Hospice Compassus - Yuma

“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, observation, and interview. In 4 of 16 (19%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 02/22/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in an assisted living facility (ALF). The HA care plan dated 05/08/2025 assigned the HA the relevant tasks: “pericare, skin care, dressing, hair care, oral care, shampoo, transfer to/from bed/chair” every visit. During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 05/13/2025, the HA was observed to remove the patient’s oxygen briefly during tasks. The patient used oxygen 2-4 liters via a nasal canula. The HA care plan documented “oxygen precautions.” However, the HA care plan did not document instructions for the HA regarding the patient’s use of oxygen during personal care. Clinical Record 8: The patient elected hospice care on 04/25/2025 with a diagnosis of malignant neoplasm of vagina. The patient resided at a skilled nursing facility (SNF). The plan of care ordered HA services twice weekly. The initial nursing assessment, dated 04/25/2025, documented that the patient had a “wound on her labia.” The (Licensed Practical Nurse) LPN visit note dated 05/05/2025 documented “patient refused wound care. RN (registered nurse) stated she would complete treatment as the patient gets agitated.” The HA care plan dated 04/25/2025 assigned the HA the relevant tasks: “pericare, skin care, bathing-shower, dressing, hair care, oral care, shampoo, transfer to/from bed/chair” every visit. The HA care plan did not notify the HA of the wound or provide the HA with instructions should the wound dressing become soiled, dislodged, or wet during personal care. Clinical Record 15: The patient elected hospice care on 05/09/2023 with the diagnosis of generalized atherosclerosis. The patient resided in an assisted living facility (ALF). The plan of care dated 05/09/2023 ordered HA services three times weekly. The initial skilled nursing (SN) comprehensive assessment dated 05/09/2023 documented that the patient had “a Foley and Stage II to coccyx.” The physician’s order dated 05/09/2023 ordered “Wound care to Stage II to coccyx. Cleanse with NS (normal saline). Pat dry with gauze, cover with bordered form dressing.” The HA care plan(s) dated 05/09/2023, which was not updated, assigned the HA the relevant tasks: “fall precautions, turn and position in bed, partial sponge bath, shampoo, hair care, skin care, perineal care, foot care, oral care, dressing, relieve pressure points, position for comfort, transfer to/from bed/chair” every visit. The HA care plan did not notify the HA of the presence of the Foley catheter or the coccyx wound, nor did it provide specific instructions should the wound dressing become soiled, dislodged, or wet, or instructions for the Foley catheter care and maintenance during the bath and perineal care. Clinical Record 19: The patient elected hospice care on 09/12/2024 with a diagnosis of malignant neoplasm of the descended right testis. The patient resided at home. The plan of care dated 09/12/2024 ordered HA services twice weekly. The initial SN comprehensive assessment, dated 09/12/2024, documented that the patient had a “nephrostomy tube.” The SN visit note dated 09/27/2024 documented “patient expressed anger regarding his nephrostomy tube constantly leaking urine and becoming saturated.” The SN visit note dated 09/29/2024 documented “dressing change to nephrostomy tube.” The HA care plan(s) dated 09/12/2024 assigned the HA the relevant task of “provide comfort and support.” The HA care plan revised on 09/13/2024 assigned the HA the relevant tasks: “Apply moisture barrier; assist to toilet; bathing via partial sponge bath; denture care; foot care; hair care; HOB (head of bed) elevated; oral care; perineal care; position for comfort; relieve pressure points; shampoo; skin care; turn and position in bed; offer fluids; provide comfort and support; fall precautions and infection control precautions” every visit. The HA care plan did not notify the HA of the nephrostomy tube nor provide instructions should the wound dressing become soiled, dislodged, or wet during bathing. During an interview and a joint clinical record review on 05/14/2025, the Director of Clinical Services, Regional Quality, and Regional Executive of Clinical Operations confirmed that the specific instructions for the HA had not been added to the care plans and stated: “We’re in agreement they should have been added.””

“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. Agency policy #HOS-C-12 “Evaluation of Clinical Competency for Licensed Professionals and Hospice Aides” (effective 04/07/2021) (revised 04/17/2025) stated in part, “Performing the skills competency for the hospice aide...Once the aide has completed all tasks via observation, the registered nurse and aide sign off on the evaluation form and date it to indicate the process is complete.” Agency policy #HOS-C2 “Hospice Aide and Homemaker Services. (effective 12/01/2017, revised 03/20/2025) stated in part, “(Agency name) ensures hospice aides receive a competency and skills evaluation by a qualified RN prior to independent care delivery and at least annually to validate high-quality care. Prior to independent care and at least annually, hospice aides are evaluated for skills proficiency by direct observation in the following areas: a. Communication skills... b. Reading and recording temperature, pulse, and respirations...c. Basic infection control...d. Maintenance of clean, safe environment...e. ADLs, including bed bath, sponge, tub or shower, shampoo...f. Safe transfer techniques....g. Normal range of motion...h. Adequate nutrition...” In 1 of 1 (100%) personnel records reviewed of a Hospice Aide, the agency did not ensure that a Registered Nurse (RN) made an annual on-site visit to the location where a patient was receiving HA care to observe and assess the HA while he or she was performing care. Personnel Record 7: The Hospice Aide (HA) was hired on 09/23/2019. A review of the personnel record revealed a 2023 “annual visit” which documented that the HA was “following policies, had good attendance, was liked by patients/caregivers.” The 2023 annual visit did not contain documentation of the skills evaluated. The “annual visit” in 2024 had check boxes to indicate that the skills were performed. The column for patient/pseudo-patient was blank. The column for the date(s) of skills performed was blank, and was missing the patient names with a line drawn down, dates, and check-offs. During an interview and a joint record review on 05/14/2025, the Director of Clinical Services, Regional Quality, and Regional Executive of Clinical Operations stated that the “form was changed in 2023 to better align with the policy for actual skills evaluations.” It was also agreed that the “2024 and 2025 on-site visits had not been documented per policy.””

“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 clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included physician orders for care and services provided. Clinical Record 8: The patient elected hospice care on 04/25/2025 with a diagnosis of malignant neoplasm of vagina. The patient resided at a skilled nursing facility (SNF). A physician’s order dated 04/26/2025 ordered: “Clean wound with WC (wound cleanser). Pat dry with 4x4 gauze, apply Santyl 2 wk (week) and PRN (as needed).” The physician’s order did not include the location of the wound, the person(s) to provide the wound care, and the indications for the as-needed wound care. Clinical Record 19: The patient elected hospice care on 09/12/2024 with a diagnosis of malignant neoplasm of the descended right testis. The patient resided at home. A physician’s order dated 09/21/2024 ordered: “Cleanse site with NS (normal saline), pat dry with 4x4 gauze, apply antbx (antibiotic) ointment, cover with split gauze, secure with Tegaderm and tape 2 x week and PRN (as needed) soiled or dislodged dressing.” The physician’s order did not include the location of the wound or the person(s) to provide the wound care. During an interview and a joint clinical record review on 05/14/2025, the Director of Clinical Services, Regional Quality, and Regional Executive of Clinical Operations agreed that the orders “were lacking all the information.””