Every finding on record at University Home 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 effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. 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, document review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the drug profile included the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy and as a result, the current medication profile was not reviewed for the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. Document 1: Policy III.20 Medication Management & Administration revision date June 2024 stated in part "All medications will be reviewed for potential adverse effects, drug reactions, ineffective drug therapy, significant drug interactions, duplicate drug therapy, and for patient non-compliance with drug therapy. The admitting nurse will contact the patient's physician immediately if there are any questions or concerns regarding the medications a patient is taking. The medication profile will be updated when there are any medication changes and will be reviewed at least every 15 days as part of the patient plan of care." Clinical Record 2: The election of hospice care was 04/17/2024. The skilled nursing visit note dated 04/17/2024 included documentation that the patient was on Oxygen 2L/NC as needed. The patient was observed using a portable oxygen concentrator during the home visit observation (Clinical Record 2/Home Visit 2) with the registered nurse (Personnel Record 1) on 07/25/2024. The clinical record lacked evidence that the hospice medication profile included Oxygen. In a joint record review and interview on 07/25/2024, the Administrator confirmed the finding that the oxygen was not included on the medication profile.