Compassus - Kalamazoo

“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, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the drug profile included all the patient’s current medications. Clinical Record 8: The patient elected hospice care on 05/23/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The comprehensive nursing assessment completed by the skilled nurse (SN) on 05/23/2024 documented, “Oxygen 3 LPM via nasal canula.” The hospice medication profile did not document the oxygen noted in the comprehensive assessment. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the medication profile did not accurately represent the medications the patient received.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected the patient’s and family’s goals based on problems identified in the initial and comprehensive assessments. Clinical Record 2: The patient elected hospice care on 12/12/2024 with a diagnosis of senile degeneration of the brain. On 02/26/2025, the physician ordered Amoxicillin 875mg Potassium Clavulanate 125mg, one (1) tablet by mouth twice daily for 7 days for pneumonia. The skilled nursing (SN) visit note dated 02/26/2025 documented, “Patient’s primary physician started the patient on Amoxicillin 875mg Potassium Clavulanate 125mg, one (1) tablet by mouth twice daily for 7 days for pneumonia with start date 02/20/2025 and end date 02/27/2025.” The “Hospice Interdisciplinary Group (IDG) Comprehensive Assessment” and “Plan of Care Update” reports dated 03/05/2025 and 03/19/2025 did not document patient and family goals for the identified respiratory infection. Clinical Record 16: The patient elected hospice care on 11/26/2024 with a diagnosis of malignant neoplasm of the prostate. The SN visit note dated 01/08/2025 documented that the patient reported “difficulty getting his urine started and is only dribbling and burns.” On 01/08/2025, the SN received a physician order for Bactrim DS 800 mg - 160 mg tablet, two (2) tablets by mouth two times daily for a UTI (Urinary Tract Infection. The “Hospice IDG Comprehensive Assessment” and “Plan of Care Update” reports dated 01/15/2025 and 01/29/2025 did not document patient and family goals for the identified UTI. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the plans of care for clinical records 2 and 16 did not include goals related to the infections.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for 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, document review, and interview. Agency policy and procedure #HOS-C_09A “Individualized Plan of Care” (review date 12/27/2024) stated in part, “2. Content of the Plan of Care: e. Drugs and treatments necessary to support patient care needs. i. The complete medication and treatment profile includes all medications the patient is currently consuming, whether prescribed, over the counter, herbal preparations, or Oxygen.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care included the drugs and treatments necessary to meet the patient’s needs. Clinical Record 8: The patient elected hospice care on 05/23/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The recertification assessment completed by the skilled nurse (SN) on 02/27/2025 documented, “94% at rest on 4 L...Indicate respiratory treatments utilized at home-continuous oxygen.” The “Hospice Interdisciplinary Group (IDG) Comprehensive Assessment” and “Plan of Care Update” reports (individualized plan of care), dated 03/12/2025 and 03/26/2025, did not document oxygen. During the joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that the plan of care did not include oxygen.”

“It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy and procedure #HOS-C_12A “Supervision of Hospice Aides and LP/VN Colleagues” (review date 12/31/2024) stated in part, “The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days.” In 1 of 16 (6%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN services as per agency policy. Clinical Record 13: The patient elected hospice care on 10/31/2024 with a diagnosis of heart failure, unspecified. The hospice recertification plan of care dated 01/29/2025 through 04/28/2025 ordered skilled nursing (SN) services once (1) weekly beginning 01/29/2025. The LPN completed a skilled nursing (SN) visit on 02/25/2025. A LPN supervisory visit was completed by the RN on 04/08/2025. A clinical record review revealed no evidence that LPN supervisory visits were completed every 30 days per agency policy. During a joint record review and interview on 04/09/2025, the Area Executive of Clinical Operations confirmed that LPN supervisory visits were not completed per agency policy, at least every 30 days.”