Hospice Compassus-North Central Missouri

“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, interview, and observation. Agency policy and procedure #HOS-C_15C “Medication Reconciliation and Management” (revised 01/24/2025) read in part, “For patients residing 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. 2. Nurse visually reviews the patient’s medication list in the home, comparing it to the medication list from the medical record. 4. If the medication lists do NOT match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders and the medication reconciliation process is completed.” In 1 of 23 (4%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current prescription and OTC drugs. Clinical Record 4/Home Visit 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. During the home visit with the Chaplain (CH) [Personnel Record 4] on 02/04/2025, the patient’s medication list (updated by the daughter on 01/08/2025) was reviewed. The patient’s daughter was not present during the home visit. The patient’s medication list and the medications in the home did not match the hospice medication profile or the Hospice IDG Comprehensive Assessment. The hospice medication profile did not document Preservision, one (1) pill two times daily, and donepezil 5 mg tablet daily. A clinical record review revealed the medications were reviewed with the patient’s medication regimen. However, Preservision and donepezil were not documented in the hospice medication profile. During a joint phone call on 02/05/2025 with the Director of Clinical Services, the patient’s home medication list was reviewed with the patient’s daughter, who stated in part, “Mom has been taking both of those medications (Preservision and donepezil) for a while.” During a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that Preservision and donepezil were not documented on the medication profile for clinical record 4.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that a Registered Nurse provided coordination of care to ensure continuous assessment of the patient and family needs and implementation of the interdisciplinary plan of care. Agency policy #HOS-C15 “Nursing Services” (reviewed 12/24/2024) stated in part “Nursing services include the following: g. Collaboration with the interdisciplinary team and coordination of all patient care/support activities.” Clinical Record 6: The patient elected hospice on 05/09/2024 with a diagnosis of other sequelae of cerebral infarction. The volunteer assignment completed on 08/27/2024 documented volunteer services four (4) times a month beginning in September for patient companion visits and socialization. Two (2) volunteer visits were documented in September. The coordination note completed by the Volunteer Coordinator on 09/27/2024 documented, “Visits will be paused for a while. Volunteer is out with a surgery. Paused on 09/19/2024.” A clinical record revealed no evidence that the Registered Nurse coordinated with the interdisciplinary group to ensure the implementation of the interdisciplinary plan of care to meet the patient’s volunteer needs for companionship and socialization needs. Clinical Record 12: The patient elected hospice on 06/14/2024 with a diagnosis of Alzheimer’s Disease. The volunteer assignment request dated 06/17/2024 documented, “Patient wants/needs a volunteer. Patient needs socialization, caregiver needs socialization.” The volunteer assignment completed on 07/30/2024 documented volunteer services two (2) times per month for patient companion visits and life review video/audio/journal. A clinical record revealed no evidence that the Registered Nurse coordinated with the interdisciplinary group to ensure the implementation of the interdisciplinary plan of care to meet the patient’s volunteer needs for companionship and socialization needs. During the joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that the clinical records lacked evidence that the RN coordinated with the interdisciplinary group regarding volunteer needs identified in the initial and updated comprehensive assessments.”

“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. Agency policy #C9 “Written Interdisciplinary Plan of Care” (revised 09/27/2019) stated in part, “The content of the plan of care includes at minimum: a. An assessment of the the patient’s and family’s needs and goals f. Measurable goals and outcomes for planned interventions.” In 5 of 23 (22%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 2: The patient elected hospice care on 11/29/2024 with a diagnosis of unspecified sequelae of cerebral infarction. On 12/27/2024, the physician ordered Bactrim DS 800 mg-160 mg, one (1) tab twice daily for urinary tract infection (UTI). A coordination note dated 12/27/2024 documented, “Noted urine in drainage bag to be dark and cloudy. Notified Dr. (name) of patient’s (pts) symptoms and received a new order for Bactrim DS BIDx7D.” On 12/31/2024 the physician ordered wound care “Coccyx wound-cleanse area to coccyx with wound cleanser, apply barrier cream bid and prn.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/03/2025 and 01/17/2025 did not document patient and family goals and planned interventions for the identified urinary tract infection and coccyx wound. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). On 01/13/2025, the physician ordered, “Amoxicillin 875 mg 1 tablet by mouth 2 times daily for 7 days Reason: UTI.” The skilled nursing (SN) visit dated 01/13/2025 documented, “Foley draining blood-tinged urine with sediment, pt complains of burning in the genital area. New order received from Dr. (name) for Amoxicillin 875mg 1 PO BID X7D.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/17/2025 and 01/31/2025 did not document patient and family goals and planned interventions for the identified urinary tract infection. Clinical Record 13: The patient elected hospice care on 05/28/2024 with a diagnosis of COPD. On 01/13/2025, the physician ordered, “Doxycycline 100mg capsule by mouth 2 times daily for 7 days Reason: respiratory infection.