Hospice Compassus-South Central Missouri

“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 drug profile is updated per the hospice policy and procedure, but at a minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, document review, and interview. In 5 of 19 (26%) clinical records reviewed it was revealed that the hospice did not ensure that the medication profile included the patient’s current medications or that new medications were added or changes were made to existing medications. POLICY: The agency policy titled, Medication Reconciliation and Management (Procedure: HOS-C_15C), last reviewed and revised 10/28/2025, stated in part, “...For patients in their own residence, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit: 1. Nurse obtains the most current copy of the medication list (whether this is in the EMR system or on paper), 2. Nurse visually reviews the patient’s medication list in the home, comparing it to the medication list from the medical record...If the medication lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders...” CLINICAL RECORD 4/HOME VISIT 4: The patient elected the hospice benefit on 10/30/2024 with a terminal diagnosis of atherosclerotic heart disease without angina. During the home visit conducted with the Licensed Practical Nurse (LPN) (Personnel Record 8) on 04/01/2026, the patient’s home medications were compared with the hospice medication profile dated 04/01/2026. The patient discussed his ongoing use of Mucinex and Omega-3 fatty acid supplements. Multiple boxes of both products were observed in the home during the visit. Despite the patient’s verbal confirmation of use and the observed presence of these items, neither the medication nor the supplement was documented on the patient’s active medication list. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/03/2025 with a terminal diagnosis of malignant neoplasm of the breast with secondary neoplasms to the lung, bone, and peritoneum. During the Registered Nurse (RN) admission visit on 09/03/2025, the patient was documented as experiencing labored respirations with an oxygen saturation of 95% on 3 liters per minute (LPM) of oxygen via nasal cannula. The oxygen was not included on the patient’s medication list. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/11/2024 with a terminal diagnosis of senile degeneration of the brain and a comorbid condition of atherosclerotic heart disease. On 12/11/2025, the Registered Nurse (RN) documented that the patient was experiencing dyspnea with use of accessory muscles and required intermittent oxygen at 2–4 liters per minute (LPM) PRN and during nighttime, due to oxygen saturation levels dropping into the 80s. On 03/12/2026, nursing documentation indicated that the patient’s wife was administering oxygen via nasal cannula at 2 LPM overnight due to oxygen saturation readings in the upper 80s. During the IDG meeting on 03/17/2026, intermittent oxygen use and periodic oxygen saturation levels in the 80s were again noted. Despite repeated documentation of clinically indicated oxygen use across multiple nursing visits and IDG review, oxygen was not included on the patient’s active medication list. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and comorbid conditions of heart failure and lumbosacral radiculopathy. During the Registered Nurse (RN) admission visit on 08/20/2025, the patient was documented as experiencing significant respiratory distress, requiring continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The oxygen was not included on the patient’s active medication list. CLINICAL RECORD 19: The patient elected the hospice benefit on 04/16/2025 with a terminal diagnosis of senile degeneration of the brain. During a Licensed Practical Nurse (LPN) visit on 10/13/2025, the patient was documented as experiencing diarrhea two to three times daily, and the patient’s wife reported that she was initiating Imodium for symptom management. The patient’s wife also reported that she was giving the patient Ivermectin. Despite documented use and administration, neither Imodium nor Ivermectin were listed on the patient’s active medication list. During a joint clinical record review and interview with the Director of Clinical Services (Personnel Record 3) on 04/02/2026, she confirmed that discrepancies were identified in the patient medication profiles within the active medical records. She further confirmed that the medication listings were not accurate or complete at the time of review. The Director stated that the necessary corrections and updates were entered into the medical records during the site visit.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions 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 4 of 19 (21%) clinical records reviewed, it was revealed that the agency did not ensure that the patient’s plan of care reflected patient and family problems, interventions, and goals based on problems identified by the assessment data. POLICY: In the hospice’s policy “Interdisciplinary Team Meeting (Procedure: HOS-C_09E)” last reviewed and revised 08/11/2025, included in part “...The IDT will follow the cadence of discussing each patient’s needs/condition over the previous 2 weeks and plan to meet the patient’s needs for the next 2 weeks...Comfort, Safety, and Quality of Life...each team member contributes insight, information, assessment data, and details concerning problems, goals, and interventions. The focus of the discussion is what has happened in the previous 2 weeks and what is expected to happen in the next 2 weeks...includes...changes in the Plan of Care (POC)...and changes in interventions for the patient...” CLINICAL RECORD 1: The patient elected the hospice benefit on 01/16/2026 with a terminal diagnosis of malignant neoplasm of