Every finding on record at Valued Heart Hospice & Palliative Care 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, 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, interview, and observation. In 1 of 3 (33%) home visit observations revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile. Home Visit 1: The patient's date of election was 6/23/2023. The patient resides in a facility. The medication profile reviewed between 6/23/2023-3/7/2024 revealed Atropine Ophthalmic 1% Solution: instill two drops SL/PO every 4 hours as needed for secretions started 6/23/2023. During the home visit with the registered nurse (RN) (Personnel Record 2) on 3/7/2024, the Atropine was not included on the facility medication list. The registered nurse stated that Hyoscyamine was used instead of Atropine. There was no documented evidence that the medications were reconciled and updated to the hospice medication profile. The Director of Nursing confirmed in a joint record review and an interview on 3/7/2024 that there was no documented evidence the medication reconciliation was completed, and medications were updated to the medication profile.

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 and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. Clinical Record 7: The discharge summary dated 8/15/2023 lacks documentation that the discharge summary was forwarded to the patient's attending physician. Clinical Record 5: The discharge summary dated 1/6/2024 lacks documentation that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 3/6/2024, the Director of Nursing confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.