Every finding on record at Shekina Glory Legacy Hospice and Palliative Services 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, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: 1. The effectiveness of drug therapy; 2. Drug side effects; 3. Actual or potential drug interactions; 4. Duplicate drug therapy; 5. 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, document review, observation, and interview. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient's current prescription and over the counter drugs. Agency policy PC.17 Medication List and Monitoring stated in part, “The medication profile will include dosage, frequency, and route.” Clinical Record 1: The patient elected the hospice benefit dated 08/03/2023. The 09/27/2023 updated medication profile included orders that stated, Albuterol Sulfate solution 2.5mg/3ml 1 vial every six hours as needed for shortness of breath and Albuterol H-F14 90mcg 2 puffs every six hours as needed for shortness of breath. The orders did not include a routine of administration for the Albuterol Sulfate or Albuterol H-F14. During the home visit observation, it was observed that the patient had bottles of Nyquil and Centrum on the bedside table. The patient stated, “I took Nyquil for flu like symptoms, and I take a Centrum vitamin every single day for my health.” Centrum and Nyquil were not listed on the patient’s medication profile. Clinical Record 2: The patient elected the hospice benefit dated 09/05/2023. The medication profile updated 09/27/2023 included an order that stated Potassium Chloride 20Meq daily. The order on the medication profile did not include a route of administration for the medication. Clinical Record 4: The patient elected the hospice benefit dated 07/13/2023. The medication profile updated 08/02/2023 included an order that stated MiraLAX 75 gm daily. The order on the medication profile did not include a route of administration for the medication. During an interview on 10/05/2023, the Administrator reviewed the associated records and stated routes of medication administration had inadvertently been omitted. Administrator stated a follow up nursing visit had been made on 10/04/2023 to Clinical Record 1 patient, medications had been reviewed, physician orders obtained, and the medication profile updated.

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. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that entries in the patient record were appropriately authenticated and dated by the person performing the care/service. Clinical Record 1: The patient elected the hospice benefit dated 08/03/2023. The initial psychosocial assessment dated 08/05/2023 was completed by the Social Worker. The psychosocial assessment was signed by the Social Worker and included the Social Worker’s credentials but did not include the date the assessment was signed by the Social Worker. Clinical Record 2: The patient elected the hospice benefit dated 09/05/2023. The initial psychosocial assessment dated 09/08/2023 was completed by the Social Worker. The psychosocial assessment was signed by the Social Worker and included the Social Worker’s credentials but did not include the date the assessment was signed by the Social Worker. Clinical Record 3: The patient elected the hospice benefit dated 09/22/2023. The initial psychosocial assessment dated 09/25/2023 was completed by the Social Worker. The psychosocial assessment was signed by the Social Worker and included the Social Worker’s credentials but did not include the date the assessment was signed by the Social Worker. Clinical Record 4: The patient elected the hospice benefit dated 07/13/2023. The initial psychosocial assessment dated 07/17/2023 was completed by the Social Worker. The psychosocial assessment was signed by the Social Worker and included the Social Worker’s credentials but did not include the date the assessment was signed by the Social Worker. Clinical Record 5: The patient elected the hospice benefit dated 07/13/2023. The initial psychosocial assessment dated 07/15/2023 was completed by the Social Worker. The psychosocial assessment was signed by the Social Worker and included the Social Worker’s credentials but did not include the date the assessment was signed by the Social Worker. The initial spiritual assessment and bereavement risk assessment dated 07/13/2023 were completed by the Chaplain. The assessments were signed by the Chaplain and included the Chaplain’s credentials but did not include the dated the assessment was signed by the Chaplain. During an interview on 10/05/2023, the Administrator reviewed the associated records and stated that education had been provided to clinicians and dates had since been entered.