Every finding on record at Vitas Healthcare Corporation of California

It is required that medical social services are provided per the plan of care and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. 2 of 5 (40%) clinical records reviewed, the organization did not ensure that medical social services were provided per the plan of care and under the direction of a physician. Clinical Record 3: The patient elected hospice care on 11/18/22. The Interdisciplinary Plan of Care/Physician's Orders for the week of 04/05/23 through 04/11/23, did not include documentation of orders for Medical Social Worker (MSW) visits. A MSW telephone visit was documented as conducted on 04/10/23 that included interventions as outlined in the patient's plan of care. Additionally, the Interdisciplinary Plan of Care/Physician's Orders for the week of 04/19/23 through 04/25/23 ordered, "two (2) MSW visits." The MSW documented two (2) visits completed on 04/19/23 and 04/20/23 and two (2) telephone visits conducted on 04/19/23 and 04/21/22 that included interventions as outlined in the patient's plan of care. The actual visit frequency was four (4) MSW visits completed for the week of 04/19/23 through 04/25/23. Clinical Record 5: The patient elected hospice care on 05/03/23. The Interdisciplinary Plan of Care/Physician's Orders for the week of 05/31/23 through 06/06/23 ordered, "two (2) MSW visits." The MSW documented visits completed on 05/31/23, 06/01/23, and 06/04/23 which was a recertification assessment. The actual visit frequency was three (3) MSW visits completed for the week of 05/31/23 through 06/06/23. During an interview, the Administrator stated, "We're having a meeting with them [Medical Social Workers] tomorrow to discuss these very issues. Here are some good examples to share." The Administrator stated, "We're having a meeting with them [Medical Social Workers] tomorrow to discuss these very issues. Here are some good examples to share."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record review of a patient that received hospice aide services, the organization did not ensure that the hospice aide was provided specific written instructions by the Registered Nurse (RN). Clinical Record 5: The patient elected hospice care on 05/03/2023. The aide plan of care, effective 05/03/2023, assigned the hospice aide the task: sponge bath each visit. On 05/17/2023, the Registered Nurse updated the aide plan of care to include the assigned tasks: sponge bath and shower..."Shower patient if tolerable." The hospice aide visits completed on 05/30/2023 and 06/06/2023 documented "Shower with bath chair: Performed" and "Gave Sponge Bath: Performed." The aide plan of care assigned the hospice aide a sponge bath and a shower and did not provide clear instructions to the hospice aide regarding the type of bath, forcing the aide to make decisions outside of the aide's scope of practice. The Patient Care Administrator confirmed that both types of baths were documented on 05/30/23 and 06/06/23 and verbalized that aides are to call to report any patient request for a different type of bath or to report a change in patient status that does not allow for the type of bath on the plan of care to be performed or to be performed safely. "There should be only one type of bath." The Patient Care Administrator confirmed that aides are instructed to contact an RN case manager or nurse supervisor if the type of bath indicated on the aide plan of care is refused or cannot be performed due to the patient's health status or possible change in condition.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, including the development and inclusion of a plan for each hospice patient during a natural or artificial disaster as part of a patient/family comprehensive assessment. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that RN Initial Comprehensive Assessment included an assessment of the patient’s level of risk during a natural or artificial disaster. Clinical Record 5: During joint clinical record review, the PCA confirmed that sections of the emergency preparedness assessment were not complete for the patient, a risk level was not identified or assigned, and no plan in case of emergency was prepared. The Patient Care Administrator (PCA) stated that RNs are instructed to complete the Emergency Preparedness Assessment section of the RN's initial comprehensive assessment document to assign a risk level and to prepare a plan for each patient in the event of a disaster or emergency declaration. The Patient Care Administrator (PCA) stated that RNs are instructed to complete the Emergency Preparedness Assessment section of the RN initial comprehensive assessment document to assign a risk level and to prepare a plan for each patient in the event of a disaster or emergency declaration.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and an interview with the management team. The Registered Nurse failed to complete an initial patient-specific comprehensive assessment to identify the patient's and family's needs [HCPC11.1/L524]; the Registered Nurse failed to complete a comprehensive initial evaluation of the patient's pain [HCPC12.I/L524]; the Registered Nurse failed to conduct a comprehensive medication review as a component of their initial comprehensive assessment [HCPC.15.I//L530], and the Intradisciplinary Group failed to complete an initial bereavement assessment and subsequently incorporate the assessment into the plan of care [HCPC.13.I/L531]. The cumulative effect of these deficiencies demonstrates a lack of oversight of the plan of care and could negatively impact the agency's ability to provide quality, safe end-of-life patient care by not identifying significant issues from the comprehensive assessment in order to meet the patient's and family needs.

