Compassus-Southern Indiana

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s written plan of care identified planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/12/2025 with diagnoses of acute and chronic respiratory failure. The plan of care dated 03/12/2025 through 06/09/2025 included orders for “Clopidogrel (antiplatelet) 75mg tablet daily.” The plan of care did not include interventions related to the patient being at risk for bleeding. CLINICAL RECORD 16: The patient elected the hospice benefit on 04/22/2025 with a diagnosis of peripheral vascular disease. The plan of care dated 04/22/2025 through 07/20/2025 included orders for “Clopidogrel (antiplatelet) 75mg tablet daily.” The plan of care did not include interventions related to the patient being at risk for bleeding. During joint record reviews on 08/07/2025, the Director of Clinical Services confirmed that the plans of care did not include interventions for bleeding risk.”

“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 5 of 13 (38%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/03/2025 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). The physician’s order dated 06/30/2025 ordered wound care with a dressing to a wound on the patient’s right buttock. The plan of care dated 06/03/2025 through 08/31/2025 ordered “HA 2 times per week.” The Hospice Aide care plan dated 06/03/2025 assigned the HA the relevant task: “Shower at every visit.” The Hospice Aide care plan was not updated to include instructions for the HA regarding the wound dressing on the patient’s right buttock, should the wound dressing become wet or dislodged during the shower. CLINICAL RECORD 3: The patient elected the hospice benefit on 09/27/2023 with a diagnosis of cerebrovascular disease. The patient resided in an assisted living facility (ALF). The physician’s order dated 12/05/2023 ordered wound care with a dressing to a wound on the patient’s left leg. The plan of care dated 09/27/2023 through 12/25/2023 ordered “HA 2 times per week.” The Hospice Aide care plan dated 09/27/2023 assigned the HA the relevant task: “Shower at every visit.” The Hospice Aide care plan was not updated to include instructions for the HA regarding the wound dressing on the patient’s left leg, should the wound dressing become wet or dislodged during the shower. CLINICAL RECORD 8: The patient elected the hospice benefit on 06/09/2025 with a diagnosis of multiple sclerosis (MS). The patient resided in a SNF. The physician’s order dated 06/10/2025 ordered wound care with a dressing to a wound on the patient’s right heel. The plan of care dated 06/09/2025 through 09/06/2025 ordered “HA 1 time per week.” The Hospice Aide care plan dated 06/09/2025 assigned the HA the relevant task: “Bed bath at every visit.” The Hospice Aide care plan was not updated to include instructions for the HA regarding the wound dressing on the patient’s right heel, should the wound dressing become wet or dislodged during the bed bath. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/16/2025 with a diagnosis of Parkinson’s disease. The patient resided at home. The physician’s order dated 07/31/2025 ordered wound care with a dressing to a wound on the patient’s left arm. The plan of care dated 07/16/2025 through 10/13/2025 ordered “HA 2 times per week.” The Hospice Aide care plan dated 07/17/2025 assigned the HA the relevant task: “Bed bath at every visit.” The Hospice Aide care plan was not updated to include instructions for the HA regarding the wound dressing on the patient’s left arm, should the wound dressing become wet or dislodged during the bed bath. CLINICAL RECORD 16: The patient elected the hospice benefit on 04/22/2025 with a diagnosis of peripheral vascular disease. The patient resided at home. The physician’s order dated 04/23/2025 ordered wound care with a dressing to a wound on the patient’s left leg. The plan of care dated 04/22/2025 through 07/20/2025 ordered “HA 2 times per week.” The Hospice Aide care plan dated 04/23/2025 assigned the HA the relevant task: “Shower at every visit.” The Hospice Aide care plan was not updated to include instructions for the HA regarding the wound dressing on the patient’s left leg, should the wound dressing become wet or dislodged during the shower. During joint record reviews on 08/06/2025 and 08/07/2025, the Director of Clinical Services confirmed that wound dressing instructions were not included in the Hospice Aide care plans.”

“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 volunteers provided 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. A review of the agency’s “Volunteer Cost Savings Report” for 2024 (01/01/2024 through 12/31/2024) revealed that the total percentage of hours worked by volunteers for the year 2024 was 2.19%. Documentation of a performance improvement plan (PIP) initiated in January 2024 to increase the percentage of volunteer hours to 5% was reviewed. The agency’s Volunteer Cost Savings Report for 2025 revealed that the total percentage of hours worked by volunteers for 01/01/2025 through 07/31/2025 was 2.23%. During an interview on 08/07/2025, the Area Executive of Clinical Operations confirmed the finding, stating, “We have struggled to serve 5% of our hours with volunteers since the waiver was lifted last year. Our new volunteer coordinator has been working on onboarding more volunteers.” The agency did not ensure that volunteers provided 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.”