Hospice Compassus - Northwest Illinois

“It is required that the documented comprehensive assessment include 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 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 measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but at a 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 1 of 23 (4 %) of clinical records reviewed revealed the agency did not ensure the comprehensive assessment included 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. POLICY: Agency policy #HOS-C_15C “Medication Reconciliation and Management” (dated 01/30/2019) (reviewed 04/09/2025) stated in part, “Regardless of setting, it is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation according to the following steps of documenting a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand. In the facility setting, review the patient’s MAR at the medication cart to ensure a complete accounting of all current medications and treatments.” CLINICAL RECORD 1/HOME VISIT 1: The patient’s election of benefit was dated 07/29/2025 with a diagnosis of senile degeneration of the brain. The patient resided in a Long-Term care facility (LTC). The initial comprehensive assessment was dated 07/29/2025. During the home visit (Home Visit 1) at the facility on 08/12/2025 with the Registered Nurse [Personnel Record 1], it was revealed during medication reconciliation that the patient was ordered Zinc Oxide topical ointment on 05/20/2025. There was no documented evidence that the medication reconciliation was performed during the initial comprehensive assessment. The agency’s current medication list, printed on 08/11/2025 did not include the medication Zinc Oxide. During an interview on 08/14/2025, the Administrator and the Regional Director of Clinical Services reviewed and confirmed the findings.”

“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. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed revealed the hospice did not ensure that the comprehensive assessment included an initial bereavement assessment of the patient’s family and other individuals. CLINICAL RECORD 5: The patient’s election of the hospice benefit was dated 04/24/2025 with diagnosis of COPD, HTN, encephalopathy, Type 2 Diabetes Mellitus with diabetic nephropathy, morbid obesity, fibromyalgia, paraplegia, major depressive disorder, and protein-calorie malnutrition. The skilled nurse completed a comprehensive assessment on 04/24/2025. The Social Worker completed a comprehensive assessment on 04/28/2025. The Chaplain completed the initial chaplain assessment on 04/25/2025. There was no documented evidence that an initial bereavement assessment was completed as part of the initial comprehensive assessment. During an interview on 08/14/2025, the Administrator and the Regional Director of Clinical Services reviewed and confirmed the findings.”

“It is required that each patient’s individualized written plan of /care contains all Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and observation. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) included drugs and treatments necessary to meet the needs of the patient. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 07/29/2025 with a diagnosis of senile degeneration of the brain. The patient resided in a Long-Term facility (LTC). During the home visit(home visit 1) with the Registered Nurse [Personnel Record 1] on 08/12/2025, the following medication was included on the LTC medication profile: Zinc Oxide 25%, apply to buttocks every morning and at bedtime. The hospice plan of care dated 07/29/2025 did not include the medication Zinc Oxide. During a joint clinical record review and interview on 08/12/2025, the Administrator/Area Director of Clinical Services [Personnel Record 7] confirmed that the medication was not on the hospice plan of care.”