It is required that the comprehensive assessment includes consideration of the following factors: the nature and condition causing admission, including the presence, or lack of, objective data and subjective complaints, co-morbid psychiatric diagnosis or complications and risk factors that affect care planning, including risk for drug diversion, functional status, and cognitive status, including the patient’s ability to understand and participate in her or his own care, imminence of death, symptoms and symptom severity, including dyspnea, nausea, vomiting, constipation, restlessness, anxiety, emotional distress, sleep disorders, skin integrity, confusion, bowel regimen when opioids are prescribed, patient and family support systems, and patient and family need for counseling and education. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure the initial RN comprehensive assessment was complete and fully identified the physical needs of the patient related to the terminal illness that must be addressed to promote the patient’s well-being, comfort, and dignity throughout the dying process. Clinical Record 5: The PCA confirmed that sections of the initial comprehensive assessment were incomplete and, therefore, could not fully identify patient needs. The Start of Care was completed on 4/3/2022 for routine Hospice services with a Primary Hospice Diagnosis: Cerebral Infarction. The following sections of the RN Initial Comprehensive Assessment were blank and/or were not marked as assessed by the RN: Neurosensory, Respiratory, Cardiovascular, Genitourinary, Gastrointestinal, Musculoskeletal, and Integumentary. The Patient Care Administrator (PCA) stated that RNs are instructed to complete all sections of the RN's initial comprehensive assessment document, including a complete physical assessment at the initiation of care and services. The Patient Care Administrator (PCA) stated that RNs are instructed to complete all sections of the RN initial comprehensive assessment document which includes a complete physical assessment at the initiation of care and services.

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 a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the RN initial or subsequent comprehensive assessments included a drug profile that contained all the patient’s current medications. Clinical Record 1: The RN initial or comprehensive assessment and the Interdisciplinary Plan of Care/Physicians Orders documents dated 3/28/22 were blank in the section designated for Medications. "See electronic medication orders" is marked on the signed order, but the electronic printout of "Medication active on 3/29/22" indicates "No Medication profile found." The PCA confirmed that a drug profile was never completed during the patient’s course of care. The Patient Care Administrator (PCA) stated that RNs are instructed to identify all drugs and biologicals related to the palliation and management of the patient’s care in all comprehensive assessments and to then include the medications in the plan of care/plan of care updates after confirmation/orders received from the hospice medical director and/or designated attending physician (if applicable). The Patient Care Administrator (PCA) stated that RNs are instructed to identify all drugs and biologicals related to the palliation and management of the patient’s care in all comprehensive assessments and to then include the medications in the plan of care/plan of care updates after confirmation/orders received from the hospice medical director and/or designated attending physician (if applicable).

