Compassus - Greater Denver

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 5 of 19 (26%) clinical records reviewed, the hospice did not ensure that the Interdisciplinary Group completed the initial spiritual and psychosocial assessment no later than five (5) days after the election of hospice care. Clinical Record 5: The patient elected the hospice benefit on 08/14/2024. The Social Worker (SW) completed the initial psychosocial assessment on 08/20/2024, with six (6) days outstanding. The Chaplain (SC) completed the initial spiritual assessment on 08/21/2024, with seven (7) days outstanding. There was no documented reason for the delay. Clinical Record 11: The patient elected the hospice benefit on 06/27/2024. The initial nursing assessment dated 06/27/2024 documented a referral to the SC. A missed visit was documented on 07/01/2024. There was no documented evidence that the initial spiritual assessment was completed within 5 days. Clinical Record 14: The patient elected the hospice benefit on 10/13/2024. The SC documented a telephone call on 11/11/2024 (with 29 days outstanding) to introduce himself and set up the initial spiritual assessment visit. There was no documented reason for the delay. Clinical Record 15: The patient elected the hospice benefit on 06/21/2024. The SW completed the initial psychosocial assessment on 06/28/2024, with seven (7) days outstanding. There was no documented reason for the delay. Clinical Record 16: The patient elected the hospice benefit on 10/13/2023. The SC documented a telephone call on 10/27/2023 (with 14 days outstanding), documenting the patient declined the SC visit. There was no documented reason for the delay. During a joint record review and interview on 01/17/2025, the Administrator agreed there was no documented evidence that the Interdisciplinary Group completed the initial spiritual and psychosocial assessment no later than five (5) days after the election of hospice care. Additionally, the Administrator stated, “We had a PIP on this and need to reopen it due to the lack of follow-through in response to the education.””

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluation programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. A qualified hospice aide has successfully completed a competency evaluation program that evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: bed bath; sponge, tub, and shower bath; hair shampoo (sink, tub, and bed); nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; normal range of motion and positioning. Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: observation, reporting, and documentation of patient status and the care or service provided; basic infection control procedures; basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; maintenance of a clean, safe, and healthy environment; recognizing emergencies and the knowledge of emergency procedures and their application; the physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; adequate nutrition and fluid intake; any remaining task(s) that the hospice chooses to have an aide perform. The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy, “HH-C13 Home Health Aide Services,” stated in part, “ensures home health aides receive a competency and skills evaluation by a qualified RN prior to independent care delivery. Prior to independent care and at least annually, home health aides are evaluated for skills proficiency by direct observation.” In 1 of 1 (100%) personnel record reviewed of a Hospice Aide, the hospice did not ensure a skills competency with the required observed skills was completed before the hospice aide began providing independent care to patients. Personnel Record 5: The Hospice Aide, contracted, was hired on 09/18/2023. A personnel record review revealed no documented evidence of an initial competency assessment before the aide began providing independent care. During a joint review of the personnel record and an interview on 01/17/2025, the Administrator agreed the hospice did not ensure an RN completed a competency with observed required aide skills before the aide performed independent care. Additionally, the Administrator stated, “We do not have any evidence that it was done. We are completing one now. We identified quality issues with the previous business office coordinator and Director of Clinical Services during that time. They are no longer here.” The Administrator confirmed the Hospice Aide began visits just after 09/18/2023.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s Hospice Volunteer Requirement Report on 01/17/2025 for 01/01/2024 through 12/31/2024 revealed a cost savings of 4.66%. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff in 2024. During a joint review of the Hospice Volunteer Requirement Report and interview on 01/17/2025, the Administrator agreed the hospice agency did not meet the minimum five percent cost savings requirement for 2024. Additionally, the Administrator stated, “We need to provide more education on being more proactive in getting volunteers in the homes.””