Every finding on record at Signature Hospice, 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. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included a drug profile containing all the patient's prescription medications. Clinical Record 4: The patient elected the hospice benefit on 5/12/23. The initial comprehensive assessment completed by the Registered Nurse (RN) on 5/12/23 documented that the patient used "O2 @ 2L via N/C with continuous frequency." The drug profile did not include documentation of oxygen. Clinical Record 5: The patient elected the hospice benefit on 5/26/23. The initial comprehensive assessment completed by the RN on 5/26/23 documented that the patient used "O2 @ 2L via N/C with continuous frequency." The drug profile did not include documentation of oxygen. During an interview on 8/24/23, the Alternate Clinical Director confirmed that Record 4 and Record 5 drug profiles did not include all medications.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the agency did not ensure the plan of care (POC) included current medications necessary to meet the patient's needs. Clinical Record 4: The patient elected the hospice benefit on 5/12/23. The comprehensive assessment completed by the Registered Nurse on 5/12/23 documented that the patient used "O2 @ 2L via N/C with continuous frequency." The POC for the benefit period dated 5/12/23 to 6/28/23 did not include documented evidence of a medication order for oxygen. Clinical Record 5: The patient elected the hospice benefit on 5/26/23. The comprehensive assessment completed by the Registered Nurse on 5/26/23 documented that the patient used "O2 @ 2L via N/C with continuous frequency." The POC for the benefit period dated 5/26/23 to 6/11/23 did not include documented evidence of a medication order for oxygen. During an interview on 8/24/23, the Alternate Clinical Director confirmed that Record 4 and Record 5 did not include medication orders for oxygen, and they should have.