Every finding on record at Compassus Aah of Michigan IV, LLC

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) stated 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 19 (5%) clinical records reviewed, the agency did not ensure that all current medications were included in the patient's drug profile. Clinical Record 2: The patient elected the hospice benefit on 12/30/2024. The initial nursing assessment dated 12/30/2024 documented, "Patient is receiving 3 liters oxygen." The drug profile dated 12/30/2024 did not include documentation of oxygen. During a joint record review on 01/27/2025, the Area Executive of Clinical Operations confirmed that oxygen was not included in the patient's drug profile.

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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included the drugs and treatment necessary to meet the patient’s needs. Clinical Record 2: The patient elected the hospice benefit on 12/30/2024. The plan of care dated 12/30/2024 through 03/28/2025 ordered: “Supplies: Oxygen Concentrator... Safety Precautions: Oxygen Precautions.” The plan of care did not include documentation of the oxygen flow rate, route of administration, or frequency of administration. Clinical Record 6: The patient elected the hospice benefit on 11/25/2024. The plan of care dated 11/25/2024 through 02/22/2025 ordered: “Supplies: Foley Catheter...SN to educate the family on maintenance and care of Foley catheter.” The plan of care did not include specific orders for the size or the care and maintenance of the Foley catheter. Clinical Record 18: The patient elected the hospice benefit on 09/16/2024. The plan of care dated 09/16/2024 through 12/14/2024 ordered: “Supplies: Foley Catheter...SN to educate the family on maintenance and care of Foley catheter.” The plan of care did not include specific orders for the size or care and maintenance of the Foley catheter. During a joint record review on 01/28/2025, the Area Executive of Clinical Operations confirmed that the plans of care did not include specific physician’s orders for the dosage, route, and frequency of oxygen and the size and maintenance of the Foley catheter.

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, read in part, "The Registered Nurse is responsible for performing a supervisory visit of the LPN/LVN at least every 30 days." In 9 of 19 (47%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that supervisory visits were completed by the Registered Nurse (RN) no less frequently than every 30 days per agency policy. Clinical Record 4: The patient elected the hospice benefit on 11/10/2024. The plan of care dated 11/10/2024 through 02/08/2025 ordered "SN 2x/week." The LPN documented visits on 11/17/2024 and 12/02/2024. A clinical record review revealed a RN supervisory visit dated 11/20/2024. No other LPN supervisory visits were documented. Clinical Record 5: The patient elected the hospice benefit on 12/05/2024. The plan of care dated 12/05/2024 through 02/02/2025 ordered "SN 2x/week." The LPN documented a visit on 12/06/2024. A clinical record review revealed a RN supervisory visit dated 01/07/2025, with 31 days outstanding. Clinical Record 7: The patient elected the hospice benefit on 04/18/2024. The plans of care dated 04/18/2024 through 05/16/2024, 05/17/2024 through 07/15/2024, 07/16/2024 through 09/14/2024, 09/15/2024 through 11/13/2024, 11/14/2024 through 01/12/2025, and 01/13/2025 through 03/13/2025 ordered "SN 2x/week." The LPN documented visits on 04/25/2024, 09/11/2024, 10/17/2024, 11/07/2024, 12/19/2024, and 01/14/2025. A clinical record review revealed no documented RN supervisory visits. Clinical Record 9: The patient elected the hospice benefit on 07/09/2024. The plans of care dated 07/09/2024 through 10/06/2024, 10/07/2024 through 01/04/2025, 01/05/2024 through 03/05/2025 ordered "SN 2x/week." The LPN documented visits on 07/17/2024, 10/16/2024, 10/30/2024, 11/27/2024, 12/10/2024, and 01/08/2025. A clinical record review revealed no documented RN supervisory visits. Clinical Record 11: The patient elected the hospice benefit on 10/14/2024. The plan of care dated 10/14/2024 through 01/11/2025 ordered "SN 1x/week." The LPN documented a visit on 11/05/2024. A clinical record review revealed no documented RN supervisory visit. Clinical Record 12: The patient elected the hospice benefit on 06/07/2024. The plans of care dated 09/04/2024 through 12/01/2024 and 12/02/2024 through 02/01/2025 ordered "SN 2x/week." The LPN documented visits on 11/08/2024, 11/11/2024, 12/09/2024, 01/07/2025 and 01/20/2025. A clinical record review revealed RN supervisory visits dated 12/06/2024 and 01/22/2025, with 47 days outstanding. Clinical Record 13: The patient elected the hospice benefit on 12/11/2024. The plan of care dated 12/11/2024 through 03/10/2025 ordered "SN 1x/week." The LPN documented visits on 12/26/2024 and 01/02/2025. A clinical record review revealed no documented RN supervisory visit. Clinical Record 16: The patient elected the hospice benefit on 10/30/2024. The plan of care dated 10/30/2024 through 12/31/2024 ordered "SN 2x/week." The LPN documented visits on 11/18/2024 and 11/25/2024. A clinical record review revealed no documented RN supervisory visit. Clinical Record 18: The patient elected the hospice benefit on 09/16/2024. The plan of care dated 09/16/2024 through 12/14/2025 ordered "SN 3x/week." The LPN documented visits on 10/03/2024, 10/30/2024, 11/01/2024 and 11/20/2024. A clinical record review revealed a RN supervisory visit dated 11/22/2024, with 50 days outstanding. During a joint record review on 01/29/2025, the Area Executive of Clinical Operations confirmed the findings, stating, "We just discovered during some audits a few days ago that LPN supervisory visits were not being completed every 30 days."

