Hospice Compassus - Bullhead City

“It is required that the written Patient Bill of Rights includes the right to: voice grievances regarding treatment or care that is—or fails to be—provided; This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C_06A “Complaints and Grievances Procedure” (effective 01/24/2021) (revised 07/07/2025) stated in relevant part(s): “Purpose: Provide prompt investigation and resolution to patient and/or family complaints or grievances. Procedure: A) Complaint or grievance-a concern expressed by anyone about the quality of care, care delivery, services, colleagues, or any area under the influence or responsibility of the XXXXXX program, if from a patient or family member. 4. The Director of Clinical Services or designee will be responsible for the following actions: a. Complete the top portion of the written complaint report...g. Complete the complaint log.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that a concern expressed by the patient or family was documented in a complaint log for investigation and resolution in accordance with the agency’s policy. CLINICAL RECORD 19: The patient elected hospice care on 08/13/2025 with a diagnosis of Waldenstrom macroglobulinemia. A clinical record review revealed a Social Worker note dated 10/07/2025 documenting: “Son was frustrated that patient was on morphine and declining so fast. He would like updates after each visit. He would like a nurse to call and explain the morphine because he is concerned he is overmedicated and would like the morphine stopped. SW relayed the message to DCS (Director of Clinical Services) in person.” A clinical record review revealed no documented evidence that a nurse called the patient’s son to discuss the medication concern. During an interview, joint clinical record review, and review of the complaint log on 01/30/2026, the Administrator explained she was “the acting DCS on the date in question, and the son was out of town and wanted his father to sign some financial paperwork, and it was believed he was too medicated to do so.” The Administrator stated that “It was not documented as a concern or complaint at the time, but reading the policy now, it should have been.””

“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 16 (6%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 18: The patient elected hospice care on 01/28/2025 with a diagnosis of malignant neoplasm of the pancreas. The patient resided in an assisted living facility. The HA care plan dated 01/28/2025 assigned the HA the relevant tasks: “Shower; shampoo; hair care; nail care; companionship.” All tasks were to be completed on every visit. The plan of care for the certification period dated 01/28/2025 to 02/11/2025 ordered HA services three times weekly. The HA visit dated 02/05/2025 documented: “Shower- No.” The HA documented that a “Chair bath” was provided during the visit on 02/05/2025. An interview and joint clinical record review on 01/30/2026, the Director of Clinical Services (DCS) confirmed the finding, stating that the HA “Did not follow the plan of care and should have called the nurse to request the care plan be changed before providing a different bath type.””

“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 interview, document review, and personnel record review. Agency policy and procedure #HOS-C_12A “Supervision of Hospice Aides” (effective 08/18/2022) (reviewed 12/31/2024), stated in relevant part(s): “At least annually, the RN must directly observe the hospice aide in the performance of care delivery.” 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 care to observe and assess the Hospice Aide performing care. PERSONNEL RECORD 7: The Hospice Aide was hired on 10/06/2008. A personnel record review on 01/29/2026 revealed documentation dated 01/09/2024 documenting that the tasks were performed on a “pseudo” patient. During the interview and joint personnel record review on 01/29/2026, the Director of Clinical Services described this as “discussing how to complete the tasks with the aide.” There was no documentation of an on-site supervisory visit by the RN in 2024. During an interview and joint personnel record review on 01/29/2026, the Director of Clinical Services (DCS) described the form marked as an annual on-site visit as a “discussion marked off as a pseudo patient for many of the tasks.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure volunteer services were provided to the patient. CLINICAL RECORD 6: The patient elected hospice care on 11/20/2025 with a diagnosis of nutritional deficiency. The initial assessment conducted by the Social Worker on 11/24/2025 documented a referral for a volunteer, as the patient “requested one for companionship.” A clinical record review revealed no documentation that a volunteer had been assigned as of 01/30/2026. During an interview and joint clinical record review on 01/30/2026, the Director of Clinical Services (DCS) confirmed a volunteer had not been assigned, stating that “During the time the referral came in, the Volunteer Coordinator had been out on medical leave and had not returned to work. Additionally, the DCS stated that the referral had gone to their inbox and had not been followed up on, and the DCS “thought the family had been looking more for caregivers, but that had not been documented in the clinical record.””