Every finding on record at Nivalis Health 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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and 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 clinical record review, document review, interview and observation. In 2 of 14 (14%) clinical records reviewed, it was revealed that the agency did not ensure that the drug profile included the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and as a result, the current medication profile was not reviewed for the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. Document 1: Policy 11.10.1 (revised 2019) titled, Medication Profile, stated in part, "All prescribed medications, over-the-counter medications and home remedies will be documented on the medication profile." Home Visit 1: During the home visit performed on 01/31/2024 with the hospice aide, an oxygen concentrator with a nasal canula attached was in the patient's room. The patient's spouse stated, "He has been using the oxygen quite a bit lately, especially in the late afternoon and evenings after his naps". The initial plan of care dated 01/04/2024 included the intervention of Oxygen 3L/nasal canula (NC) intermittently and Oxygen 4L/BIPAP continuously. The medication profile reconciled on 01/24/2024 did not included Oxygen 3L/NC intermittently as noted in the plan of care dated 01/4/2024. Clinical Record 5: The initial plan of care dated 01/12/2024 included the intervention of oxygen 3L/NC continuously. The medication profile reconciled on 01/28/2024 did not include the use of oxygen as noted in the plan of care plan dated 01/12/2024. Personnel Record 2: The administrator confirmed findings in a joint record review and interview on 01/31/2024, that the medication profiles did not include the use of oxygen.