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 10 (40%) clinical records reviewed, the agency failed to ensure that an initial bereavement assessment was completed per agency process and subsequently incorporated into the plan of care. Clinical Record 5: Neither RN, Social Work, or Chaplain completed an initial bereavement assessment. Clinical Record 20: Neither RN, Social Work, or Chaplain completed an initial bereavement assessment. Clinical Record 17: Neither RN, Social Work, or Chaplain completed an initial bereavement assessment. Clinical Record 13: Neither RN, Social Work, or Chaplain completed an initial bereavement assessment. The Patient Care Administrator stated that IDG members are instructed to complete a bereavement assessment within the first five days of the hospice benefit of the election that includes a reported level of bereavement risk, and that is used to determine patient/family/caregiver specific goals or outcomes. The Patient Care Administrator stated that IDG members are instructed to complete a bereavement assessment within the first five days of the hospice benefit of election that includes a reported level of bereavement risk and that is used to determine patient/family/caregiver specific goals or outcomes.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interview which revealed significant issues with the preparation of a written plan of care and care coordination for a patient admitted to General Inpatient Care [HCPC.18.I/L537]; the written plan of care lacked documentation of the services necessary for the palliation and management of the terminal illness and related conditions, including interventions to manage pain [HCPC.21.I/L546]; the written plan of care lacked documentation of the scope and frequency of services [HCPC.21.I/L547]; the written plan of care lacked documentation for the necessary drugs and treatments to meet patient needs [HCPC.21.I/L549]; the written plan of care lacked documentation of the medical supplies and appliances necessary to meet the needs of the patient.[HCPC.20.I/L544] and significant issues with providing education and training to patients and caregivers [HCPC.20.I/L544]. The cumulative effects of the Hospice Agency's failure to maintain an integrated system of communication to ensure coordination and supervision of the Plan of Care and services delivered, has the potential to place patients at risk for unmet care needs, services and information.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, it was revealed that the agency failed to ensure that a written plan of care was prepared for each patient. Clinical Record 1: This patient was admitted to Hospice General Inpatient Services on 3/28/22 with a Hospice Primary Diagnosis: Malignant Neoplasm of the Breast. During a joint clinical record review with the PCA, it was revealed that the document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include a description of the Home Medical Equipment, Supplies, Medications, or Disciplines/Visit frequencies required to provide Hospice care and services. The document was also not signed by a physician. There were no clinical notes provided that detailed interaction or communication with the members of the Interdisciplinary Group (IDG) or Hospice Medical Director to prepare a written plan of care addressing the individual patient's needs for hospice care or services. The Patient Care Administrator (PCA) stated that the IDG is instructed to prepare a written plan of care for each patient that specifies all care and services necessary to meet the needs of the patient and family. The Patient Care Administrator (PCA) stated that the IDG is instructed to prepare a written plan of care for each patient that specifies all care and services necessary to meet the needs of the patient and family.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including intervention to manage pain and symptoms. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that each patient’s plan of care included all services necessary and used to palliate and manage terminal illness, including interventions to manage pain and symptoms. Clinical Record 1: During joint clinical record review with the PCA, it was revealed that the patient’s initial RN comprehensive assessment indicated that the patient was experiencing discomfort, as evidenced by terminal restlessness and agitation that required regular dosing and dosage increases of IV Ativan. No documented plan of care or physician orders included Ativan or any medications included in RN visit notes as being administered to palliate pain and manage symptoms. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes interventions to manage pain and symptoms for all patients. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes interventions to manage pain and symptoms for all patients.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient was admitted for General Inpatient Services on 3.28.2022 with nursing services providing care. A primary Hospice Diagnosis: Malignant Neoplasm of Breast. During joint clinical record review with the PCA, it was revealed that the document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include any orders for any disciplines, including nursing, to assess or to provide care and services to the patient. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. All services provided by the hospice should be included along with the frequency of visits in the plan of care/physician orders. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. All services provided by the hospice should be included along with frequency of visits in the plan of care/physician orders.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the written plan of care included drugs and treatments identified by the IDG as necessary to meet the needs of the patient. Clinical Record 1: During joint clinical record review with the PCA, it was revealed that the document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include drugs and treatments documented in clinical notes that were used to meet the needs of the patient. "See electronic medication orders" was marked on the document, but an electronic printout of "Medication active on 3/29/22" included the statement, "No Medication profile found." The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes all drugs and treatments necessary to palliate the symptoms of the patient. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes all drugs and treatments necessary to palliate the symptoms of the patient.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the written plan of care included medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 1: During joint clinical record review with the PCA, it was revealed that the document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include any medical supplies or DME documented as necessary in the care of the patient in individual clinical visit notes. The supplies and DME not listed include IV supplies/IV pumps, oxygen supplies, and a delivery system. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes all supplies and DME necessary to meet the needs of the patient. The Patient Care Administrator (PCA) stated that the IDG is instructed to document an individualized written plan of care that includes all supplies and DME necessary to meet the needs of the patient.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records and interviews. 3 of 20 (15%) clinical records reviewed, the agency failed to ensure that nursing care and services were performed per the plan of care. Clinical Record 1: During joint clinical record review with a Team Manager, the Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include an order for Skilled Nursing services or a visit frequency of Skilled Nursing visits to be performed. There were documented Skilled Nursing visits performed on 3/28/22, 3/29/22, and 3/30/22. Clinical Record 17: There was one missing Skilled Nursing visit during the first week after the start of care, as confirmed by a Team Manager during a joint clinical record review. Clinical Record 3: Two missed Skilled Nursing visits effective Wednesday, 4/20/22, as confirmed by a Team Manager during a joint clinical record review. The Team Manager confirmed during the joint clinical records review that nursing care and services were not performed as ordered in the patient plan of care. The Team Manager confirmed during joint clinical records review that nursing care and services were not performed per the patient plan of care.

