Hospice Compassus - White Mountain

“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%) home visits observed and clinical records reviewed, the agency did not ensure that the comprehensive assessments included a drug profile that 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 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 07/15/2025 with a diagnosis of ASCVD (Atherosclerotic Cardiovascular Disease). The patient resided in an assisted living facility (ALF). During the observed home visit with the Hospice Aide (Personnel Record 7) on 02/04/2025, the hospice medication profile (printed on 02/03/2025) was compared to the ALF medication profile (printed on 02/04/2025). The hospice medication profile included the following medications not listed on the ALF medication profile: “Acetic acid 0.25% irrigation solution. Flush Foley with 80 ml weekly as needed for sediment (ordered 09/05/2025).” Additionally, the following discrepancy was noted: the hospice medication profile included Milk of Magnesia 30 ml daily as needed (ordered 07/16/2025); the ALF medication profile included Milk of Magnesia 30 ml every 18 hours as needed (ordered 07/15/2025). HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 11/07/2024 with a diagnosis of Parkinson’s disease. The patient resided in an ALF. During the observed home visit with the Social Worker (Personnel Record 5) on 02/04/2025, the hospice medication profile (printed on 02/03/2025) was compared to the ALF medication profile (printed on 02/04/2025). The hospice medication profile included the following medication that was not listed on the ALF medication profile: Nystatin cream, apply to groin two times a day for rash. (ordered 05/02/2024). An interview and joint clinical record review was conducted with the Director of Clinical Services on 02/05/2026 during which she stated “she thought the Nystatin was a duplicate that hadn’t been removed as there was a PRN (as needed) one as well. She also said she “did not know why the facility would put every 18 hours on the Milk of Magnesia but it should have been caught.””

“It is required that 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. 2 of 17 (12%) clinical records reviewed in which hospice aide (HA) services were accepted revealed the agency did not ensure the registered nurse (RN) provided patient-specific written instructions for the hospice aide. CLINICAL RECORD 16: The patient elected the hospice benefit on 01/05/2026 with a diagnosis of Osteoarthritis. The HA care plan dated 01/07/2026 included assignment of the following task: “Turn and position in bed; ROM (range of motion) to RUE (right upper extremity); ROM to LUE (left upper extremity); ROM to RLE (right lower extremity); ROM to LLE (left lower extremity); bathing (bed bath); bathing (shower); skin care; nail care; relieve pressure points; position for comfort; apply moisture barrier; transfer to/from bed/chair 2-person assist; and companionship.” All tasks were to be completed at every visit, inclusive of the two bath types. The HA visit frequency was twice weekly. CLINICAL RECORD 18: The patient elected the hospice benefit on 01/11/2025 with Alzheimer’s Disease, and died on 10/23/2025. The HA care plan dated 10/16/2025 included assignment of the following tasks: “Bathing (bed); shampoo; hair care; skin care; perineal care; foot care; shaving; oral care; dressing (clothing); position for comfort; apply moisture barrier; companionship.” All tasks were to be completed every visit. The HA visit frequency was twice weekly. A nursing visit dated 10/18/2025 documented that a foley catheter was inserted; the catheter had not been added to the HA care plan. The HA was not provided with specific instructions regarding catheter care. An interview and joint clinical record review was conducted with the Director of Clinical Services on 02/05/2026 during which she stated “There should have been specific instructions regarding the bath type” regarding Clinical Record 16 and the “On-call nurse who put in the foley probably thought the case manager would add it to the aide care plan” regarding Clinical Record 18.”

“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 and interview. 1 of 17 (6%) clinical records reviewed in which hospice aide (HA) services were accepted revealed the agency did not ensure the HA provided services included in the plan of care. CLINICAL RECORD 19: The patient elected the hospice benefit on 06/12/2025 with a diagnosis of ASCVD (Atherosclerotic Cardiovascular Disease) and died on 10/10/2025. The HA care plan dated 09/18/2025 included assignment of the following tasks: “Bathing (shower); assist to toilet; stand by assistance with ambulation; change linens; shampoo; hair care; skin care; perineal care; foot care; shaving; oral care; dressing (clothing); position for comfort; apply moisture barrier; companionship,’ All tasks were to be completed every visit. A HA visit dated 10/07/2025 documented “Completed bed bath.” The HA care plan assigned task was for a shower; bed bath was not an assigned task. An interview and joint clinical record review was conducted with the Director of Clinical Services on 02/05/2026 during which she stated “The aide should have followed the plan of care or had the nurse adjust it.””

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) personnel records of hospice aides (HA) reviewed revealed the agency did not ensure that a registered nurse (RN) made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each HA while he or she is performing care in accordance with the hospice’s policies and procedures and federal regulation. The agency policy titled “Supervision of Hospice Aides Procedure” HOS-C_12A, Effective 08/18/2022, Reviewed 12/31/2024, stated in relevant part: “g. At least annually, the RN must directly observe the hospice aide in the performance of care delivery.” The agency policy titled “Hospice Personnel Qualifications” Policy HOS-C12, Effective 08/01/2017, Revision 09/19/2025, stated in relevant parts: “Home Health aides require routine supervision by a RN. b. At least annually, the RN must make a visit on-site with the HA (health aide) to validate competency in the provision of health aide services.” PERSONNEL RECORD 7: A review of the personnel record was conducted on 02/05/2026 for this HA hired on 07/08/2024. The review revealed there was no documented evidence of an on-site aide supervisory visit for 2025 by a RN. An interview and joint personnel record review was conducted with the Administrator on 02/05/2026 during which she confirmed that the front page of the “Annual on site visit for 2025 had been left blank and there was no documentation (in the record that) it had been completed.””