Volume 2025 | No. 2
SURVEYOR
HOSPICE
■ Monitor time frames to ensure completion of comprehensive assessments within five calendar days of the election of hospice care ■ Audit patient records to ensure inclusion of:
Nerd Apprentices (audit for excellence) continued
Frequency of the citation: 54%
Overview of the requirement: A registered nurse creates and maintains a medication profile by reviewing all prescription and over- the-counter drugs, herbal remedies, and alternative treatments that could affect drug therapy. The interdisciplinary group (IDG) reviews the profile at each meeting and additionally, as needed. Comment on deficiencies: Evidence of compliance is assessed through response to interviews, observation of home visits, and review of patient records, policies, and procedures. Surveyors noted specific inconsistent, incomplete, and accurate medication profiles as evidenced by: ■ Medications with incomplete instruction as to dose, frequency, diluent, route, application location, or purpose.
ٝ Demographic information. ٝ Physical health assessment. ٝ Functional limitations. ٝ Pain and symptom assessments. ٝ Mental health assessment. ٝ Social assessment. ٝ Home environment, including emergency preparedness plan assessment. ٝ Economic assessment. ٝ Spiritual assessment. ٝ Bereavement assessments. ٝ Evidence that qualified personnel conducted assessments.
■ Discontinued medications that remain on the profile as active. ■ Medications ordered that are not present on the medication profile.
■ Educate staff about how to handle refusal of an assessment component. If the patient or their family declines to speak to a specific discipline, e.g., a chaplain or social worker, those components of the comprehensive assessment are still required. Other professional staff who have built relationships may be able to elicit information needed to promote well- being, comfort, and dignity throughout the dying process and identify the spiritual, psycho-social, and bereavement needs of the patient and family.
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings: ■ Patient records include treatment orders for oxygen. Oxygen is not noted on the medication list. ■ Medication profile includes oxygen delivery rate that differs from the rate documented on nursing visits. ■ Medication instructions state, “Benadryl 2% topical gel. Apply one inch to affected area twice daily as needed for rash” with no indication of the application site. ■ The record includes duplicate medication entries with varying instructions for dosage. ■ During patient interview at home visit, the patient stated that she takes 25mg labetalol rather than the 100mg listed on the medication profile, lactulose PRN rather than scheduled twice daily, and had not taken Lyrica for two weeks. ■ Patient record has order for triple antibiotic cream to be applied to stage 2 skin tear. This medication is not on medication profile. ■ Medications ordered for specific periods (10 days) remained active on the medication profile beyond the period of administration. ■ Wound care medication remains current for a wound that has been noted as resolved on plan of care. ■ The medication profile includes entries for different forms of acetaminophen: 500mg - 2 tabs every 4 hours as needed for pain and 650 mg suppository every 6 hours as needed for pain with no instruction not to exceed 4000 mg of acetaminophen daily.
HSP5-3D
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