the ampulla of Vater with secondary malignant neoplasms of other digestive organs, and comorbid conditions including heart failure and chronic obstructive pulmonary disease (COPD). At the time of hospice admission on 01/16/2026, the patient was documented as experiencing anorexia only, with no nausea or chest pain noted. During the Registered Nurse visit on 01/21/2026, the nurse documented that the patient had been experiencing intermittent chest pain over several days, described as sharp pains that varied in duration, along with decreased appetite and nausea. Physician orders were obtained and documented on 01/21/2026 for Isosorbide Mononitrate 30 mg daily for chest pain and Zofran 4 mg every 4 hours as needed (PRN) for nausea. At the Interdisciplinary Group (IDG) meeting on 02/03/2026, these medication additions were noted; however, the IDG did not identify chest pain or nausea as active problems, nor did it develop or revise goals or interventions to address these symptoms within the plan of care. On a visit on 03/02/2026, the patient reported to the nurse that her nausea was worsening and not adequately controlled with the Zofran 4 mg dose. The physician’s order was increased to Zofran 8 mg every 8 hours PRN. The patient also continued to experience intermittent daily chest pain. A review of IDG documentation confirmed that the patient’s ongoing and worsening chest pain and nausea were not reviewed or discussed during the IDG meetings held on 02/17/2026 or 03/03/2026. During a nursing visit on 03/04/2026, the patient complained of constant nausea throughout the day and worsening angina. New physician orders were received and documented the same day: Scopolamine 1 mg transdermal patch every 72 hours for nausea, and Nitroglycerin 0.4 mg sublingual tablets PRN for angina, with a maximum of 3 tablets in 15 minutes. At the IDG meeting on 03/17/2026, the medication changes were acknowledged; however, the IDG again did not revise the plan of care to reflect the patient’s increased symptom burden. No new problems were identified, and no updated goals or interventions were developed to address the persistent and worsening nausea and chest pain. A review of the patient’s plan of care for the benefit period from 01/16/2026 through 04/15/2026 revealed a single, generalized comfort-related problem with a broad goal for the patient and caregiver to understand symptom scales, manage symptoms, and report changes to hospice. Interventions remained limited to monitoring pain, shortness of breath, and appetite using scoring scales. Despite the patient’s documented progression of symptoms, including escalating nausea and chest pain requiring multiple medication adjustments, the IDG did not update the comprehensive plan of care. There were no new or revised problems, goals, or interventions documented after 01/20/2026. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/03/2025 with a terminal diagnosis of malignant neoplasm of the breast with secondary neoplasms to the lung, bone, and peritoneum. During a Registered Nurse (RN) visit on 01/06/2026, the patient reported feeling depressed, stated she was utilizing Lorazepam on a PRN (as needed) basis, and was observed to be tearful at times during the visit. A physician’s order was obtained and documented the same day for Lexapro 10 mg daily. On 02/03/2026, a physician’s order was entered to increase the Lexapro dose to 20 mg daily. During the RN visit on 02/03/2026, the patient responded “yes” to screening questions indicating she felt overwhelmed, down or depressed, and experienced loss of pleasure and interest in activities. At the Interdisciplinary Group (IDG) meeting on 02/17/2026, the IDG reviewed the increased PRN use of Lorazepam, the initiation and dose increase of Lexapro, and the patient’s reports of depression and tearfulness. Despite this review, no new goals or interventions related to the patient’s depression or emotional distress were added to the plan of care. During the subsequent IDG meeting on 03/03/2026, the documented comfort and pain goals for the following two weeks included “pain, increased confusion, appeared to improve emotionally”, with no further discussion, assessment, or care planning documented related to the patient’s ongoing depression. A review of the patient’s plans of care for the benefit periods 12/02/2025–03/01/2026 and 03/02/2026–04/30/2026 identified a generalized problem related to comfort, with goals for the patient and caregiver to understand symptom scales, manage symptoms, and report changes to hospice. Additional goals included identifying sensory and neurological changes and implementing prompt interventions to minimize discomfort. Interventions were broad, non-specific, and focused on general symptom monitoring. Despite repeated documentation of depression, emotional distress, tearfulness, and reliance on anxiolytic and antidepressant medications, the patient’s plan of care was not revised to include depression as an identified problem. No individualized goals, psychosocial interventions, or interdisciplinary strategies were developed to address or monitor the patient’s mental health needs. CLINICAL RECORD 14: The patient elected the hospice benefit on 01/11/2024 with the terminal diagnosis of senile degeneration of the brain with the comorbid condition of atherosclerotic heart disease. During the Registered Nurse (RN) Admission visit on 01/11/2024, the patient was alert but oriented to person only. He was noted to be pleasantly confused, smiling with no abnormal mood or respiratory findings. On 12/11/2025, the RN documented that the patient had dyspnea with use of accessory muscles with intermittent oxygen use of 2-4 liters per minute (LPM) as needed (PRN) and at night while sleeping as he occasionally dropped his oxygen