Compassus- Santa Fe

“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. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 4 (50%) observed home visits, it was revealed that the agency did not ensure the drug profiles contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 10/22/2025 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). During the observed home visit with the Registered Nurse (Personnel Record 4) on 07/29/2026, the hospice medication profile (printed on 07/29/2026) was compared to the SNF medication profile (printed on 07/29/2026). The following discrepancies were noted: the hospice list had Hyoscyamine 0.125 mg, 1 tablet every six hours as needed (ordered 10/22/2025) vs the SNF which listed Hyoscyamine 0.125 mg, 1 tablet every four hours as needed (ordered 04/22/2026). The hospice list had Ipratropium-Albuterol 1 vial, inhale orally twice daily (ordered 10/22/2025) vs the SNF which listed Ipratropium-Albuterol 1 vial, inhale orally four times daily (ordered 04/22/2026). The hospice list had Oxycodone 10 mg, 1 tablet every 6 hours as needed (ordered 10/22/2025) vs the SNF which listed Oxycodone 10 mg, 1 tablet every 4 hours as needed (ordered 04/22/2026). The hospice list had Senna 8.6 mg, take daily as needed (ordered 10/22/2025) vs the SNF which listed Senna 8.6 mg, take daily (ordered 04/22/2026). HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 04/23/2026 with a diagnosis of end-stage renal disease. The patient resided in a private home. During the observed home visit with the Social Worker (Personnel Record 5) on 07/29/2026, the hospice medication profile (printed on 07/29/2026) was compared to the home medications provided by the patient’s spouse. The spouse advised that the patient “had been taking quite a few medications she came home with from the hospital...but currently was only taking 1 or 2.” One of the medication bottles he provided was labeled “Tacromulis 0.5 mg. 1 tablet twice daily. Dated 04/23/2026.” The spouse advised the last call to the “lung doctor told them to just take 1 tablet daily.” He advised this was after the “hospice nurse had completed a blood draw for the patient and the doctor had received the results.” This medication was not listed on the hospice medication profile. A joint clinical record review and interview was conducted with the Director of Patient Care on 07/30/2026 during which time she advised they had been aware the patient in Home Visit 3 “had been taking that medication but they had been unable to put it on the medication list as they were waiting on it to be added by IT (information technology) and she would need to follow up on it.” The other medications she would need to ask the nurses to reconcile.”

“It is required that medical social services are provided by a qualified social worker according to the patient’s and family’s needs and acceptance of these services. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (13%) clinical records reviewed for patients accepting medical social worker services, the agency did not ensure that a medical social worker provided psychosocial assessments based on the patients’ and families’ acceptance of these services. CLINICAL RECORD 19: The patient elected the hospice benefit on 12/11/2025 and died on 12/31/2025. The Registered Nurse (RN) completed the initial medical social work assessment and noted: “Patient and family need help with final arrangements.” The medical social worker documented a phone call on 12/18/2025, “MSW spoke with patient’s daughter over the phone. Declined in-person visit. Daughter explained the patient was originally from California and moved to this area 34 years ago. Patient worked as a housekeeper and had four children. The patient is of Catholic faith. The family does not currently have funeral plans, but MSW offered a list for when the family was able to discuss it with each other. The family declined MSW at this time, but MSW will remain available as needed.” On December 29th, 2025, there was a note from the RN stating, “Patient is imminent, and assistance with funeral plans was needed.” There was no documentation in the record of the social worker’s follow-up. A joint clinical record review and interviews were conducted with the Hospice Area Executive of Clinical Operations on 07/30/2026 and 07/31/2026, during which time it was explained that the social worker who was here during this time was “only here a couple of months (10/27/2025 to 01/30/2026) before being let go for performance issues.””

“It is required that written patient care instructions for a hospice aide are prepared by a RN (registered nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 2 of 10 (20%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the RN provided specific written instructions for the hospice aide. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/05/2026. The hospice aide care plan dated 06/03/2026 included the following relevant tasks: “Assist to BSC (bedside commode) and assist to toilet.” Both tasks were to be completed every visit and included additional details of “Assist to bedside commode or toilet at patient request.” The hospice aide visit frequency was once weekly. These instructions did not provide the hospice aide with specific instructions regarding toileting the patient and whether they should utilize the bedside commode or the toilet/bathroom. CLINICAL RECORD 18: The hospice benefit was elected on 11/25/2025 and the patient died on 12/28/2025. The hospice aide care plan(s) dated 11/25/2025, and updated 12/09/2025 and 12/17/2025 included the following relevant task(s): “Stand-by assistance with ambulation. Every visit. Details: Ambulate patient to BR (bathroom) if he needs it; Assist to toilet; Bathing (shower). Every visit. Details: Shower patient if he is up to it; Shampoo; Dressing. Every visit. Details: Dress patient if he desires it.” The hospice aide visit frequency was twice weekly. These instructions did not provide the hospice aide with specific instructions regarding ambulation, toileting, dressing. A joint clinical record review and interview was conducted with the Hospice Area Executive of Clinical Operations on 07/30/2026 during which time she agreed the hospice aide care plans should not allow the patient or aide to “make decisions about the tasks to be performed.””

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group (and) included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. 1 of 10 (10%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the hospice aide provided services included in the plan of care. HOME VISIT 2/CLINICAL RECORD 2: The hospice aide care plan dated 07/28/2026 included the following relevant tasks: “Fall precautions; infection control precautions; bathing (shower); shampoo; hair care; skin care; oral care-brush teeth with toothpaste; nail care-clean under fingernails; dressing; transfer to/from bed/chair; empty trash; change linens-when soiled or wet; communicate with other disciplines; write a narrative note; RN (registered nurse) communication for any tasks not completed.” All tasks were to be completed every visit with a hospice aide visit frequency of twice weekly. During an observed home visit on 07/29/2026 with a hospice aide (Personnel Record 7), it was noted that the hospice aide did not complete the assigned tasks of oral care, brushing teeth, empty trash, cleaning under the nails or checking the bed/change linens. A joint clinical record review and interview was conducted with the Hospice Area Executive of Clinical Operations on 07/30/2026 during which time she advised that the hospice aide would be counseled on completing all tasks in accordance with the hospice aide care plan.”