Compassus - Greater Colorado Springs

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, “Completing the Initial and Comprehensive Assessments,” stated in part, “The first comprehensive assessment for psychosocial and spiritual needs is completed not more than 5 days following the date of election. If the SW cannot complete the psychosocial portion of the first comprehensive assessment, the RN will use the Coordination Note in the EMR labeled, Psychosocial Assessment Completed by RN. If the Spiritual Counselor cannot complete the spiritual portion of the first comprehensive assessment, the RN will use the Coordination Note in the EMR labeled, Spiritual Assessment Completed by the RN.” In 4 of 19 (21%) clinical records reviewed, the hospice did not ensure the Interdisciplinary Group completed an initial spiritual and psychosocial assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected hospice care on 11/10/2023. The chaplain documented the initial spiritual assessment on 11/28/2023, with 18 days outstanding. The documentation revealed the family requested a visit after the holiday. There was no documented evidence that the initial spiritual assessment was completed no later than five (5) calendar days after the election of hospice care. The Director of Clinical Services was interviewed on 03/07/2024 and stated, “Even if the family requests a delay, the RN should have done the initial spiritual assessment, but I don’t see that it was completed.” Clinical Record 10: The patient elected hospice care on 06/08/2023. The Registered Nurse (RN) admission documentation dated 06/08/2023 documented, “Medical Social Worker (MSW) welcomed, they would like to get patient placed.” “The family declined a visit on the weekend and would like to schedule for Monday or Tuesday” was documented on 06/10/2023. There was no documented evidence that the Social Worker (SW) had followed up prior to the initial psychosocial assessment completed on 07/20/2023, with 42 days outstanding. There was no documented evidence that the initial psychosocial assessment was completed no later than five calendar days after the election of hospice care. Clinical Record 11: The patient elected hospice care on 05/21/2023. The RN admission documentation dated 05/21/2023 documented that a referral was made to the Chaplain/Pastoral counselor. On 05/23/2023, the Chaplain documented, “Chaplain services declined at initial admission. Nurse case manager to complete the comprehensive spiritual assessment.” The Director of Clinical Services was interviewed on 03/07/2024 and stated, “It looks like the chaplain was talking about a previous admission; the RN or Chaplain should have done the spiritual assessment, but I don’t see that it was done.” Clinical Record 14: The patient elected hospice care on 09/16/2023. The SW documented the initial psychosocial assessment on 09/22/2023, with six (6) days outstanding. There was no documented evidence that the initial psychosocial assessment was completed no later than five calendar days after the election of hospice care. There was no documented reason for the delay. During a joint record review and interview on 03/07/2024, the Director of Clinical Services agreed there was no documented evidence that the initial spiritual and psychosocial assessments were completed no later than five days after the election of hospice care.”

“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 vitamins. The medication review process includes the identification of the following: actual or potential drug interactions. 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 2 of 19 (11%) clinical records reviewed, the hospice did not ensure the patient’s current medications were reviewed as part of the comprehensive assessment and updated to the drug profile. Clinical Record 1/Home Visit 1: The patient elected hospice care on 12/11/2023. During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 03/04/2024, the patient was using oxygen at 5 liters per minute (LPM). The RN visit note dated 12/11/2023 documented the patient was on oxygen at 5 LPM. The medication profile dated 12/11/2023 through 03/04/2024 did not document oxygen. Clinical Record 4/Home Visit 4: The patient elected hospice care on 02/06/2024. During the home visit with the Social Worker [Personnel Record 6] on 03/06/2024, a medication review was completed comparing the hospice medication profile dated 03/06/2024 to the patient’s medication bottles. The patient reported they self-administered their medications and was knowledgeable of the medication regimen. The medication bottles presented by the patient revealed the patient was taking Hyoscyamine 0.125mg, one tablet every 6 hours as needed for secretions, dated 02/07/2024 (patient reported taking once or twice since hospice started), and multivitamin Vitajoy (patient reported taking two gummies every morning). The medication profile dated 02/06/2024 through 03/06/2024 did not document Hyoscyamine and Vitajoy. There was no evidence that Hyoscyamine and Vitajoy were reviewed with the patient’s medication regimen. During a joint record review and interview on 03/07/2024, the Director of Clinical Services agreed there was no documented evidence the medications were reviewed and updated to the medication profile.”

“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 the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the patient’s written plan of care included drugs and treatments necessary to meet the patient’s needs. Clinical Record 4/Home Visit 4: The patient elected hospice care on 02/06/2024. During the home visit with the Social Worker [Personnel Record 6] on 03/06/2024, a medication review was completed comparing the hospice medication profile dated 03/06/2024 to the patient’s medication bottles. The medication bottles presented by the patient revealed the patient was taking Hyoscyamine 0.125mg, one tablet every 6 hours as needed for secretions, dated 02/07/2024 (patient reported taking once or twice since hospice started), and the multivitamin Vitajoy (patient reported taking two gummies every morning). The plan of care did not include documentation of Hyoscyamine and Vitajoy.”

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed in which Hospice Aide services were ordered, the hospice did not ensure that the Hospice Aide (HA) provided services as ordered by the interdisciplinary group (IDG). Clinical Record 10: The patient elected hospice care on 06/08/2023. On 11/03/2023, the physician ordered HA services effective 11/05/2023, three (3) times a week for (4) four weeks. During the week of 11/12/2023 through 11/18/2023, the HA documented visits completed on 11/15/2023 and 11/17/2023. A clinical record review revealed no documented evidence of a third HA visit or documented reason for the missed visit. Clinical Record 15: The patient elected hospice care on 04/12/2022. The update to the plan of care effective 02/06/2023 ordered HA visits one (1) time a week for nine (9) weeks. During the week of 03/26/2023 through 04/01/2023, there was no documented evidence of a HA visit or documented reason for the missed visit. During a joint record review and interview on 03/07/2024, the Director of Clinical Services agreed there was no documented reason for the missed visits.”