saturation readings to the 80’s. All lung fields were diminished upon auscultation. He exhibited declining neurological status but no abnormal mood or affect. The Interdisciplinary Group (IDG) Meeting on 12/22/2025 echoed the same intermittent oxygen needs. Then, on 03/06/2026, during the nursing visit, it was documented that the “...Wife reports pt restless at times, utilizing Lorazepam some. Refills for Lorazepam concentrate and tabs sent to pharmacy per MD order...” The Social Worker noted on her visit on 03/10/2026 that the primary caregiver had been giving the patient Lorazepam at times for agitated behavior. On 03/12/2026, the nurse documented during her visit that the “...Pt showing signs of slight anxiousness by scratching at the back of his head and face occasionally...Wife reported that she had to utilize pt’s O2NC at 2LPM during the night due to pt’s O2 sat dropping down in the upper 80’s...” The nurse documented on 03/17/2026 that the patient would suddenly become anxious at times. During the IDG Meeting on 03/17/2026, intermittent oxygen use and occasional oxygen saturations in the 80s were documented, but the comfort/pain goal for the next 2 did not identify any respiratory or anxiety/agitation issues. A review of the patient’s plans of care from 12/31/2025 to 02/28/2026 and 03/01/2026 to 04/29/2026 identified the need for comfort as a problem with the goals that sensory/neurologic changes are identified promptly and interventions initiated quickly to minimize associated uncomfortable symptoms, as evidenced by the patient/caregiver reporting an acceptable level of comfort within 20 visits. The patient’s respiratory and anxiety were not identified, nor were any planned interventions or patient-specific measurable goals documented for their treatment. There were no new problems, interventions, or goals added since 04/14/2025. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and comorbid conditions of heart failure and lumbosacral radiculopathy. During the admission visit on 08/20/2025, the patient was documented as experiencing significant respiratory compromise, including use of accessory muscles for breathing, abnormal breath sounds, and a requirement for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. The patient reported a dyspnea score of 8/10, with the worst level in the prior 24 hours reported as 9/10, and identified a personal dyspnea goal of 6/10. At the Interdisciplinary Group (IDG) meeting on 09/02/2025, documentation reflected a progressive decline in respiratory function, increased oxygen dependence, and decreased activity tolerance, with a respiratory rate of 20 breaths per minute, labored with conversation. However, the comfort and care goals for the upcoming two-week period focused primarily on pain and general comfort during activities of daily living, without clear, individualized goals or interventions to address the severity of the patient’s dyspnea. At the time of recertification on 11/05/2025, the patient continued to demonstrate ongoing dyspnea with an increasing respiratory rate, was utilizing continuous oxygen at 2 LPM, and fatigued after ambulating 10 feet, requiring approximately five minutes to recover. The patient was also documented as using non-invasive ventilation at night. Oxygen saturation was 95% on 2 LPM, and dyspnea scores ranged from 3 to 5. On 01/08/2026, a Licensed Practical Nurse (LPN) documented that the patient’s daughter reported the patient had removed oxygen during the night, resulting in oxygen saturation levels dropping into the 60s, accompanied by confusion. Despite this ongoing and severe respiratory symptom burden, the IDG meeting on 11/11/2025 again focused comfort goals for the next two weeks on pain only, without identifying dyspnea as a primary symptom requiring targeted care planning, despite oxygen saturation levels documented as dropping into the 60s–70s on room air and improving only with oxygen therapy. A review of the patient’s plans of care for the benefit periods 08/20/2025 to 11/17/2025 and 11/18/2025 to 01/13/2026 identified a generalized problem related to comfort with goals, specifically that the patient and caregiver need to understand symptom rating scales and report changes to the hospice. Interventions were limited to monitoring pain and dyspnea using appropriate scales. However, the patient’s self-identified dyspnea score and stated dyspnea goal were not incorporated into the plan of care, and no patient-specific, measurable goals or detailed interventions were developed to address the patient’s persistent and severe shortness of breath. After a joint clinical record review and interview on 04/01/2026 with the Area Executive of Clinical Operations (Personnel Record 2) and the Director of Clinical Services (Personnel Record 4), the findings were confirmed.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group, and written patient care instructions for a hospice aide be prepared by an 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 1 of 11 (9%) clinical records reviewed revealed that the hospice did not ensure that the Registered Nurse provided the Hospice Aide full, complete instructions in the aide’s plan of care. CLINICAL RECORD 18: The patient elected the hospice benefit on 08/25/2025. The patient’s plan of care for the benefit period from 08/25/2025 to 11/22/2025 included orders for the hospice aide (HA) to visit the patient once a week. For the benefit period from 11/23/2025 to 12/21/2025, the aide was to visit the patient twice weekly. During the Registered Nurse (RN) visit on 10/24/2025, the patient was noted to be incontinent of bowel and bladder with chronic diarrhea. She had developed a stage 2 pressure ulcer on her coccyx measuring 0.5cm x 0.45cm x 0cm. A physician’s order on the same date included