Every finding on record at Solterra Hospice Corporation

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, 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 and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure the drug profile contained the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and was updated when new medications were added, or changes were made to existing medications. Home Visit 1: The patient elected the hospice benefit on 12/10/2024 with a diagnosis of osteomyelitis of the vertebra. The patient resided in a skilled nursing facility (SNF). During the home visit observation on 03/12/2025 with the Nurse Practitioner (Personnel Record 2), a medication review was completed by comparing the hospice medication profile (printed on 03/12/2025) to the SNF medication list (printed on 03/12/2025). The SNF medication list included an order dated 11/29/2024 for Levothyroxine 125 mcg, take 2 tablets by mouth six days a week. The hospice medication profile included Levothyroxine 125 mcg, take 1 tablet by mouth six days a week. Home Visit 2: The patient elected the hospice benefit on 02/26/2025 with a diagnosis of ischemic cardiomyopathy. The patient resided in a SNF. During the home visit observation on 03/12/2025 with the Spiritual Counselor (Personnel Record 5), a medication review was completed by comparing the hospice medication profile (printed on 03/12/2025) to the SNF medication list (printed on 03/12/2025). The hospice medication profile included an order for "Zyprexa 5 mg. give one tablet by mouth once daily (ordered 02/28/2025)." Zyprexa was not listed on the SNF medication list. During an interview and medication review conducted with the Administrator on 03/13/2025. The Administrator stated the "omission of Zyprexa in Home Visit 2's record was noticed yesterday, after the home visits but they had not noticed the Levothyroxine until today." The Administrator acknowledged both discrepancies.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized care plan was reviewed and revised as frequently as the patient's condition required, but no less frequently than every 15 calendar days. Clinical Record 9: The patient elected the hospice benefit on 01/01/2025. Clinical record review revealed the nurse documented on the nursing visit note dated 02/02/2025 that the "Patient is anxious with care from aide. Wounds not assessed today due to anxiety. Increased respiration rate due to anxiety. Lorazepam 0.5 mg added for anxiety." The patient’s individualized plan of care did not include problems, interventions, or goals related to anxiety, and the plan of care was not updated or revised after the nurse assessed the change in the patient’s condition related to increased signs of anxiety. During a joint clinical record review and interview on 03/13/2025, the Director of Quality agreed the patient’s plan of care should have been updated to reflect the "patient's latest status, medication changes, and level of care changes."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure the clinical record contained clinical notes that included the care and services provided. Clinical Record 1: The patient elected the hospice benefit on 12/10/2024. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. Clinical Record 2: The patient elected the hospice benefit on 02/26/2025. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. Clinical Record 4: The patient elected the hospice benefit on 12/23/2024. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. Clinical Record 5: The patient elected the hospice benefit on 12/06/2024. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. Clinical Record 6: The patient elected the hospice benefit on 03/01/2024. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. Clinical Record 7: The patient elected the hospice benefit on 03/10/2025. The plan of care included orders for skilled nurse and hospice aide services. Clinical record review revealed the skilled nurse was providing the hospice aide visits. However, the skilled nurse did not complete an aide visit note that included documentation of the aide tasks provided to the patient and the patient’s response to the aide services provided. During an interview on 03/11/2025, the Administrator and the Director of Quality stated, "the RNs [Registered Nurse] were completing the aide tasks during their RN visits and not documenting them as separate [aide] visits." They further explained that the "RNs had extended visit time to be able to complete the aide tasks and become more familiar with each patient but didn't realize each visit would need to be separated out." A review was conducted of Clinical Records 1, 2, 4, 5, 6, and 7 on 03/11/2025 and 03/12/2025. During this review, it was noted the registered nurses (RN) were providing hospice aide services for these patients. The RNs were not documenting these hospice aide visits on clinical notes and accounting for the tasks they were performing as aides. During an interview on 03/11/2025 with the Administrator and Director of Quality, they stated "the RNs were completing the aide tasks during their RN visits and not documenting them as separate visits." They further explained that the "RNs had extended visit time to be able to complete the aide tasks and become more familiar with each patient but didn't realize each visit would need to be separated out."