Every finding on record at Compassus Op of Arizona, 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 01/30/2019 read in part, "Regardless of setting, 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 remedies the patient is currently taking or has on hand....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: Nurse obtains the most current copy of the medication list; 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." In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient's drug profile included all medications. Clinical Record 3: The patient elected the hospice benefit on 04/07/2025. A physician's order dated 04/07/2025 ordered, "Oxygen at 2 liters via nasal cannula as needed for shortness of breath." The drug profile dated 04/07/2025 did not include oxygen. The drug profile was not updated to include oxygen until 06/16/2025. During a joint record review on 06/17/2025, the Area Executive of Clinical Operations confirmed that oxygen was not listed on the patient's drug profile until 06/16/2025.

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 a review of clinical records, document review, and interview. In 1 of 13 (8%) clinical records reviewed, the patient's individualized written plan of care lacked patient goals and interventions based on problems identified in the initial and updated comprehensive assessments. The Policy, "Plan of Care (Revised: 1/20/2020)," states in part, "Procedure 1e. PLAN OF CARE - the plan of care is the complete treatment plan that provides the pathway for the hospice IDG to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team as well as input from the patient and/or caregiver, as appropriate." Clinical Record 7: The patient was admitted on 6/17/22. In the Certificate of Terminal Illness, dated 6/17/22, for the certification period 6/17/22 to 9/14/22, the physician stated the patient had bladder incontinence. The Interdisciplinary Group Plan of Care dated 6/17/22 lacked a goal and interventions for bladder incontinence. During an interview on 8/23/22, the Director of Clinical Services reviewed and agreed with the above finding.