Every finding on record at Stch Wausau Wi 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; [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; [and] 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, interview, and observation. In 2 of 6 (33%) clinical records reviewed and home visits observed, the hospice did not ensure that all medications were reviewed as part of the comprehensive assessment and updated to the drug profile. Clinical Record 1/Home Visit 1: The patient elected hospice care on 03/28/2024 and resided at home. A medication reconciliation was performed during the home visit with the Hospice Aide [Personnel Record 7] on 05/01/2024. The hospice medication profile dated 03/28/2024 through 05/01/2024 was compared to the patient’s current medication regimen. The medications presented and confirmed by the patient’s son included Ondansetron 4 mg, every 6 hours as needed for nausea and Cranberry plus probiotic every day. The Registered Nurse (RN) visit note dated 04/18/2024 documented that the patient reported feeling nauseated, that Ondansetron 4 mg did not relieve the nausea, and that Ondansetron was increased to 8 mg per the physician. The son reported Ondansetron has been used as needed while on hospice, and Cranberry plus probiotic tablets is part of the patient's daily medication regimen. There was no documented evidence that the Ondansetron 4 mg and Ondansetron 8 mg were updated to the hospice medication profile. There was no documented evidence that the Cranberry plus probiotic was reviewed as part of the comprehensive assessment and updated to the drug profile. Clinical Record 2 /Home Visit 2: The patient elected hospice care on 04/01/2024 and resided at home. A medication reconciliation was performed during the home visit with the Social Worker [Personnel Record 5] on 05/01/2024. The hospice medication profile dated 04/01/2024 through 05/01/2024 was compared to the patient’s current medication regimen. The medications presented and confirmed by the patient and spouse included Tums Calcium Carbonate extra strength 750mg and Mucinex (Guaifenesin) 100mg/5 ml twice daily for cough. The patient and spouse reported that Mucinex was taken twice a day. The RN visit note dated 04/27/2024 documented that the RN reached out to the physician for an order for Mucinex and then ordered it from the pharmacy. There was no documented evidence that the Mucinex (Guaifenesin) was updated to the drug profile. The patient reported that Tums have been part of their regimen and are used at least a few times a week. There was no documented evidence that Tums were reviewed as part of the comprehensive assessment and updated to the drug profile. During a joint record review and interview on 05/02/2024, the Manager of Clinical Services agreed there was no documented evidence that the medications were reviewed as part of the comprehensive assessment and updated to the drug profile.