Every finding on record at Sweet Memories Palliative Hospice Care 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 treatment that could affect drug therapy. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the drug profile included the patient’s current prescription medications. Clinical Record 2: This patient elected the hospice benefit 11/16/2024 with a hospice diagnosis of congestive heart failure with a comorbidity of diabetes. In the comprehensive assessment, dated 11/16/2024, the Registered Nurse (RN) documented that they “observed the caregiver administer insulin to the patient.” In review of the clinical record, there was no documentation that the insulin had been included on the drug profile. The clinical record did include orders from the hospitalization for the insulin and that the patient resided in a group home. The Alternate Administrator and Registered Nurse (Personnel Record 2) were interviewed on 12/05/2024. The RN stated that the patient returned from the hospital with orders for insulin, but the patient's son, who was the health care decision maker, was adamant that the patient not receive insulin. The RN reportedly did not include the insulin on the drug profile because the intention was to discontinue it, but there was no documented evidence that the insulin had been discontinued.

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 1 of 5 (20%) clinical records reviewed, the agency did not ensure that the plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 2: This patient elected the hospice benefit 11/16/2024 with a terminal diagnosis of congestive heart disease with a comorbidity of diabetes. In the RN comprehensive assessment dated 11/16/2024, the Registered Nurse (RN) documented the patient had a diagnosis of diabetes and the RN observed the caregiver administer insulin to the patient. The plan of care dated 11/17/2024, stated “the patient's blood sugar would be maintained at an optimal level for patient's illness and that patients' neuropathy/radiculopathy would be managed with medications.” There was no evidence of interventions to measure the patient's blood sugar and no documentation of parameters for the blood sugar level. The Alternate Administrator and Registered Nurse were interviewed on 12/05/2024 and confirmed the plan of care did not include interventions based on problems identified in the initial comprehensive assessment.