Every finding on record at West River 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, 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/or 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. 1 of 19 (5%) clinical records reviewed and an observed home visitrevealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 4/CLINICAL RECORD 7: The patient's date of hospice election was 10/22/2024. The patient resides in a skilled nursing facility (SNF). The patient's hospice clinical record medication profile, printed on 03/03/3036, included the following: - haloperidol 2 mg/ml oral concentrate, administer 1 milliliter orally every 6 hours as needed for terminal agitation or nausea, dated 10/22/2024; - hyoscyamine 0.125 mg/ml oral solution, take 1 milliliter orally every 4 hours as needed for terminal secretions, dated 10/22/2024; - Morphine 20 mg/ml oral concentrate, administer 0.25-1 milliliter(s) orally every 2 hours as needed for pain or SOB [shortness of breath], dated 10/22/2024; - Aspi-Cor 81 mg oral delayed release tablet, take 1 tab orally once a day for 731 day(s), dated 10/22/2024 - End Date 10/22/2026; and - Pantoprazole 40 mg oral delayed release tablet, take 1 tab orally once a day for 731 day(s), dated 10/22/2024 - End Date: 10/22/2026. During the observed home visit on 03/04/2026 with the Registered Nurse (RN - Personnel Record 5), the hospice record's medication profile was compared to the medication list at the facility. Discrepancies were noted between the hospice medication profile and the SNF medication list. The SNF medication list included the following: - Atropine Sulfate 1% opthalmic solution, give 4 drops sublingually every 4 hours as needed for secretions, dated 10/22/2024; - Fleet Enema, give one per rectum prn constipation if no BM [bowel movement] after dulcolax suppository, dated 08/14/2025; - Geri-Tussin oral liquid 100 mg/5 ml, give 10 ml by mouth every 6 hours as needed for cough, dated 03/17/2025; - Imodium A-D oral tab 2 mg; give one tablet by mouth every 4 hours as needed for diarrhea, dated 08/02/2024; - Magnesium Citrate solution lemon, give one application by mouth as needed for constipation, dated 11/22/2021; - Geri-Lanta suspension 200-200-20 mg/5 ml (Alum & Mag Hydroxide - Simethicone), give 30 ml by mouth as needed for indigestion, give 30 ml by mouth every 4 hours as needed for indigestion/nausea, dated 08/14/2025; - Mirtazepine oral tablet 7.5 mg, give one tablet at bedtime, dated 10/22/2024; - Morphine Sulfate 20 mg/ml, give 0.25 ml by mouth every 1 hour as needed for shortness of breath [SOB] or pain, dated 10/25/2024; - Morphine Sulfate 20 mg/ml, give 0.25 ml by mouth every 6 hours for SOB or pain, dated 02/01/2025; - Neurontin capsule 100 mg, give one capsule by mouth twice a day, dated 11/22/2021; and - Zofran 4 mg, give one tablet by mouth every 8 hours as needed for nausea, dated 09/19/2024. The haloperidol, hyoscyamine, Aspi-Cor, and pantoprazole were not listed on the facility's medication list. The Atropine Sulfate, Fleet Enema, Geri Tussin, Immodium A-D, Magnesium Citrate, Geri-Lanta, Mirtazepine, Neurontin, and Zofran were not listed on the hospice medication profile. Additionally, the morphine sulfate frequencies did not match between the facility's list and the hospice medication profile. The record lacked evidence that complete, accurate medication reconciliation occurred when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 03/04/2026, the Executive Director/Administrator confirmed that there was no documented evidence that medications were accurately reconciled when new medications were added or when changes were made to existing medications.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed revealed that the agency did not ensure the patients' signed consents included the date of hospice election. CLINICAL RECORD 8: The patient was admitted to services on 04/01/2025. The Election of Benefit Statement was signed and dated 04/01/2025. There was a space for the election date, but it was left blank. CLINICAL RECORD 19: The patient was admitted to services on 07/28/2025. The Election of Benefit Statement was signed and dated 07/28/2025. There was a space for the election date, but it was left blank.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records of discharged patients reviewed revealed that the agency did not ensure the discharge summary, inclusive of all required elements, was forwarded to a facility receiving a hospice patient for care, or to the patient’s community attending physician upon hospice discharge. CLINICAL RECORD 15: The patient resided in a skilled nursing facility and elected the hospice benefit on 04/25/2023. The patient's date of revocation was 10/09/2025. The discharge summary lacked evidence of a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. During a joint record review and interview on 03/05/2026, the Executive Director/Administrator confirmed that the record lacked evidence of a completed discharge summary that included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management.

