Compassus St Louis

“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 and interview. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure that the patient’s drug profile included the patient’s current medications. Clinical Record 6: The patient elected the hospice benefit on 09/12/2024. The Registered Nurse (RN) assessment dated 09/25/2024 documented that the patient had oxygen in the home and received oxygen continuously @ 2 liters (L). On 09/26/2024, the RN documented an increase in oxygen continuously to 3L via nasal cannula (NC). A clinical record review revealed oxygen was not listed on the patient’s medication profile. During an interview and a joint record review, the Director of Clinical Services confirmed that the medication profile did not document oxygen.”

“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, observation, and interview. In 2 of 6 (33%) clinical records reviewed and home visits observed, the hospice did not ensure that the written plan of care included planned interventions based on problems identified in the comprehensive assessment, Clinical Record 2: The patient elected the hospice benefit on 09/25/2024 with a diagnosis of severe protein-calorie malnutrition. The patient resided in an adult living facility (ALF). The Registered Nurse’s (RN’s) initial comprehensive assessment dated 09/25/2024, documented that the patient had a stage 1 pressure ulcer and a small wound on the right ankle. The initial plan of care dated 09/25/2024 did not include documentation of planned interventions for the wounds identified in the initial comprehensive assessment. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of diastolic congestive heart failure. The patient resided in an ALF. The RN’s comprehensive assessment dated 9/19/2024 documented “3-4 plus edema bilaterally.” During the home visit with the RN [Personnel Record 4], the patient had 4+ edema to bilateral legs. The patient’s shoes did not fit on his feet due to the edema. The initial plan of care dated 08/23/2024 and the updated plan of care dated 09/23/2024 did not include documentation of planned interventions for the patient’s identified problem with edema. During a joint record review and interview, the Director of Clinical Services confirmed that the written plans of care were missing interventions for problems identified in the comprehensive nursing assessments.”

“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: a) Intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 6 (33%) clinical records reviewed, the hospice did not ensure that the patient’s plan of care included interventions to manage pain and symptoms. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of diastolic congestive heart failure. The patient resided in an ALF. On 09/24/2024, the RN’s assessment documented, “Patient (pt) did inform nurse having right hip pain yesterday that radiates down the right leg. Pt says he has taken Tylenol once yesterday and once today and reduces it from 8/10 to 0/10.” The initial plan of care dated 08/23/2024 and the updated plan of care dated 09/23/2024 did not include documentation of planned interventions for the patient’s pain. Clinical Record 4: The patient elected the hospice benefit on 09/05/2024 with a diagnosis of heart failure. The RN’s comprehensive assessment dated 09/26/2024 documented, “Pain is still waking him every night...pain is in the right iliac sacral area but radiates up his right back and down his right leg.” The initial plan of care dated 09/05/2024 and the updated plan of care dated 09/23/2024 did not include documentation of interventions to address the patient’s pain. During a joint record review and interview, the Director of Clinical Services confirmed that the written plans of care were missing interventions for problems identified in the comprehensive nursing 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: physician orders. This standard was not met as evidenced by clinical record review. In 1 of 3 (33%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included physician orders for care and services. Clinical Record 6: The patient elected the hospice benefit on 09/12/2024. The Registered Nurse (RN) assessment dated 09/25/2024 documented that the patient had oxygen in the home and received oxygen continuously @ 2 liters (L). On 09/26/2024, the RN documented an increase in oxygen continuously to 3L via nasal cannula (NC). A clinical record review revealed no physician order for continuous oxygen via NC @2 liters or 3 liters via NC.”