the treatment orders to clean the wound with normal saline and pat dry. Apply Calmoseptine and cover with a border dressing twice a week and as needed (PRN) if soiled. The order was changed on 10/29/2025 to clean the wound with normal saline, pat dry, and apply sterile honey to the wound. Then cover with a Mepilex border foam dressing twice weekly and PRN if soiled. On 11/03/2025, the nurse noted the wound continued as a stage 2 and measured 1.6cm x 0.5cm x 0cm. During the Licensed Practical Nurse (LPN) visit on 11/24/2025, the patient had experienced an episode of diarrhea, and wound care was performed by facility staff. An order was documented the same day for the dressing to be changed twice daily and PRN if soiled. The HA plan of care dated 08/28/2025 included the interventions for the HA to perform at each visit: a partial sponge bath and perineal care. It was noted that the patient was at high risk for skin breakdown. The aide care plan was not updated on 10/24/2025 to give the aide specific instructions on what to do if the wound dressing fell off or got soiled during the aide visit. During a joint clinical record review and interview with the Area Executive of Clinical Operations (Personnel Record 2) on 03/31/2026, she confirmed that no instructions related to the patient’s wound care had been provided by the Registered Nurse (RN) to the Home Aide (HA). She further acknowledged that wound-related instructions should have been communicated to the HA to support appropriate care delivery.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the hospice Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 03/31/2026, revealed that the hospice did not meet the regulatory requirement that volunteer services account for at least five percent (5%) of the total patient care hours. Review of year-end data showed that volunteer hours averaged 3.03% in 2024 and 4.66% in 2025, both below the required threshold. Additionally, the year-to-date average for 2026 was 4.41%. During the interview, the Volunteer Coordinator acknowledged that the hospice had not consistently met the required 5% minimum. The agency further confirmed that this ongoing deficit led to the initiation and subsequent revision of a QAPI Performance Improvement Project (PIP), beginning in January 2025, to address volunteer recruitment and utilization. During a review of the hospice Volunteer Program documentation and an interview with the Volunteer Coordinator (VC) (Personnel Record 7) on 03/31/2026, it was determined that the hospice did not meet the regulatory requirement that volunteer services account for at least five percent (5%) of the total patient care hours. Review of year-end data showed that volunteer hours averaged 3.03% in 2024 and 4.66% in 2025, both below the required threshold. Additionally, the year-to-date average for 2026 was 4.41%, confirming that the hospice had not achieved sustained compliance with the volunteer utilization requirement across multiple reporting periods. During the interview, the Volunteer Coordinator acknowledged that the hospice had not consistently met the required 5% minimum. The agency further confirmed that this ongoing deficit led to the initiation and subsequent revision of a QAPI Performance Improvement Project (PIP), beginning in January 2025, to address volunteer recruitment and utilization. Documentation reflected multiple volunteer recruitment efforts, including the posting of flyers, use of an online volunteer-matching platform, engagement with local assisted living facilities, and participation in marketing events and health fairs. Most recently, outreach to local colleges and universities resulted in 11 students expressing interest in volunteering, with 3 having completed the background check at the time of the survey. The agency also demonstrated volunteer-retention activities, including a monthly volunteer newsletter, volunteer appreciation luncheons, ongoing communication via phone calls and text messages, and recognition through birthday and holiday cards. Despite these recruitment and retention strategies, the hospice had not yet achieved or maintained volunteer service hours at or above the required 5% level.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of discharged patients, it was revealed that the agency did not ensure that the Discharge Summary was sent to the hospital upon the patient’s discharge from hospice and admission to the hospital. CLINICAL RECORD 15: The patient elected the hospice benefit on 08/20/2025 and was discharged from services on 01/13/2026 due to admittance to the hospital. A Discharge-Transfer Summary Report dated 01/13/2026 included the required information on the patient’s plan of care, latest orders, and medications, but contained no documentation that the discharge summary was provided to the hospital. The post-discharge Interdisciplinary Group Meeting on 01/20/2026 included “Pt discharged from hospice services on 01/13/2026 due to moving out of service area to hospital location. There was no documentation in the clinical record that the discharge summary was provided to the hospital upon the patient’s discharge from hospice and hospital admission in the IDG, a Care Coordination note, or in scanned documentation. During a joint clinical record review and interview with the Area Executive of Clinical Operations (Personnel Record 2) on 04/01/2026, she confirmed that there was no documentation in the medical record indicating that the discharge summary had been provided to the hospital at the time of the patient’s hospital admission and discharge from hospice. She further confirmed that the discharge summary was faxed to the hospital on 04/01/2026, and the fax transmission confirmation was uploaded to the electronic medical record on that same date.”