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 and 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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the drug profile included current prescription and over the counter medications and was updated per agency policy. Agency policy, No 2-004 Medication Profile revised December 2018, stated in part, "Patients receiving medications administered by the agency will have a current, accurate medication profile in the clinical record. The medication profile will be updated for each change to reflect current medications, and new and/or discontinued medications... Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time of administration... A drug regimen review will be performed at the time of each initial and comprehensive assessment, when updates to the comprehensive assessments are performed, and with the addition of new medication." Clinical Record 3: The patient elected the Hospice Benefit on 3/20/23. Benefit Period #1 (BP#1) was dated 3/20/23 to 6/17/23. A Registered Nurse (RN) conducted an initial nursing comprehensive assessment on 3/20/23 and documented the following: "Pt requires 2L of Oxygen to maintain saturation in the 90’s, desaturates to 87% or less without O2;" and "Medication Profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications: no issues identified.” The medication profile for BP#1 dated 3/20/23 lacked evidence of medication orders for the administration of Oxygen. Clinical Record 5: The patient elected the hospice benefit on 6/18/22. Benefit period #4 (BP#4) was dated 2/13/23 to 4/13/23. The current benefit period, #5 (BP#5), was dated 4/14/23 to 6/12/23. A RN conducted routine skilled nurse visits on 3/1/23 and 3/9/23, and documented the following: "Intermittent rash in peri and buttock area. Treated with Calmoseptine;" and "Review of prescription/non-prescription medication for new or changed medications, no evidence of change since last review.” The medication profile for BP#4 and BP#5 lacked evidence that it had been updated to include medication orders for the administration of Calmoseptine. Clinical Record 6: The patient elected the hospice benefit on 10/5/22. Benefit period #2 (BP#2) was dated 1/3/23 to 4/2/23. Benefit period #3 (BP#3) was dated 4/3/23 to 6/1/23. A RN conducted a skilled nurse visit on 3/31/23 and documented the following: "Patient to start Colace 100mg 2 caps BID and Miralax 17gm am, Senna gummies 1-2 QHS;" and "Medication Profile reviewed for new or changed medications and identification of possible issues with both prescription and non-prescription medications: New/ Changed medications identified, medication profile updated." Communication/instruction, dated 3/31/23, provided to patient/caregiver included the following instructions: "Give 1-2 Senna gummies every evening." The medication profile for BP#2 and BP#3, lacked evidence that it had been updated to include medication orders for the administration of Senna gummies. During a joint clinical record review and interview on 4/25/23, the VP of Clinical Services confirmed the finding.

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 and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure the written plan of care included planned interventions identified in a comprehensive assessment necessary to meet the needs of the patient. Clinical Record 9: The patient elected the hospice benefit on 6/7/22. Benefit period #4 (BP#4) was dated 2/2/23 to 4/2/23. Benefit period #5 (BP#5) was dated 4/3/23 to 6/1/23. A Registered Nurse (RN) completed a recertification comprehensive assessment on 3/20/23 and documented the following: "Resident with pink fragile area on right heel, skin prep being applied". The plan of care for BP#4 and BP#5 lacked evidence of any problems, goals, or interventions related to skin integrity. During a joint clinical record review and interview on 4/25/23, the VP of Clinical Operations confirmed the finding.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as, hand hygiene. This standard was not met as evidenced by observation, document review, and interview. In 1 of 4 (25%) home visits observed, the agency did not ensure that the staff member used standard precautions, such as, hand hygiene that followed accepted standards of practice and agency policy. The agency's policy, 7-009 Hand Hygiene, revised October 2019, stated in part, "Hand decontamination with an alcohol-based hand rub... Hand decontamination using alcohol-based hand rub should be performed: When moving from a contaminated body site to a clean body site during patient care... After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." Home Visit 1: The home visit was conducted on 4/26/23 with the hospice aide (Staff 13). Staff 13 was observed reaching into a drawer to access patient's clean supplies, without first removing soiled gloves and performing hand hygiene. Staff 13 was also observed moving from providing perineal care to providing back care, without first removing soiled gloves and performing hand hygiene. During a joint home visit observation and interview on 4/26/23, the Vice President of Clinical Services confirmed the finding.