It is required that medical social services are provided per the plan of care and under the direction of a physician. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 20 (10%) clinical records reviewed, the agency failed to ensure that medical social services were provided per the plan of care and under the direction of a physician. Clinical Record 1: During a joint clinical record review with the Patient Care Administrator (PCA), it was revealed that the Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include an order for a social work initial assessment to be performed. There was an initial social work assessment documented as performed on 3/29/22. Clinical Record 20: One social work visit was documented as performed by an MSW that was not ordered per the plan of care, as revealed during a joint clinical record review with a Team Manager. During joint clinical record reviews, the PCA and Team Manager stated that clinical staff is instructed that medical social services were to be provided per the plan of care and under the direction of a physician. The PCA and team manager stated during joint clinical record reviews that clinical staff is instructed that medical social services were to be provided per the plan of care and under the direction of a physician.

It is required that spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 20 (10%) clinical records reviewed, the agency failed to ensure that spiritual counseling visits were performed in accordance with patient's and family's acceptance of the services as ordered by the IDG as included in the plan of care. Clinical Record 1: The Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 did not include an order for an initial spiritual counselor assessment. There was an initial assessment documented as performed by a chaplain on 3/29/22. Clinical Record 20: Two (2) spiritual counselor visits were documented after the initial assessment that was not included in the plan of care established by the IDG. During the joint clinical records review, the Team Manager confirmed that spiritual counseling visits were not performed per the plan of care or physician orders. The Team Manager confirmed during joint clinical records review that spiritual counseling visits were not performed per the plan of care or physician orders.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 16 (31%) clinical records were reviewed in which hospice aide services were provided, the hospice agency failed to ensure hospice aide visits were performed as ordered by the IDG as included in the care plan. Clinical Record 3: There was one missed hospice aide visit for Team, effective Wednesday, 4/27/22, as confirmed by a Team Manager during a joint clinical record review. Clinical Record 5: No hospice aide visits were performed after the start of care. The hospice aide visits were ordered three times per week from the start of care. No communication notes or physician orders were used to justify the lack of aide visits. Clinical Record 7: Effective Thursday, 4/6/22, there was one missed hospice aide visit confirmed by a team manager during a joint clinical record review. Clinical Record 17: There were three missing hospice aide visits during the first week after the start of care. There was one extra hospice aide visit performed during the Week of 1/19/20. Shower and Sponge bath were marked to be completed each visit on the aide plan of care. Aide care notes for visits had both sponge bath and shower marked as performed each visit. Clinical Record 18: Hospice aide visits on 8/26/22, 8/29/22, 9/9/22, and 9/12/22 documented that the patient declined a shower (as designated on AIDE POC) and the hospice aide provided a sponge bath (not on POC). On 9/1/2022 and 9/6/2022, the hospice aide documented a Bed Bath was provided. The Patient Care Administrator confirmed that there was no evidence that the aide spoke to an RN and was not instructed to provide a type of bath other than a shower. The Patient Care Administrator stated that the hospice aide visit frequencies were to be performed according to the hospice aide plan of care and that it was the agency's practice to include only one type of bath on the hospice aide plan of care. A team manager confirmed that hospice aides are instructed to contact an RN case manager or nurse supervisor if the type of bath indicated on the hospice aide plan of care is refused or cannot be performed due to the patient's health status. The Patient Care Administrator stated that aide visit frequencies were to be performed according to the aide plan of care and that it was the agency's practice to include only one type of bath on the aide plan of care. A team manager confirmed that aides are instructed to contact an RN case manager or nurse supervisor if the type of bath indicated on the aide plan of care is refused or cannot be performed due to the patient's health status.