Compassus - Greater Western Massachusetts

“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 measurements 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, document review, interview, and observation. Agency policy #C_15C “Medication Reconciliation” (revised 1/30/2019) stated in part, “Regardless of the 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 step...Perform a comprehensive clinical assessment and identify whether medication changes or new interventions are needed to manage the patient’s symptoms or comfort...For patients residing in their residence, it is the responsibility of the hospice RN to perform the following at every scheduled nursing visit. One (1) Obtain the most current copy of the medication list (whether this is in the EMR or on paper). Two (2) Nurses visually review the patient’s medication list in the Home, comparing it to the medication list from the medical record. Four(4) If the medication list does not match, the nurse promptly updates the incorrect list to reflect the current orders, and the medication reconciliation is completed.” In 1 of 14 (7%) clinical records reviewed and home visits observed, the hospice did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 3/Home Visit 1: The patient elected hospice care on 12/09/2023. Medication reconciliation was performed during the home visit on 03/19/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient reported taking “Dextromethorphan/Guaifenesin 30 milliliters (ml) two times daily for a cough. The patient reported they had been taking the Dextromethorphan/Guaifenesin for at least one (1) month. The patient stated, “The (hospice) nurse knows I take it because she told me to stop taking it after this week.” In addition, the patient’s medications at home included Compazine 10 milligrams (mg), taken one (1) every six (6) hours as needed (PRN) for nausea, Hyoscyamine 0.125 mg take one (1) tablet every four (4) hours PRN for secretions, and Tylenol suppository 650 mg insert one (1) suppository for fever every six (6) hours. The agency medication profile dated 03/19/2024 did not contain Dextromethorphan/Guaifenesin, Compazine, Hyoscyamine, or Tylenol Suppository. There was no evidence that the medications had been reviewed during the patient’s medication regimen review. During a joint record review and an interview on 03/19/2024, the Area Executive of Clinical Services, who was present for the home visit, confirmed that the patient’s current medication list did not contain Dextromethorphan/Guaifenesin, Compazine, Hyoscyamine, or Tylenol suppository.”

“The hospice must designate a registered nurse member of the IDG to ensure coordination of care, continuous assessment of each patient’s needs, and the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the Registered Nurse (RN) provided coordination of care to meet the patient’s needs. Agency policy #C15 “Nursing Services” (revised 8.18.2022) sub-section three (3) stated in part, “Nursing services include the following...Nursing evaluation and review of medication regimen including management and disposal... Implementation of the plan of care and recommendations for revision...documentation of assessment outcomes, interventions, and planning for additional needs.” Clinical Record 5: The patient elected hospice care on 03/30/2023. The assessment completed by the Registered Nurse (RN) on 11/09/2023 documented, “RN visits today caregiver concerned about rash on nose and lips, which caused swelling. Upon assessment, it is definitely impetigo from the outer corner of the right eye down to the right side of the nose and the top of the right lip. RN called Dr (name) to get treatment. Left a message with the secretary to have the nurse call the caregiver back with new orders, and the caregiver will relay the new orders to the hospice RN. RN had called two (2) times but continues to wait on callback.” The following RN visit dated 11/14/2023 documented, “Patient is recovering from shingles on the face. Caregiver stated...drying and will continue new med regimen as directed.” Per the physician’s order, the antiviral Valacyclovir one (1) gram (G). three (3) times a day was started on 11/11/2023 and completed on 11/18/2023. During an interview, the Area Executive of Clinical Services confirmed that the patient did not receive follow-up by the agency for five (5) days, from 11/09/2023 until 11/14/2023. During a joint record review and interview on 03/18/2024, the Area Executive of Clinical Services confirmed the agency did not ensure the RN coordinated the patient’s care. The Area Executive of Clinical Services stated, “The nurse should have been the one to follow up with the physician, not the caregiver. We should have made another RN visit before 11/14/2023.””

“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 treatments necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #C_09A “Individualized Plan of Care” (revised 1/1/2024) sub-section two (3), stated in part, “Content of the Plan of Care is to include (e) Drugs and treatments necessary to support patient care needs.” In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the written plan of care contained drugs and treatments necessary to meet the patient’s needs. Clinical Record 3/Home Visit 1: The patient elected hospice care on 12/09/2023. Medication reconciliation was performed during the home visit on 03/19/2024, comparing the agency’s medication profile to the patient’s current medication regimen. The patient reported taking “Dextromethorphan/Guaifenesin 30 milliliters (ml) two times daily for a cough. The patient reported they had been taking the Dextromethorphan/Guaifenesin for at least one (1) month. The patient stated, “The (hospice) nurse knows I take it because she told me to stop taking it after this week.” In addition, the patient’s medications at home included Compazine 10 milligrams (mg), taken one (1) every six (6) hours as needed (PRN) for nausea, Hyoscyamine 0.125 mg take one (1) tablet every four (4) hours PRN for secretions, and Tylenol suppository 650 mg insert one (1) suppository for fever every six (6) hours. The plan of care dated 03/08/2024 through 06/05/2024 did not document Dextromethorphan/Guaifenesin, Compazine, Hyoscyamine, or Tylenol Suppository. During a joint record review and an interview on 03/19/2024, the Area Executive of Clinical Services, who was present for the home visit, confirmed the plan of care did not contain the medications. Clinical Record 8: The patient elected hospice care on 06/23/2023, residing in a Skilled Nursing Facility (SNF). The Certificate of Terminal Illness (CTI) dated 06/23/2023 and the initial comprehensive assessment completed by the Registered Nurse (RN) documented the patient’s colostomy. The initial RN assessment documented in the sub-section titled, “gastrointestinal... ostomy/colostomy. The stoma site was assessed as pink and moist.” The plan of care dated 06/23/2023 through 09/2023 ordered “teaching/ reinforcement of ostomy care including stomal care and irrigation, and instruction/reinforcement related to the preservation of integumentary status including ostomy site.” The plan of care did not document the physician’s order for care of the stoma and ostomy care. During a joint record review and interview on 03/19/2024, the Area Executive of Clinical Services confirmed the plan of care did not contain an order for stoma or ostomy care.”