Hospice Compassus -Monroe

“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, [and] 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, [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 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. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s drug profile was updated at the time of each comprehensive assessment, when new medications were added, or when changes were made to existing medications. CLINICAL RECORD 2/HOME VISIT 1: The patient elected hospice care on 04/01/2021 with a primary diagnosis of chronic diastolic congestive heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 08/27/2025, a review of the patient’s hospice medication profile and the ALF medication list revealed the following medications listed on the hospice medication profile were not documented on the ALF medication list: acetaminophen extra strength 500 mg tablet, 1 tablet orally every 6 hours as needed for mild pain dated 04/02/2021; Flovent HFA 110 mcg/Actuation Aerosol Inhaler, 1 puff by inhalation every 4 hours as needed for SOB [shortness of breath] dated 04/02/2021; fluocinonide 0.05% topical solution, apply to scalp daily dated 04/02/2021; gabapentin 100 mg capsule, 100 mg orally at bedtime dated 09/10/2024; hyoscyamine 0.125 mg disintegrating tablet, 1 tablet orally every 6 hours as needed for abdominal cramps dated 04/02/2021; ketoconazole 2% shampoo, wash hair one to two times per week dated 09/10/2024; loperamide 2 mg tablet, 1 tablet orally every 6 hours as needed for diarrhea dated 04/02/2021; meclizine 12.5 mg tablet, 1 tablet orally 3 times daily as needed for dizziness dated 04/02/2021; MiraLAX 17 grams/dose oral powder, 17 grams orally daily mixed with 8 oz water dated 03/14/2024; morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution, 0.5 ml orally every 4 hours as needed for SOB, pain dated 04/14/2022; nitroglycerin 0.4 mg sublingual tablet, 1 tablet sublingually Q 5 min x3 PRN [every 5 minutes times 3 doses as needed for] chest pain dated 04/02/2021; nystatin 100,000 unit/gram topical powder, apply under breast Q 12 HRS [hours]/PRN dated 10/19/2021; potassium chloride 20 mEq/15 ml oral liquid, mix 7.5 ml of potassium chloride oral liquid into 4 ounces of water and drink by mouth twice daily dated 09/01/2023; Senna Plus 8.6 mg-50 mg tablet, 1 tablet orally 2 times daily dated 07/16/2023; Systane (Propylene Glycol) 0.4 %-0.3 % eye drops, 1 GTT [drop] both eyes prn dry eyes dated 604/02/2021; and tramadol 25 mg tablet, 1 tablet orally every 6 hours as needed for pain dated 10/03/2024. The following medications documented on the ALF medication list were not documented on the hospice medication profile: amitriptyline 10 mg tablet, 1 tablet by mouth at bedtime started 11/06/2024; atorvastatin calcium 40 mg tablet, 1 tablet by mouth at bedtime started 11/06/2025; Colace 100 mg capsule, 2 capsules by mouth once daily started 11/06/2024; hydralazine hcl 25 mg tablet, 1 tablet BID [twice a day] started 11/06/2024; levalbuterol hcl Nebulizer 0.63 mg/3 ml, 1 nebulizer by inhalation every 8 hours PRN [as needed] started 11/06/2024; losartan kcl 100 mg tablet, 1 tablet by mouth once daily started 11/06/2024; metoprolol succinate er [extended release] 25 mg tablet, 1 tablet by mouth daily started 11/06/2024; omeprazole DR [delayed release] 20 mg capsule, 1 capsule by mouth daily, started 11/06/2024; and Singulair 10 mg tablet, 1 tablet by mouth daily, started 11/06/2024. The patient’s drug profile was not reconciled to reflect the patient’s current medications. CLINICAL RECORD 14/ HOME VISIT 4: The patient elected hospice care on 02/16/2023. The patient resided in an ALF. During the with the Registered Nurse (RN) [Personnel Record 2] on 08/28/2025, a review of the patient’s ALF medication list revealed the following medications: Duoneb 1 vial by nebulizer once daily and PRN [as needed] up to 3 times per day dated 06/23/2024; acetaminophen 650 mg tablet, 1 tablet by mouth once daily dated 04/29/2025; acetaminophen 500 mg tablet, 2 tablets by mouth every 4 hours PRN pain/fever dated 11/21/2024; ondansetron hcl 8 mg tablet, 1 tablet by mouth TID [three times a day] PRN pain/fever dated 11/21/2024; and potassium chloride 20 mEq tablet, 1 tablet by mouth daily dated 11/07/2023. The agency’s medication profile documented albuterol sulfate 2.5 mg/3 ml (0.083%) solution for nebulization, 3 ml 3 times daily inhalation dated 03/16/2023; loperamide 2 mg capsule, 2 caplets after first loose stool, 1 caplet after each subsequent loose stool, no more than 4 caplets in 24 hour period dated 03/16/2023; hydrocodone 5 mg-acetaminophen 325mg tablet, 1 tablet every 6 hours as needed for pain dated 03/16/2023; ipratropium bromide 0.02% solution for inhalation, 2.5 ml 3 times a day inhalation dated 03/16/2023; mupirocin 2% topical ointment, apply topically to affected area 3 times daily as needed dated 12/07/2022; ondansetron 8 mg disintegrating tablet, 1 tablet every 6 hours as needed for nausea, dated 01/06/2025; and acetaminophen 650 mg tablet, extended release, 1 tablet every 8 hours as needed for analgesic, mild pain dated 04/10/2023. The ALF’s medication list and the hospice medication profile differed for the medications: acetaminophen, ondansetron, and albuterol sulfate/ipratropium bromide. The loperamide, hydrocodone, and mupirocin documented on the agency’s medication profile were not documented on the ALF medication list. During a joint record review and interview on 08/28/2025, the Area Executive of Clinical Operations/Registered Nurse confirmed that there was no documented evidence that the medications were reconciled at the time of each medication change and updated in the drug profile.”