Every finding on record at Trilateral Consulting 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. 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, interview, and observation. In 2 of 3 (67%) medication profiles for active hospice patients reviewed revealed that the hospice agency did not ensure that the patient's drug profile contained the patient's current prescription and over-the-counter drugs. The hospice agency did not ensure the patient's drug profile was updated per the hospice policy and procedure. Agency Policy: HCL/PC.85, last reviewed: 100121, stated in part, the hospice will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient. (Medication Profile) Home Visit 1: During home visit #1 with the aide (Personnel Record 8) on 04/25/2024, a review of the assisted living facility (ALF) medication profile was reviewed. The medication profile listed dicyclomine 20mg by mouth (PO) four times a day. The medication was ordered 03/06/2024. The hospice agency's medication profile listed dicyclomine 20mg PO twice a day. The facility also listed gas relief 125 mg soft gel PO every four hours scheduled. The hospice agency listed gas relief 125 mg soft gel PO as needed. The facility had listed Lantus as 100 units/ml, giving 15 units subcutaneously daily at bedtime. The hospice had Lantus 10 units subcutaneously daily. Home Visit 2: During home visit #2 with the social worker (Personnel Record7) on 04/252024, the ALF medication profile was reviewed. The ALF medication profile listed acetaminophen 650 mg suppository rectally every four hours as needed, bisacodyl 10 mg suppository daily as needed, promethazine 25 mg by mouth every six hours as needed, and morphine sulfate 100mg/5ml, give 0.25 ml by mouth or sublingually every four hours as needed. The medications were ordered on 12/22/2023. Memantine Hcl 10 mg by mouth daily was ordered on 03/13/2023. None of these medications were listed on the hospice agency's medication profile provided by the Director of Nursing on 04/24/2024. The Director of Nursing agreed that the medication profiles had not been reconciled on 04/25/2024.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) volunteer program binder reviewed revealed that the hospice agency did not ensure that the Volunteer Coordinator documented viable and ongoing efforts to recruit and retain volunteers. During an interview, the Volunteer Coordinator stated she recruited volunteers at churches and colleges. The Volunteer Coordinator stated the program subscribed to volunteer match.com for recruitment. When asked how volunteers are retained, the Volunteer Coordinator explained that the agency gives small gifts of appreciation to volunteers for retention. The Volunteer Coordinator stated she did not know she needed to document the recruitment and retention efforts. The Director of Nursing was present during the telephone interview and agreed that there was no documented evidence of ongoing recruitment or retention of volunteers on 04/26/24.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 2 (50%) clinical records reviewed for patients who were live discharges while on services revealed that the hospice did not ensure that a copy of the hospice discharge summary was forwarded to the attending physician. Agency Policy HCL/PE.35 Mcr., last reviewed: 100121, stated in part, the hospice will forward copies of the following information to the patient's attending physician: hospice discharge summary and patients clinical record, if requested. Clinical Record 12: The patient revoked hospice on 06/28/2023. A documented discharge summary was completed on 06/28/2023. There was no documented evidence that the discharge summary was forwarded to the patient's attending physician. During an interview on 04/26/2024, the Director of Nursing agreed that there was no documented evidence of the discharge summary being forwarded to the patient's attending physician.