Every finding on record at Willow Hospice 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. 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, interview, and observation. In 1 of 2 (50%) home visits observed revealed that the agency did not ensure that the drug profile was updated when new medication was added. Policy and Procedures/Survey Readiness Binder: Agency policy number PC.17 titled, "Medication List and Monitoring" dated 05/01/2010 read in part, "Changes in medication regimen will be documented in the medical record on the medication profile, on a verbal order and in the Plan of Care." CLINICAL RECORD 1/HOME VISIT 1: The patient was admitted on 08/18/2024 with a diagnosis of COPD and CHF. The skilled nurse (SN) frequency for the certification period 02/13/2025-04/14/2025 included an order: SN one time per week for each week of the certification period. The plan of care and medication record for 02/13/2025-04/14/2025 included Senokot -S PO PRN for constipation. During the home visit with the vocational practical nurse (LVN) (Personnel Record 1) on 03/20/2025 a review of the medication record in the home which matched the clinical record. In a review of the medications, the patient's son provided a bottle of docusate sodium and stated, "This is what I have been giving her, just like I told the nurse. If she does not go for three days, I give her this." The caregiver was asked how long he had been giving her this medication? Caregiver reported, " Oh I don't know but it's been several weeks." There was no documented evidence on the medication profile in the patient's home or in the clinical record related to docusate sodium. During the home visit interview with the LVN (Personnel Record 1), the LVN confirmed that the Docusate Sodium was not on the medication profile and acknowledged that changes or additions should be made timely.

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, interview, and observation. In 1 of 2 (50%) clinical records reviewed with an aide revealed that the agency did not ensure that the aide care plan provided specific individualized instruction to the aide. CLINICAL RECORD 2/HOME VISIT 2: The patient was admitted on 10/11/2024 with a diagnosis of Malignant Neoplasm of the cecum. The plan of care dated 10/11/2024 -01/06/2025 and 01/07/2025 -04/08/2025 included orders for daily wound care dressing until the wound is healed and for the home health aide three times a week (3 x week). During the home visit with the licensed vocational nurse (LVN) (Personnel Record 2) on 03/20/2025, the abdominal wound care was observed. The aide care plan was dated 10/11/2024 included the task of a shower every visit. There was no documented evidence for an update to the aide care plan or for specific instructions to the aide for the abdominal dressing. The General Manager/ Owner Speech Therapist (Personnel Record 3) confirmed in an interview on 03/20/2025 that the aide care plan has not been updated since 10/11/2024 and was absent of instructions to the aide related to the abdominal wound. The General Manager stated, "The RN should have marked the section that read, "cover wound with plastic wrap for showering" but it was not marked “N”.