Compassus Hospice and Palliative Care-Birmingham

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received patient care instructions to meet the patient’s needs. Clinical Record 6: The patient elected hospice care on 03/04/2025 with a diagnosis of senile degeneration, residing at home. The patient was admitted with a Foley catheter with a large drainage bag that was placed on 02/262025 and remained until 04/02/2025, when it was discontinued. The HA care plan, documented on 03/06/2025, with no updates, assigned the HA the relevant task of a bed bath and perineal care every visit. The HA care plan did not include instructions for care of the Foley catheter during the bed bath and perineal care. During the interview on 04/29/2025, the Director of Clinical Services stated that reviewing HA care plans has been a process improvement and that the Foley catheter should have been on the aide’s care plan. This was a previous Required Action”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 4: The patient elected hospice care on 03/07/2025 with a diagnosis of kidney cancer. The HA care plan assigned the HA a bathing task of a shower every visit. There were no documented updates to the plan. The HA visit notes dated 03/20/2025, 03/24/2025, 03/27/2025, and 03/31/2025 documented\ that the HA provided “a wash up as the patient wasn’t able to get in the shower.” A wash-up was not the task assigned in the HA care plan. During the interview on 04/29/2025, the Director of Clinical Services stated that the aides have been educated to document their communication with the RN when the tasks are not followed.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 4: The patient elected hospice care on 03/07/2025 with a diagnosis of kidney cancer. The HA care plan assigned the HA a bathing task: to shower every visit. There were no documented updates to the plan. The HA visit notes dated 03/20/2025, 03/24/2025, 03/27/2025, and 03/31/2025 documented\ that the HA provided “a wash up as the patient wasn’t able to get in the shower.” A wash-up was not the task assigned in the HA care plan. Communication tasks with other disciplines and the Registered Nurse were marked (no) “N.” There was no evidence that the change in the bath type was reported to or coordinated with the Registered Nurse (RN). During the interview on 04/29/2025, the Director of Clinical Services stated that the aides have been educated to document their communication with the RN when the tasks are not followed. This was a previous Required Action”

“It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by document review and interview. Agency policy “Fire Drills and Sprinkler Checks - Hospice Inpatient Unit” (last revised 03/16/2022) stated in part, “The hospice inpatient unit (IPU) manager (or designee) is responsible to ensure the planning, implementation, and conduct of a quarterly fire drill to ensure staff and systems are tested for effectiveness in responding to fire risk in the IPU.” A review of the inpatient care facility fire drill logs revealed the hospice did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated, “Fire drills conducted at unexpected times under varying conditions, at least quarterly on each shift.” For the fourth quarter of 2023 there was one documented fire drill on 10/22/2023 at 1510, there was no documented fire drill for the second shift. For the first quarter of 2024 there were documented fire drills conducted on 01/23/2024 at 0825 and 02/17/2024 at 0811. There were no documented fire drills for the second shift. During an interview conducted on 05/23/2024, the Director of Quality confirmed that the above listed fire drills were the only ones documented for those quarters. The Director of Quality also stated that the IPU had two shifts (7 am to 7 pm and 7 pm to 7 am). Review of the fire drill logs revealed the agency did not ensure compliance with the National Fire Protection Act (NFPA) section 18/19.7.1.6 which stated, “Fire drills conducted at unexpected times under varying conditions, at least quarterly on each shift.””

“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. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Medication Reconciliation” (last revised 01/30/2019) stated in relevant part, “Regardless of the 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: 1. 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 30 (3%) clinical records reviewed, the agency did not ensure that the drug profile contained the patient’s current medications. Clinical Record 7: The patient elected hospice care on 04/11/2024. The initial nursing comprehensive assessment dated 04/11/2024, documented the patient utilized continuous oxygen at 4 liters per nasal cannula. The interdisciplinary group (IDG) plan of care meeting notes dated 05/09/2024 documented that the oxygen was still utilized continuously from 2-4 liters. The drug profile effective from 04/11/2024 to current did not document oxygen. On 05/23/2024 the Director of Quality confirmed that the oxygen was not included on the drug profile and said, “The Registered Nurse (RN) was contacted, and it is on there now.””

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The assessment update is completed: as frequently as the condition of the patient requires; No less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 30 (3%) clinical records reviewed, the agency did not ensure that the Registered Nurse (RN) completed a comprehensive assessment no less frequently than every 15 days. Clinical Record 12: The patient elected hospice care on 02/16/2024. A review of the clinical record revealed the following Licensed Practical Nurse (LPN) visits dated 04/25/2024, 04/29/2024, 05/02/2024, and 05/07/2024. The RN comprehensive assessment visit was dated 04/23/2024. The next RN assessment visit was documented on 05/09/2024, with 16 days outstanding. On 05/23/2024 the Director of Quality reported that there were no additional RN visits completed within the 15-day requirement.”

