Manager (RNCM). The HA visit notes dated 04/14/2025 documented new bandages applied; 04/15/2025 documented four (4) new bandages applied; and 04/16/2025 documented new bandages applied. The HA care plan did not include documentation of instructions for the HA to apply new bandages to the wounds. Clinical Record 10: The patient elected hospice care on 02/01/2023 with a diagnosis of atherosclerotic heart disease of the native coronary artery without angina pectoris. The HA care plan dated 01/21/2025 assigned the HA the relevant task: shower every visit. The HA visit note dated 01/30/2025 documented that the shower was "not completed, not ordered this visit." There was no evidence that the HA care plan bath type had changed. During a joint record review and interview on 05/21/2025, the Team Director agreed that the HA did not provide services as assigned in the care plan. Additionally, the Team Director stated that the aides will need more education, and the aides should follow the plan of care and complete the assigned tasks.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records it was revealed the agency did not ensure the clinical record contained physician orders for oxygen. Clinical Record 8: The nursing admission comprehensive assessment (dated 4/1/22) stated the patient had "oxygen in use at 4L (liters) continuous." The plan of care (effective 4/1/22 through the 5/19/22 discharge date), listed "altered respiratory status" as a problem, but did not evidence detailed oxygen usage. The medication list, (effective 4/1/22 through the 5/19/22 discharge date), did not include oxygen. In an interview with the Director of Compliance (Staff 5), conducted on 8/11/22, she reported that the plan of care and medication list are the only two areas where an order for the oxygen would be generated and agreed "continuous oxygen at 4 liters" was not present in either, thus there was no order in evidence.