Compassus - Northern Michigan

“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. Agency policy #HOS-C_15C “Medication Reconciliation and Management” (dated 01/24/2025) read in part, “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: Document a complete medication inventory, noting prescriptions, over-the-counter medications, and herbal preparations the patient is currently taking or has on hand.” In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient’s medications were included in the drug profile. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial nursing assessment dated 02/21/2024 documented, “Patient is on oxygen continuously.” The drug profile dated 02/21/2024 did not document oxygen. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed the finding, stating, “During audits in October 2024, it was identified that some patients on oxygen did not have oxygen on their medication profiles.””

“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 and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included drugs and treatments to meet the patient’s needs. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial plan of care dated 02/21/2024 through 05/18/2024 documented, “Administer oxygen as needed for dyspnea.” The plan of care did not document the flow rate, route, or frequency of oxygen administration. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed the finding, stating, “There was not a specific order for the oxygen dosage and route added until October 2024.””

“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: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 23 (17%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included the medical supplies and appliances necessary to meet the patient’s needs. Clinical Record 10: The patient elected the hospice benefit on 06/23/2023. The initial plan of care dated 06/23/2023 through 08/21/2023 ordered: “Oxygen 8 liters via nasal cannula continuously.” The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 12: The patient elected the hospice benefit on 01/24/2025. The initial plan of care dated 01/24/2025 through 04/23/2025 ordered: “Oxygen 2 liters via nasal cannula at night while asleep.” The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 13: The patient elected the hospice benefit on 01/06/2025. The initial plan of care dated 01/06/2025 through 04/05/2025 ordered: “Oxygen 6 liters via nasal cannula continuously.” The plan of care did not include documentation of the oxygen concentrator and oxygen supplies. Clinical Record 20: The patient elected the hospice benefit on 02/21/2024. The initial nursing assessment dated 02/21/2024 documented, “Patient is on oxygen continuously.” The initial plan of care dated 02/21/2024 through 05/18/2024 did not include documentation of the oxygen concentrator and oxygen supplies. During a joint record review on 02/26/2025, the Area Executive of Clinical Operations confirmed that oxygen supplies were not included in the durable medical equipment section of the plan of care.”

“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 #C_12A “Supervision of Hospice Aides and LP/VN Colleagues” (dated 08/18/2022) stated in part, “The Registered Nurse is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days.” In 1 of 18 (6%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that supervisory visits were completed at least every 30 days per agency policy. Clinical Record 16: The patient elected the hospice benefit on 10/03/2024. The plan of care dated 10/03/2024 through 12/31/2024 ordered: “SN 1 time per week.” A clinical record review revealed a LPN visit dated 11/08/2024. The clinical record did not include documentation of a LPN supervisory visit. During a joint record review on 02/25/2025, the Area Executive of Clinical Operations confirmed the LPN supervisory visits were not completed every 30 days per agency policy.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 21 (14%) clinical records reviewed of patients with Hospice Aide (HA) services provided, the agency did not ensure that the HA care plan included all written patient care instructions. Clinical Record 3: The patient elected the hospice benefit on 11/30/2023. On 12/01/2023, the physician ordered wound care with a wound dressing to a wound on the patient’s right and left buttocks. The plan of care dated 11/30/2023 through 02/27/2024 ordered “HA 2 times per week.” The HA care plan dated 11/30/2023 assigned the HA the relevant task of “shower at every visit.” The HA care plan did not include documentation of instructions for the patient’s wound dressing on the buttocks should it become wet or dislodged during the shower. Clinical Record 5: The patient elected the hospice benefit on 12/12/2024. On 12/13/2024, the physician ordered wound care with a wound dressing to a wound on the patient’s coccyx. The plan of care dated 12/12/2024 through 03/11/2025 ordered “HA 2 times per week.” The HA care plan dated 12/13/2024 assigned the HA the relevant task of “bed bath at every visit.” The HA care plan did not include documentation of instructions for the patient’s wound dressing on the coccyx should it become wet or dislodged during the bed bath. Clinical Record 10: The patient elected the hospice benefit on 06/23/2023. On 06/23/2023, the physician ordered “Oxygen 8 liters via nasal cannula continuously.” The plan of care dated 06/23/2023 through 08/21/2023 ordered “HA 2 times per week.” The HA care plan dated 06/24/2023 did not include documentation of safety precautions and instructions related to the patient’s use of oxygen during personal. During a joint record review on 02/25/2025, the Area Executive of Clinical Operations confirmed the findings, stating, “We identified some aide care plans that did not include wound dressing or oxygen instructions during audits in October 2024.””