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/17/2025 and 01/31/2025 did not document patient and family goals and planned interventions for the identified respiratory infection. Clinical Record 18: The patient elected hospice care on 12/31/2024 with a diagnosis of malignant neoplasm of an unspecified part of the lung. The initial nursing assessment visit dated 12/31/2024 documented a “safety concern related to handling/storage/use of oxygen.” The SN visit dated 01/01/2025 documented, “Indicate when dyspnea occurs at rest. PCGR states he is always dyspneic but it is worse tonight... Assisted pt to sitting position and with nebulizer (neb) treatment (tx).” The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 01/03/2025 and 01/17/2025 did not document patient and family goals and planned interventions for the identified dyspnea and oxygen safety. Clinical Record 19: The patient elected hospice care on 03/04/2024 with a diagnosis of senile degeneration of the brain. On 07/10/2024, the physician ordered, “Bactrim DS 800/160mg 1 tablet by mouth every 12 hours x 7 days for UTI.” The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 07/19/2024 did not document patient and family goals and planned interventions for the identified urinary tract infection. In a joint record review and an interview on 02/05/2025, the Director of Clinical Services confirmed that clinical record 2 did not include patient and family goals and planned interventions for urinary tract infection and coccyx wound, clinical record 8 did not document patient and family goals and planned interventions for urinary tract infection, clinical record 13 did not document patient and family goals and planned interventions for respiratory infection, clinical record 18 did not document patient and family goals and planned interventions for dyspnea and oxygen safety, and clinical record 19 did not document patient and family goals and planned interventions for urinary tract infection.”

“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, interview, and observation. In 1 of 23 (4%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s plan of care included drugs necessary to meet the needs of the patient. Clinical Record 4/Home Visit 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. During the home visit with the Chaplain (CH) [Personnel Record 4] on 02/04/2025, the patient’s medication list (updated by the daughter on 01/08/2025) was reviewed. The patient’s daughter was not present during the home visit. The patient’s medication list and the medications in the home included Preservision, one (1) pill two times daily, and donepezil 5 mg tablet daily. During a joint phone call on 02/05/2025 with the Director of Clinical Services, the patient’s home medication list was reviewed with the patient’s daughter, who stated in part, “Mom has been taking both of those medications (Preservision and donepezil) for a while.” The patient’s Plan of Care Update Reports, effective 01/17/2025 and 01/31/2025, did not document Preservision and donepezil. During a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that Preservision and donepezil were not documented on the medication profile and Plan of Care Update Reports.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. Agency policy #IPC.11 “Infection Control” (revised 09/30/2024) stated in part, “Infection control measures-Compassus utilizes reference materials from the Centers for Disease Control and Prevention for the development and implementation of infection control measures. Guideline for Hand Hygiene in Health Care Settings, CDC Morbidity and Mortality Weekly Report (MMWR).” The MMWR read in part, “Indications for hand hygiene-After glove removal.” In 1 of 6 (17%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. Home Visit 3: The patient elected hospice care on 07/08/2022 with a diagnosis of senile degeneration of the brain. The RN provided peri care during the home visit with the Registered Nurse (RN) [Personnel Record 3] on 02/04/2025. After providing peri care, the RN changed their gloves. The RN did not perform hand hygiene after changing/removing gloves per the policy. During an interview on 02/04/2025, the Director of Clinical Services confirmed the finding and the agency policy that hands should be cleansed between and after glove removal.”

“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 #C12, “Personnel Qualifications and Licensed Services” (revised 08/18/2022), stated in part, “LP/VNs are supervised by registered nurses not less than every month.” In 2 of 20 (10%) clinical records reviewed of patients that received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of the LPN nursing services per agency policy. Clinical Record 4: The patient elected hospice care on 08/08/2024 with a diagnosis of Parkinsonism. The plan of care dated 08/08/2024 through 11/05/2025 ordered skilled nursing (SN) services once (1) weekly beginning 08/08/2024. The LPN completed nursing visits on 08/14/2024 and 09/01/2024. A clinical record review revealed no evidence that LPN supervisory visits were completed in August and September per agency policy. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The recertification plans of care dated 08/19/2024 through 11/16/2025 and 11/17/2024 through 02/14/2025 ordered SN services twice (2) weekly beginning 08/19/2024. The LPN completed nursing visits on 12/06/2024, 12/13/2024, 12/20/2024, 12/23/2024, 12/27/2024, and 01/17/2025. An LPN supervisory visit was completed on 11/25/2024. A clinical record review revealed no evidence that LPN supervisory visits were completed in December and January per agency policy. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that LPN supervisory visits were not completed per agency policy, not less than monthly.