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 16 (6%) clinical records reviewed in which aide services were provided, the hospice agency failed to ensure that the aide reported potential changes in the patient's health status that may impact the hospice aide's plan of care. Clinical Record 18: Aide visits on 8/26/22, 8/29/22, 9/9/22, and 9/12/22 documented that the patient declined a shower (as designated on AIDE POC) and the aide provided a sponge bath (not on AIDE POC). On 9/1/22 and 9/6/22, the aide documented a Bed Bath was provided. The Patient Care Administrator confirmed that there was no evidence that the hospice aide spoke to an RN and was not instructed to provide a type of bath other than a shower. A team manager confirmed that aides are instructed to contact an RN case manager or nurse supervisor if the type of bath indicated on the aide plan of care is refused or cannot be performed due to the patient's health status or possible change in condition. A team manager confirmed that aides are instructed to contact an RN case manager or nurse supervisor if the type of bath indicated on the aide plan of care is refused or cannot be performed due to the patient's health status or possible change in condition.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are identified in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the drugs and biologicals used in the care of the patient were identified in the plan of care. Clinical Record 1: Joint clinical record review with the PCA revealed that "See electronic medication orders" was marked on the document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22. Still, an electronic printout of "Medication active on 3/29/22" contained no medications and included the statement, "No Medication profile found." The Patient Care Administrator (PCA) stated that RNs are instructed to identify all drugs and biologicals related to the palliation and management of the patient’s care in the initial plan of care and plan of care updates. RNs are required to perform a drug regimen review to inform the physician of any potential adverse effects or drug interactions that may be contraindicated or unsafe for the patient. The PCA said the agency’s process is for medications to be entered into a medical record profile program. Next, the electronically generated medication profile is then printed and placed in the patient’s medical record. The Patient Care Administrator (PCA) stated that RNs are instructed to identify all drugs and biologicals related to the palliation and management of the patient’s care in the initial plan of care and plan of care updates. RN’s are required to perform a drug regimen review in order to inform the physician of any potential adverse effects or drug interactions that may be contraindicated or unsafe for the patient. The PCA stated that the agency’s process is for medications to be entered into a medical record profile program; the electronically generated medication profile is then printed and placed in the patient’s hard chart/medical record.

It is required that only a physician or a nurse practitioner, in accordance with the plan of care and state law, may order drugs for the patient. If the drug order is verbal or given by or through electronic transmission, the individual receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal law and regulation. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 20 (5%) clinical records reviewed, the agency failed to ensure that the nurse receiving the order recorded and signed it immediately and had the prescribing person sign it. Clinical Record 1: The Patient Care Administrator (PCA) confirmed that drugs and biologicals documented in visit notes as verbally ordered by the Hospice Medical Director and were documented as used in the palliation and management of the patient’s terminal illness and related conditions, however, was not recorded by the receiving nurse or signed by the Hospice Medical Director. The document titled Interdisciplinary Plan of Care/Physicians Orders dated 3/28/22 includes no drugs and has no physician signature. The PCA stated that RNs are instructed to document all verbal orders, including drugs, in order for the prescribing person to sign the order within thirty days. The PCA stated that RN’s are instructed to document all verbal orders including drugs in order for the prescribing person to sign the order within 30 days.