Hospice Compassus-Southeast Kansas

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; Demonstration of staff knowledge of emergency procedures; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; More frequent training occurs if there is a significant update of EP policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 10 (10%) personnel records reviewed the agency did not ensure that all hospice employees received initial emergency preparedness training and emergency preparedness training every two years. PERSONNEL RECORD 8: The Hospice Medical Director (contracted) employee’s date of hire was 01/10/2024. The personnel record lacked documentation of emergency preparedness training. During a joint record review and interview on 01/14/2026, the Area Executive of Clinical Operations confirmed the above finding that Emergency Preparedness training was not documented in the personnel record.”

“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 14 (14%) clinical records reviewed, the agency did not ensure that all planned interventions based on problems identified in the initial and updated comprehensive assessments were included in the patients’ individualized written plans of care. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/16/2025. A physician’s order dated 06/16/2025 read in part, “Eliquis 5mg tablet by mouth twice daily”. The plans of care dated 06/16/2025 through 09/13/2025, 09/14/2025 through 12/12/2025, and 12/13/2025 through 02/10/2026 did not include interventions related to the patient being at risk for bleeding. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/21/2025. A physician’s order dated 02/21/2025 read in part, “Eliquis 2.5mg tablet by mouth twice daily”. The plans of care dated 02/21/2025 through 04/20/2025, 04/21/2025 through 06/19/2025, and 06/20/2025 through 08/13/2025 did not include interventions related to the patient being at risk for bleeding. During joint record reviews and interview on 01/12/2026 and 01/14/2026, the Area Executive of Clinical Operations confirmed the above findings, stating “There are no bleeding risk interventions on either of these patients’ plans of care”.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that all medical supplies and appliances necessary to meet the needs of the patient were included in the patient’s individualized written plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 06/23/2025. The plans of care dated 06/23/2025 through 09/20/2025, 09/21/2025 through 12/19/2025, and 12/20/2025 through 02/17/2026 included orders for “Oxygen 2 liters via nasal cannula continuously”. The plans of care did not include the patient’s oxygen supplies. During a joint record review and interview on 01/12/2026, the Area Executive of Clinical Operations confirmed the above finding, stating “There are no oxygen supplies listed on the plans of care”.”

“It is required that Hospice Aides are supervised by a Registered Nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice Aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The Hospice Aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed with Hospice Aide services provided, the agency did not ensure that Hospice Aide (HA) supervisory visits were completed no less frequently than every 14 days. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/05/2024. The plans of care dated 03/05/2025 through 06/02/2025 and 06/03/2025 through 08/01/2025 ordered “HA 1 time per week”. The first HA visit was dated 03/06/2025. HA supervisory visits were dated 03/11/2025, 03/21/2025, 04/01/2025, 04/11/2025, 04/22/2025, 05/06/2025, and 05/20/2025. The next HA supervisory visit was dated 06/06/2025, a total of 17 days later and 3 days outstanding. During a joint record review and interview on 01/13/2026, the Director of Clinical Services confirmed the above finding that Hospice Aide supervisory visits were completed less frequently than every 14 days.”