Every finding on record at Suncrest Hospice 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: 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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the medication profile was updated when new medications were added to the patient's medication regimen. Clinical Record 17: The patient elected the hospice benefit on 08/31/2023 with a diagnosis of Parkinson's Disease. The Registered Nurse (RN) recertification assessment dated 02/19/2024 documented that the patient was started on Marinol to increase appetite. A review of the clinical record revealed the medication profile did not document Marinol. During an interview and a joint record review, the Administrator confirmed that there was no evidence of a physician's order for this medication, and the medication was not included in the patient's medication profile. The Administrator confirmed that the patient was started on Marinol. Clinical Record 12: The patient elected hospice services on 04/23/2023 with a diagnosis of malignant neoplasm of the lung. An order to collect stool for C-diff (Clostridium difficile) was written on 07/26/2023. During an interview and a joint record review, the Administrator provided an email documenting that the stool sample was collected on 08/08/2023 with positive results on 08/10/2023. Additionally, the email documented that on 08/11/2023, the patient was started on Vancomycin 125mg capsule every 6 hours for (10) 10 days and placed in isolation for 48 hours. The patient's medication profile did not document Vancomycin. During the interview, the Administrator confirmed the patient's clinical record and medication profile did not document Vancomycin.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 19 (11%) clinical records reviewed, the agency did not ensure the plan of care included all problems, with specific interventions and goals, as identified in the comprehensive assessments. Clinical Record 12: The patient elected hospice services on 04/23/2023 with a diagnosis of malignant neoplasm of the lung. An order to collect stool for C-diff (Clostridium difficile) was written on 07/26/2023. A clinical record review revealed no documentation of the sample being collected, lab results, or what or when the antibiotics were started. During an interview and a joint record review, the Administrator provided an email documenting that the stool sample was collected on 08/08/2023 with positive results on 08/10/2023. Additionally, the email documented that on 08/11/2023, the patient was started on Vancomycin 125mg capsule every 6 hours for 10 days and placed in isolation for 48 hours. The plan of care did not include documentation of interventions and goals for the C Diff. During an interview and a joint review of the clinical record and plan of care, the Administrator confirmed the plan of care did not include documentation of goals and interventions for for C-Diff. Clinical Record 14: The patient elected the hospice benefit on 11/27/2023 with a diagnosis of unspecified severe protein-calorie malnutrition. The initial nursing assessment completed by the Registered Nurse (RN) dated 11/27/2023 documented that the patient has had ongoing diarrhea for several months with no relief. The plan of care dated 11/27/2023 did not include documentation of problems, goals, or interventions for the patient's diarrhea. During an interview, the Administrator and Director of Quality confirmed that the care plan lacked appropriate documentation for this identified problem.

It is required that each patient’s individualized written plan of care: 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 19 (11%) clinical records reviewed, the agency did not ensure the plan of care included drugs and treatment necessary to meet the patient's needs. Clinical Record 12: The patient elected hospice services on 04/23/2023 with a diagnosis of malignant neoplasm of the lung. An order to collect stool for C-diff (Clostridium difficile) was written on 07/26/2023. A clinical record review revealed no documentation of the collected sample, lab results, or what or when the antibiotics were started. During an interview and a joint record review, the Administrator provided an email documenting that the stool sample was collected on 08/08/2023 with positive results on 08/10/2023. Additionally, the email documented that on 08/11/2023, the patient was started on Vancomycin 125mg capsule every 6 hours for 10 days and placed in isolation for 48 hours. The plan of care did not document Vancomycin. During an interview and a joint review of the clinical record and plan of care, the Administrator confirmed the plan of care did not include Vancomycin. Clinical Record 17: The patient elected the hospice benefit on 08/31/2023 with a diagnosis of Parkinson's Disease. The Registered Nurse (RN) recertification note dated 02/19/2024 documented that the patient was started on Marinol to increase appetite. A clinical record review revealed the plan of care did not document Marinol. The Administrator confirmed that the patient was started on Marinol. During an interview and a joint record review, the Administrator confirmed that the medication was not included in the patient's medication profile and plan of care.

It is required that 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 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the patient's record contained clinical notes including the care and services provided. Clinical Record 12: The patient elected hospice services on 04/23/2023 with a diagnosis of malignant neoplasm of the lung. An order to collect stool for (Clostridium difficile) C-diff was written on 07/26/2023. A review of the clinical record revealed no documentation of the sample being collected, lab results or what or when the antibiotics were started. During an interview and a joint record review, the Administrator provided an email documenting the stool sample was collected on 08/08/2023 with positive results on 08/10/2023. Additionally, the email documented that on 08/11/2023 the patient was started on Vancomycin 125 mg capsule every 6 hours for 10 days and placed on isolation for 48 hours.

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 19 (5%) clinical records reviewed, the agency did not ensure that physician orders were obtained for patient medications. Clinical Record 17: The patient elected the hospice benefit on 08/31/2023 with a diagnosis of Parkinson's Disease. The Registered Nurse (RN) recertification assessment dated 02/19/2024 documented that the patient was started on Marinol to increase appetite. During an interview and a joint record review, the Administrator confirmed that there was no evidence of a physician's order for this medication. The Administrator confirmed that the patient was started on Marinol.