Every finding on record at Pro Care 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. 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. 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 a review of clinical records, interviews and observations. 2 of 7 (29%) clinical records reviewed revealed that the hospice did not ensure drug profiles were updated to include all medications. Clinical Record 2: The clinical record was reviewed and identified that the patient elected the hospice benefit on 1/6/2023. During a home visit completed with the Social Worker on 1/11/2023 it was observed that the patient was on Oxygen at 3 lpm. Oxygen was not included on the drug profile. Clinical Record 6: The clinical record was reviewed and identified that the patient elected the hospice benefit on 12/10/2022. The narrative note completed by the nurse during the admission assessment stated, in part "Sleep interrupted due to shortness of breath, patient has severe shortness of breath and has to sleep with oxygen." Oxygen was not included on the drug profile. The designated Administrator was interviewed on 1/11/2022 and he had no additional information to provide.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 7 (43%) clinical records reviewed identified that all entries in the patient record were not appropriately authenticated by the person performing the care. Clinical Record 5: The clinical record was reviewed and identified that the patient elected the hospice benefit on 12/11/2022. There were two notes from the CNA completed on 12/13/2022 and 12/16/2022 that had a computer-generated signature that did not include the verbiage "electronically signed by" to indicate the signature was authenticated with a password or PIN. Clinical Record 6: The clinical record was reviewed and identified that the patient elected the hospice benefit on 12/10/2022. The admission nurse assessment was not signed/dated by the nurse who completed the assessment. Clinical Record 7: The clinical record was reviewed and identified that the patient elected the hospice benefit on 12/18/2022. There were numerous entries in the clinical record that had a computer-generated signature that did not include the verbiage "electronically signed by" to indicate the signature was authenticated with a password or PIN. These entries included: CTI on 12/19/2022, RN Admission Assessment on 12/19/2022, Bereavement Assessment completed on 12/19/2022, LPN visit on 12/27/2022 and the Discharge Summary completed on 12/30/2022. The designated Administrator was interviewed on 1/11/2022. He agreed that the signatures were not appropriately authenticated and stated that all employees were in the process of getting trained on the EMR which would require electronically authenticated signatures.