“It is required that each patient’s individualized written plan of care: 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, interview, and observation. In 4 of 30 (13%) clinical records reviewed, the agency did not ensure that the plans of care included specific interventions based on the problems identified in the comprehensive assessment. Clinical Record 2/Home Visit 2: The patient elected hospice care on 07/26/2023. During the home visit on 05/21/2024, the patient was noted to have bilateral heel protectors on and a wedge pillow between the knees. The patient’s wife reported “This prevents him from crossing his legs as he developed a blister when his legs were crossed.” The plan of care identified an altered skin integrity problem and documented, “Skin integrity will be assessed, potential skin issues addressed and measures to prevent breakdown implemented promptly as evidenced by assessment of skin breakdown on each visit.” The POC intervention documented, “Assess skin for signs/symptoms of breakdown as well as preventive measures provided to maintain skin integrity.” The specific interventions of the heel protectors and placing the wedge pillow between the knees were not documented with the interventions. Clinical Record 14: The patient elected hospice care on 12/14/2022. The initial comprehensive nursing assessment dated 12/14/2022 documented that the patient was admitted with a colostomy. The comprehensive nursing assessment dated 05/20/2024 documented that the colostomy was still present. The plans of care, effective from 12/14/2022 to current, did not identify and document a problem, goal, or intervention related to the patient’s colostomy. Clinical Record 17: The patient elected hospice care on 02/01/2024. The initial comprehensive nursing assessment dated 02/01/2024 documented, “Patient was prescribed Seroquel for agitation.” The physician narrative dated 02/16/2024 documented, “The patient has increased cognitive impairment, increased aggressive behavior...and aggression and agitation with combative behavior.” On 05/22/2024, an “emergent” nursing visit was documented due to the patient’s behaviors. The plans of care, effective from 02/01/2024 to current, did not identify and document problems, goals, or interventions related to the patient’s agitation, aggression, or behaviors. Clinical Record 19: The patient elected hospice care on 09/08/2023. The nursing comprehensive assessment dated 02/12/2024 documented “3 or more falls in past 3 months.” The nursing note dated 04/18/2024 documented, “The facility called to report the patient fell.” The interdisciplinary group (IDG) meeting notes for 04/24/2024 documented the patient had one fall in the last two weeks and asked, “Are there safety concerns to be addressed? Patient noted to be drowsy.” The plans of care, effective from 09/08/2023 to current, did not identify and document problems, goals, or interventions related to the patient’s safety or falls. During an interview and a joint record review on 05/23/2024, the Director of Quality confirmed the above plans of care were missing the specific interventions being provided.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure the Registered Nurse (RN) provided specific care instructions for the HA to follow. Clinical Record 14: The initial comprehensive nursing assessment dated 12/14/2022 documented that the patient was admitted with a colostomy. The comprehensive nursing assessment dated 05/20/2024 documented that the colostomy was still present. Per the plan of care orders, HA services were initiated on 12/14/2022 and continued through all benefit periods, including 04/07/2024 through 06/05/2024. The HA care plans effective from 12/14/2022 through 05/21/2024 assigned the HA the relevant tasks: bed bath, dressing, and skin care. The RN did not alert the HA that the patient had a colostomy, if the HA should empty the colostomy bag, or what the HA should report regarding the colostomy. Clinical Record 20: The initial comprehensive nursing assessment 05/09/2024 documented the patient had three (3) wounds covered with dressings. The HA care plan, effective 05/09/2024 to current, assigned the HA the relevant task: bed bath at every visit. The RN did not alert the HA to the wound dressing nor provide instructions for the HA to follow if the dressing was wet, soiled, or dislodged. During an interview on 05/23/2024, the Director of Quality reported that the aide care plans should have included information about the colostomy and wounds and stated, “We have fixed these.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the plan of care to the Registered Nurse (RN). Clinical Record 10: The patient elected the hospice benefit on 02/29/2024 with a diagnosis of hemiplegia due to cerebral infarction. The patient resided in a skilled nursing facility (SNF). The HA care plan, effective 02/29/2024 to current, ordered the visit frequency of one (1) time per week. A review of the clinical record revealed the missed visit note dated 05/09/2024 completed by the HA that documented, “Caregiver provided care today.” There was no documented evidence that the HA notified the RN of the missed visit and change in the care plan. Clinical Record 18: The patient elected the hospice benefit on 03/19/2024 with a diagnosis of heart failure and resided at home. The HA care plan, effective 03/19/2024 to current, ordered the visit frequency of one (1) visit for week one (1), then two (2) visits per week. The agency calculated visit frequencies based on a Monday to Sunday billing week. A review of the clinical record revealed the missed visit notes dated: 04/05/2024, 04/12/2024, 04/23/2024, 04/26/2024, 04/30/2024, and 05/07/2024 completed the the HA that documented in the narrative, “No Answer.” There was no documented evidence that the HA notified the RN of the missed visits and change in the care plan. The HA care plan did not provide instructions that the patient was a decision maker and could refuse care without RN notification. During an interview and a joint review of the records on 05/23/2024, the Director of Quality confirmed there was no additional documentation to support the missed visits were communicated to the RN. The Director of Quality further stated, “I know missed visits are discussed with the case managers (RNs) but they didn’t write it down.””