Every finding on record at Patmos Hospice Inc

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 measurements 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 revealed that the agency did not ensure that the comprehensive assessment identified medications or treatments that the patient was currently taking, and that any potential adverse effects and drug reactions were identified. 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 measurements 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 revealed the agency did not ensure that the drug administration record was reconciled at the time of the comprehensive assessments. CLINICAL RECORD 2/HOME VISIT 2: This patient elected the hospice benefit 03/27/2025 with a terminal diagnosis of COPD. The registered nurse initial comprehensive assessment and medication profile was dated 03/27/2025. During the home visit with the registered nurse (RN) (Personnel Record 2) on 05/08/2025, a review of the agency medication profile was reviewed with the RN and patient’s caregiver. The agency medication profile listed Atorvastatin 10 mg daily per G-tube and the patient’s home medication list was Atorvastatin 80mg 80 mg daily per G-tube. An interview was conducted with the Registered Nurse (RN) during the home visits on 05/08/2025 and the RN stated that the hospice drug profile did not reconcile with the patient's medication list in the home. The RN reconciled the medication lists to ensure accuracy between the hospice drug profile and the medication list in the home. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit 03/28/2025 with a terminal diagnosis of COPD. During the home visit with the hospice aide (Personnel Record 3), a review of the patient’s medication was reviewed with the RN (Personnel Record 2) and caregiver revealed Hydrocodone Acetaminophen one tablet every four hours as needed for pain was included in the patient medication box but was not on the hospice drug profile. Lidocaine patch four% apply one patch daily was on the hospice drug profile, but there were no patches in the home. The RN reconciled the medication lists to ensure accuracy between the hospice drug profile and the medication list in the home and ordered the lidocaine patches during the visits.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 11: This patient elected the hospice benefit 11/03/2023 with a terminal diagnosis of atherosclerotic heart disease. The physician's orders dated 11/02/2023 stated the patient's diagnoses included Type 2 diabetes mellitus with unspecified complications. The initial drug profile from admission on 11/03/2023-01/05/2024 included Levemir subcutaneous solution 100 units/ml inject 20 units in the abdomen at night. The drug profile was updated on 11/03/2023 which included Humalog subcutaneous solution 100 units/ml 6 units in the stomach daily, Metformin HCL oral tablet 1000 mg 1 tablet by mouth daily, and Glipizide oral tablet 5 mg 1 tablet daily. In review of the plan of care there was no care plan for education of the change in medications for diabetes. In review of the Registered Nurse (RN) comprehensive visit for 12/27/2024, it was documented that the patient was reporting pain, mostly at night, at pain level of 5. The patient's pain goal was 3. The physician was notified, and an order was received for hydrocodone 10/325mg for pain of 5 at night. The documentation included titrate pain medications as ordered, always monitor the effectiveness of pain medication after it is given and notify nurse the next time pain is noted at night. The initial care plan for pain was dated 11/03/2023 and the outcome timeframe for the patient to be comfortable was within 0-24 hours of admission. In review of the plan of care for 12/27/2023-01/05/2024, there was no update to the plan of care for pain. An interview was conducted 05/07/2025 with the Administrator, and it was stated that the orders were changed but the plan of care was not updated.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that nursing services provided care for the patient as per the patient plan of care. CLINICAL RECORD 5: This patient elected the hospice benefit 02/25/2025 with a hospice diagnosis of alcoholic cirrhosis of the liver. The registered nurse (RN) comprehensive assessment dated 02/25/2025 documented a sacral stage 2 pressure ulcer L 6 cm W 4cm D 3cm, wound is approximated, wound color is gray and necrotic of 70%, with serosanguineous drainage. The physician orders written 02/25/2025 directed the RN to clean stage two sacral wound with a wound cleanser. Pat peri-wound dry with two dry 4X4 gauze pads lightly packed with collagen Ag (silver), and cover with a super-absorbent dressing daily and as needed if loose or soiled. Use aseptic techniques. In review of the clinical record, there was no documentation that the RN provided wound care from 02/26/2025-03/06/2025. This patient expired 03/06/2025. The discharge summary described the wound at discharge as a stage 2 pressure ulcer. In an interview conducted with the Administrator on 05/07/2025, it was stated that the Administrator/RN, performed the wound care daily, but did not complete documentation to support this statement.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 3 of 11 (27%) discharged clinical records reviewed, the agency did not ensure that a copy of the hospice discharge summary was sent to the attending physician. CLINICAL RECORD 5: This patient elected the hospice benefit 03/01/2024 with a terminal diagnosis of COPD. The patient was discharged 05/29/2024 as it was determined by the hospice Interdisciplinary Group (IDG) that this patient was no longer terminally ill. A discharge summary dated 05/29/2024 was included in the clinical record, but there was no documentation that the agency provided the attending physician a copy of the hospice discharge summary. CLINICAL RECORD 10: This patient elected the hospice benefit 06/13/2024 with a terminal illness of atherosclerotic heart disease. The patient revoked hospice services 06/13/2024 to seek aggressive treatment. There was no documentation that the agency provided the attending physician a copy of the hospice discharge summary. CLINICAL RECORD 11: This patient elected the hospice benefit 11/03/2023 with a terminal diagnosis of atherosclerotic heart disease and revocated hospice services on 01/05/2024 to seek aggressive treatment. There was no documentation that the agency provided the attending physician a copy of the hospice discharge summary. An interview was conducted with the Administrator on 05/07/2025, and it was stated that the clinical records did not include a discharge summary to the physician.

Upon patient record review, 3 of 5 (Patient #1-3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 The patient has orders for oxygen use that are not included in the medication profile. The patient also has orders for promethazine, levsin, tylenol, morphine and bisacodyl that are not included in the medication profile. Patient #2 The patient has order for promethazine, levsin, morphine and bisacodyl that are not included in the medication profile. Patient #3 The patient has orders for promethazine, levsin, morphine, tylenol, and bisacodyl that are not included in the medication profile. The patient record indicates teaching and encouragement of use of Ibuprofen on 1/28/22 for pain management, but there is no evidence of Ibuprofen on the medication profile.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3 The patient record indicates teaching and encouragement of use of Ibuprofen on 1/28/22 for pain management, but there is no evidence of an order for Ibuprofen.

Upon patient record review, 4 of 5 (Patient #1-4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1 There is evidence in the record that the patient was treated for a UTI starting on 1/13/22, that was not included and updated in the plan of care. Patient #2 The patient documentation reflects changes in condition to reflect dysphagia on 12/28/21, constipation on 1/18/22 and safety issues on 2/15/22 that are not updated in the plan of care. Patient #3 There is evidence in the record that the plan of care was not updated or revised to reflect constipation starting 2/6/22 and dehydration as documented on 1/21/22. Patient #4 The plan of care was not revised to reflect the patients changes in condition and s/s of approaching death on 1/21/22.

Upon client record review, 4 of 5 (Patient #1, 2, 3, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-3 There is no evidence of a SW or SC visit for the month of March, the POC order is for monthly visits for these disciplines. Patient #5 The plan of care reflects SN visits 2 x per week, but the patient record reflects one visit per week.