Every finding on record at Twin Oaks Hospice 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, 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 when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 3 (67%) home visit observations, the agency did not ensure a medication reconciliation was completed and medications were updated on the medication profile. Home Visit 2/Clinical Record 2: The medication profile included with the plan of care dated 10/08/2023 through 11/21/2023 included Seroquel 25mg 1 tablet daily and Tylenol 500mg every 4-6 hours as needed for pain. During the home visit observation review of the patient’s home medications revealed the patient was taking Gabapentin 100mg one twice a day, last distributed 10/20/2023. The caregiver stated Gabapentin was started nine months ago. Celecoxib 10mg once daily as needed for pain, last distributed 10/30/2023. The caregiver stated Celecoxib was started six to seven months ago. Amlodipine 10mg once daily, last distributed 10/30/2023, caregiver stated it was started nine months ago. Atorvastatin calcium 20mg one at bedtime for elevated cholesterol, last distributed 10/30/2023, the caregiver stated Atorvastatin was started one year ago. Aripiprazole 15mg once daily, last distributed 10/30/2023, caregiver stated was started over one year ago. Donepezil 10mg once daily, last distributed 10/30/2023, the caregiver said was started over one year ago. The caregiver denied the patient taking Seroquel 25mg daily for depression. There was no documented evidence that the medications were reconciled and updated on the hospice medication profile. Home Visit 3/Clinical Record 3: During the home visit observation, the patient said he was taking Ibuprofen 400mg 1 tab twice daily with food or milk for approximately two months. The patient stated, "The nurse knows I'm taking them." There was no documented evidence that Ibuprofen was included on the patient’s medication profile and no evidence it was included in the medication reconciliation. The Administrator/Director of Nursing confirmed in a joint record review and interview on 11/21/2023 that there was no documented evidence the medication reconciliation was completed, and medications were updated 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, observation, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure an individualized written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3/Home Visit 3: The skilled nurse assessment dated 11/07/2023 included documentation that the patient needed "Assistive Device: needs hospital bed and CPAP [continuous positive airway pressure machine used for treatment of sleep apnea].” The skilled nurse assessments on 11/07/2023 and 11/15/2023 stated in part, "Patient reports sleeping fine but wakes up during the night without a CPAP machine. The patient needs a hospital bed, he is in a twin bed currently with no side rails." During home visit observation on 11/21/2023, the patient stated he does not have a CPAP or hospital bed. The plan of care dated 10/08/2023 did not include interventions related to the patient’s assessed needs of a hospital bed and CPAP. The Administrator/Director of Nursing confirmed in a joint record review and interview on 11/21/2023 that there was no documented evidence of a follow-up or a physician's order for the CPAP or hospital bed.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by document review, clinical record review, and interview. In 2 of 2 (100%) clinical records reviewed with a patient death, the agency did not ensure controlled medication destruction was documented per agency policy. Agency policy Controlled Drugs - Safe Use and Disposal, effective 11/29/2022, stated in part, "Documentation of the disposal by hospice personnel will be documented and filed in the Clinical Record. The name of the drug, the quantity remaining; the time, date, and manner of disposal; and name and relationship of the witness to the patient." Clinical Record 4: Clinical record review revealed the skilled nurse documented a discharge death visit on 10/08/2023 and documented medication disposal of "Morphine 10 ml Lorazepam 5 ml." There was no documented evidence of the quantity of the controlled substance originally dispensed and the manner of disposal of the medications. The medication disposal witness listed a first name only, without the relationship of the witness to the patient. Clinical Record 5: Clinical record review revealed the skilled nurse documented a discharge death visit on 10/09/2023 and documented medication disposal of "Morphine and Lorazepam." There was no documented evidence of the quantity of the controlled substance originally dispensed, the quantity that was disposed, and the manner of disposal. The medication disposal witness's name did not include the relationship to the patient. The Administrator/Director of Nursing confirmed in an interview on 11/21/2023 that the documentation on the discharge visits for controlled substances was not according to agency policy and procedure.