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] ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed of patients with Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 13: The patient elected the hospice benefit on 12/11/2024. The plan of care dated 12/11/2024 through 03/10/2025 ordered "Aide 3x/week." A clinical record review revealed HA supervisory visits dated 12/19/2024 and 01/09/2025, with 21 days outstanding. During a joint record review on 01/29/2025, the Area Executive of Clinical Operations confirmed that aide supervisory visits were completed less frequently than every 14 days.

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 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 measurements 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 review of clinical records, document review, and interview. 1 of 13 (8%) records reviewed revealed the hospice failed to update the drug profile when a new medication was added. The agency's policy #C15C "Medication Reconciliation” (Revision Date 1/30/2019) reads in part, "For patients in a nursing facility setting, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit after admission: Note whether there are any new medications or medication changes; document on the nursing visit note what the medication changes are. If orders are signed, provide the copy to the Team Coordinator in the hospice office for entry into the patient's medication profile. If orders are not signed, notify the Team Coordinator of pending signed orders, update the patient's medication profile." Record #68191: For the benefit period dated 3/10/2022-6/7/2022, the registered nurse documented in the visit note dated 3/23/2022, "New order obtained for one time dose of Diflucan 200 mg." The patient's drug profile was not updated to include the new medication Diflucan. The finding was validated by the Area Director of Clinical Operations 4/6/2022 at 1:30pm during an interview and a joint review of the record.

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 review of clinical records and interview. 1 of 12 (8%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the aide services provided were ordered by the interdisciplinary group and included in the plan of care. Record #63082: For the benefit period dated 2/18/2022-5/18/2022, the "Aide Care Plan Report" dated 2/24/2022 documented, "ADL Services: Nail Care, weekly." The hospice aide visit notes dated 2/24/2022, 2/28/2022, 3/3/2022, and 3/7/2022 each documented nail care as completed. Nail care was provided by the aide two times a week and not weekly as ordered in the aide plan of care. The findings were validated by the Area Director of Clinical Operations during an interview and a joint review of the record on 4/5/2022 at 4:00 PM.

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 review of clinical records, document review, and interview. 1 of 13 (8%) records reviewed revealed the patient's clinical record failed to include physician orders for all treatments and services. The agency's policy #C30 "Written and Verbal Orders" (Revision Date 8/22/2018) reads in part, "...orders are in place for the provision or administration of medications, biologicals, durable medical equipment, treatments. Prescribers may provide orders in writing, via electronic means, or verbally." Record #61678: For the benefit period dated 2/10/2022- 5/10/2022, the registered nurse documented in the initial comprehensive assessment dated 2/10/2022, "Genitourinary - Indicate type of catheter used: Suprapubic Catheter; Insertion Date 2/7/2022; Indicate catheter size: Unknown; Indicate Balloon size: Unknown." The registered nurse documented in the “Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 3/22/2022, "Has a Foley. Current Problem List: Need for O/A of the genitourinary status." The clinical record did not include orders for the observation and assessment of a Foley or suprapubic catheter. The finding was validated by the Area Director of Clinical Operations during an interview and a joint review of the documentation on 4/6/2022 at 4:00 PM.