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C12, “Personnel Qualifications and Licensed Services” (revised 08/18/2022), stated in part, “Hospice Aides are supervised by registered nurses not less than every 14 days.” In 4 of 16 (25%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the HA. Clinical Record 7: The patient elected hospice care on 06/05/2024 with a diagnosis of chronic diastolic heart failure. The recertification plan of care dated 12/02/2024 through 01/30/2025 ordered HA services twice (2) weekly beginning 12/02/2024. The HA visits were provided beginning 12/02/2024 as ordered. The HA supervisory visits were provided on 12/03/2024 and 12/20/2025, with 17 days outstanding. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease. The recertification plan of care dated 11/17/2024 through 02/14/2025 ordered HA services twice (2) weekly beginning 11/17/2024. The HA visits were provided beginning 11/17/2024 as ordered. The HA supervisory visits were provided on 01/03/2025 and 01/20/2025, with 17 days outstanding. Clinical Record 14: The patient elected hospice care on 05/16/2024 with a diagnosis of unspecified sequelae of cerebral infarction. The recertification plans of care dated 08/15/2024 through 11/11/2024 and 11/12/2024 through 01/10/2025 ordered HA services twice (2) weekly beginning 11/11/2024. The HA visits were provided beginning 11/11/2024 as ordered. The HA supervisory visits were provided on 10/29/2024 and 11/29/2024, with 31 days outstanding. Clinical Record 19: The patient elected hospice care on 03/04/2024 with a diagnosis of senile degeneration of the brain. The recertification plan of care dated 06/02/2024 through 07/23/2024 ordered HA services three (3) times weekly beginning 06/02/2024. The HA visits were provided beginning 06/02/2024 as ordered. The HA supervisory visits were provided on 06/10/2024 and 06/28/2024, with 4 days outstanding. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are: noted in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C20 “Volunteer Services” (reviewed 12/24/2024) stated in part, “Volunteers, under the supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program’s identified needs.” In 2 of 6 (33%) clinical records reviewed of patients with identified volunteer needs, the agency did not ensure volunteers were used in day-to-day direct patient care roles and noted in the plan of care based on needs identified in the initial and updated comprehensive assessments. Clinical Record 6: The patient elected hospice on 05/09/2024 with a diagnosis of other sequelae of cerebral infarction. The volunteer assignment completed on 08/27/2024 documented volunteer services four (4) times a month beginning in September for patient companion visits and socialization. Two (2) volunteer visits were documented in September. The coordination note completed by the Volunteer Coordinator on 09/27/2024 documented, “Visits will be paused for a while. Volunteer is out with a surgery. Paused on 09/19/2024.” A clinical record revealed no evidence that the volunteer services were provided, that the patient declined volunteer visits, or that the interdisciplinary group team members increased the frequency of visits to address the patient’s companionship and socialization needs. Clinical Record 12: The patient elected hospice on 06/14/2024 with a diagnosis of Alzheimer’s Disease. The volunteer assignment request dated 06/17/2024 documented, “Patient wants/needs a volunteer. Patient needs socialization, caregiver needs socialization.” The volunteer assignment completed on 07/30/2024 documented volunteer services two (2) times per month for patient companion visits and life review video/audio/journal. A clinical record review revealed no evidence that the volunteer services were provided, the patient declined volunteer visits, or that the interdisciplinary group team members increased the frequency of visits to address the patient and caregiver socialization needs. During the joint record review and interview on 02/05/2025, the Director of Clinical Services (personnel interview 13) confirmed that the clinical record did not include evidence that volunteer services were implemented based on needs identified in the initial and comprehensive assessments.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C31 “Clinical Records” (revised 01/25/2023) stated in part, “Entries into the EMR are to be completed on the date of the visit when at all possible and not later than 10 am the next business day.” In 2 of 23 (9%) clinical records reviewed, the agency did not ensure that documentation was completed per the organization’s policy. Clinical Record 2: The patient elected hospice care on 11/29/2024 with a diagnosis of unspecified sequelae of cerebral infarction. The Licensed Practical Nurse (LPN) visited the patient on 12/12/2024. The LPN visit note documentation was submitted on 12/15/2024, with one (1) business day outstanding. The Registered Nurse (RN) visited the patient on 12/17/2024. The RN visit note documentation was submitted on 12/22/2024, with three (3) business days outstanding. The RN visited the patient on 12/31/2024. The RN visit note documentation was submitted on 01/06/2025, with three (3) business days outstanding. The RN visited the patient on 01/09/2025. The RN visit note documentation was submitted on 01/12/2025, one (1) business day after the services provided. The LPN visited the patient on 01/14/2025. The LPN visit note documentation was submitted on 01/20/2025, with three (3) business days outstanding. A clinical record review revealed no evidence that the documentation was submitted timely per the agency policy. Clinical Record 8: The patient elected hospice care on 08/19/2024 with a diagnosis of chronic obstructive pulmonary disease. The RN visited the patient on 01/13/2025. The RN visit note documentation was submitted on 01/15/2025, with two (2) business days outstanding. A clinical record review revealed no evidence that the documentation was submitted timely per the agency policy. In a joint record review and interview on 02/05/2025, the Director of Clinical Services confirmed that documentation was not submitted timely per agency policy for clinical records 2 and 8.”