Every finding on record at Sovereign 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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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 document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the medication profile was updated with the comprehensive assessment. Agency policy PC.M60 Medications-Profile, stated in part, "A patient specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy." Clinical Record 6: The patient elected the hospice benefit on 02/09/2024. The initial nursing assessment dated 02/09/2024 included documentation that the "Patient has a stage 2 wound to the sacrum. Wound care orders are for hospice and facility staff to apply zinc oxide with brief changes." The medication profile dated 02/09/2024 did not include zinc oxide. In an interview on 04/17/2024, the Administrator reviewed the record and stated, "The zinc oxide is not on the medication profile."

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 2 of 14 (14%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 5: The patient elected the hospice benefit on 03/21/2024. The initial nursing assessment dated 03/21/2024 included documentation that the "Patient is a diabetic and takes insulin. Instructed on signs and symptoms of hypo/hyperglycemia and what to report." The plan of care dated 03/21/2024 through 05/20/2024 contained no documented evidence of interventions related to the patient's diabetes diagnosis. Clinical Record 6: The patient elected the hospice benefit on 02/09/2024. The initial nursing assessment dated 02/09/2024 included documentation that the "Patient has a stage 2 wound to the sacrum. Wound care orders are for hospice and facility staff to apply zinc oxide with brief changes." The plan of care dated 02/09/2024 through 05/08/2024 contained no documented evidence of interventions related to the sacral wound. In an interview on 04/17/2024, the Administrator reviewed the records and stated, "There are no interventions on these plans of care for diabetes or the sacral wound."

It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed with aide services provided, the agency did not ensure the RN prepared written patient specific care instructions for the hospice aide. Clinical Record 6: The patient elected the hospice benefit on 02/09/2024. The initial nursing assessment dated 02/09/2024 included documentation that the "Patient has a stage 2 wound to the sacrum. Wound care orders are for hospice and facility staff to apply zinc oxide with brief changes." The aide care plan dated 02/09/2024 did not include care instructions for the aide related to the patient’s sacral wound. Clinical Record 9: The patient elected the hospice benefit on 12/22/2023. The clinical record included a physician's order dated 12/22/2023 that stated "Cleanse sacral wound with wound cleanser, fill wound with calcium alginate, and cover with a bordered gauze dressing. Change dressing three times a week." The aide care plan dated 12/26/2023 did not include care instructions for the aide related to the patient’s sacral wound. In an interview on 04/17/2024, the Administrator reviewed the records and stated, "There are no instructions regarding the wounds on these aide care plans."

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. 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 that physician's orders were included in the clinical record. Clinical Record 6: The patient elected the hospice benefit on 02/09/2024. The initial nursing assessment dated 02/09/2024 included documentation that stated "Patient has a stage 2 wound to the sacrum. Wound care orders are for hospice and facility staff to apply zinc oxide with brief changes." The clinical record contained no documented evidence that a physician order was obtained for the application of zinc oxide and the care of the sacral wound. In an interview on 04/17/2024, the Administrator reviewed the record and stated, "I do not see a physician's order for the zinc oxide."