Compassus-Ruston

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 3 (21%) home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient’s current medications. HOME VISIT 2/CLINICAL RECORD 1: The patient elected the hospice benefit on 09/10/2025. The patient resided in a private home. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 10/08/2025, the patient’s daughter provided the medications that the patient is currently taking. The hospice medication profile (printed on 10/07/2025) and the patient’s medications were reviewed. The daughter provided the following medication that was not on the hospice medication profile: alprazolam, take 0.5mg every 6 hours as needed for anxiety (09/25/2025). The hospice medication profile did not include alprazolam. HOME VISIT 3/CLINICAL RECORD 2: The patient elected the hospice benefit on 10/03/2023. The patient resided in an Assisted Living Facility (ALF). During the home visit with the Chaplain (SC) [Personnel Record 10] on 10/08/2025, the hospice medication profile (printed on 10/07/2025) and the ALF Active Medication Orders (printed on 10/08/2025) were reviewed. The hospice medication profile included dicyclomine 20mg three times daily (Start 10/03/2023). The ALF active medication list did not include dicyclomine. The ALF medication technician provided the physician’s order that showed the dicyclomine 20mg tablet was discontinued on 10/18/2024. HOME VISIT 1/CLINICAL RECORD 6: The patient elected the hospice benefit on 05/19/2025. The patient resided in a Skilled Nursing Facility (SNF). During the home visit with the Hospice Aide (HA) [Personnel Record 6] on 10/08/2025, the hospice medication profile (printed on 10/07/2025) and the SNF Active Medication Orders (printed on 10/08/2025) were reviewed. The SNF medication profile included the following medications that were not included on the hospice medication profile: duloxetine 30mg every evening (Start 09/22/2025), oxycodone 10mg every 6 hours as needed for pain (Start 06/26/2025), Zanaflex 4mg twice daily (Start 09/19/2025), ondansetron 8mg every 6 hours as needed for nausea, lorazepam intensol oral concentrate 2mg/ml 0.5ml every 4 hours as needed for anxiety/agitation (Start 09/22/2025), and insulin pen needle 30gx5mm, inject (1) one application three times a day (06/03/2025). The hospice medication profile did not include these medications. During a joint record review and interview on 10/08/2025, the Administrator confirmed that the hospice medication profile did not accurately represent the patient’s current medications.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; [and] the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with bereavement services, the agency did not ensure that bereavement services were provided according to the bereavement plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 11/20/2024 and expired on 12/12/2024. The bereavement plan of care included an initial bereavement letter within two (2) weeks of death, supportive mailings, and educational materials at one (1), three (3), six (6), and nine (9) months. There was no documented evidence that mailings were sent to the bereaved as per the bereavement plan of care. CLINICAL RECORD 14: The patient elected the hospice benefit on 09/18/2024 and expired on 02/08/2025. The bereavement plan of care included an initial bereavement letter within two (2) weeks of death, supportive mailings, and educational materials at one (1), three (3), and six (6) months. There was no documented evidence that mailings were sent to the bereaved as per the bereavement plan of care. During an interview on 10/09/2025, the Bereavement Coordinator confirmed the finding and stated, “I thought the Chaplain was doing it. I didn’t know I was the Bereavement Coordinator for this location (including previous address) until June. I don’t have access to the bereavement records for this location.” During a joint record review and interview on 10/09/2025, the Director of Quality Outcomes (DQO) agreed there was no documented evidence that bereavement services were provided as ordered on the bereavement plan of care. Additionally, the DQO stated, “This was discovered this week, and changes will be made to correct it.””

“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 10 (10%) clinical records reviewed of patients who received Hospice Aide (HA) services, the hospice did not ensure that the HA followed the plan of care as ordered. CLINICAL RECORD 11: The patient elected hospice care on 01/16/2025 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The POC dated 01/20/2025 ordered HA services twice weekly. The HA care plan dated 01/20/2025 assigned the HA the relevant tasks: shower each visit and shampoo weekly on the first visit of the week. For the week of 02/09/2025 through 02/15/2025, HA visits were completed on 02/10/2025 and 02/13/2025, with both visits documenting “Yes” that the shampoo was completed. For the week of 02/16/2025 through 02/22/2025, HA visits were completed on 02/19/2025 and 02/20/2025. The HA visit note dated 02/19/2025 documented “refused a shower, so a wash up was given.” The HA visit note dated 02/20/2025 documented that a “partial bed bath” was completed. The HA did not provide the tasks assigned by the RN and included in the plan of care. During a joint record review and interview on 10/08/2025, the Administrator agreed there was no documented evidence that the HA followed the plan of care as ordered. Additionally, the Administrator stated, “More education is needed with the aides.””

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed of patients who received Hospice Aide (HA) services, the hospice did not ensure that the HA reported changes in the patient’s needs to the Registered Nurse (RN). CLINICAL RECORD 11: The patient elected hospice care on 01/16/2025 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The POC dated 01/20/2025 ordered HA services twice weekly. The HA care plan dated 01/20/2025 assigned the HA the relevant tasks: shower each visit and shampoo weekly on the first visit of the week. For the week of 02/09/2025 through 02/15/2025, HA visits were completed on 02/10/2025 and 02/13/2025, with both visits documenting “Yes” that the shampoo was completed. For the week of 02/16/2025 through 02/22/2025, HA visits were completed on 02/19/2025 and 02/20/2025. The HA visit note dated 02/19/2025 documented “refused a shower, so a wash up was given.” The HA visit note dated 02/20/2025 documented that a “partial bed bath” was completed. During a joint record review and interview on 10/08/2025, the Administrator agreed there was no evidence that the HA reported the changes to the plan of care to the RN. Additionally, the Administrator stated, “More education is needed with the aides.””

“It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. The hospice did not ensure that ongoing efforts to recruit and retain volunteers were documented or demonstrated. The Volunteer spreadsheet was reviewed with the Volunteer Coordinator. Recruitment efforts were documented on 06/11/2025, 06/24/2025, 07/08/2025, and 08/07/2025. There was no documented evidence of recruitment and retention efforts for January 2024 through May 2025. During a joint review of the volunteer spreadsheet and interview on 10/09/2025, the Volunteer Coordinator stated, “I didn’t know I was the Volunteer Coordinator for this location (including previous address) until June. I have no information before that.” During a joint record review and interview on 10/09/2025, the Director of Quality Outcomes (DQO) agreed there was no documented evidence of recruitment and retention efforts for January 2024 through May 2025. Additionally, the DQO stated that they have searched the previous Volunteer Coordinator’s files and have been unable to locate any additional evidence. A review of the Volunteer spreadsheet revealed the hospice did not ensure to demonstrate and document viable and ongoing efforts to recruit and retain volunteers. The Volunteer spreadsheet was reviewed with the Volunteer Coordinator. Recruitment efforts were documented on 06/11/2025, 06/24/2025, 07/08/2025 and 08/07/2025. There was no documented evidence of recruitment and retention efforts for January 2024-May 2025.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HH-C04 “Discharge and Transfer” stated in part, “The summary is provided to the receiving clinician/practitioner within five (5) business days of the date of the discharge.” In 2 of 2 (100%) clinical records reviewed of patients with a live discharge, the hospice did not ensure that the discharge summary was sent to the patient’s attending physician per the agency policy. CLINICAL RECORD 11: The patient elected the hospice benefit on 01/16/2025 and was discharged (revocation) on 03/07/2025. There was no documented evidence that the discharge summary was provided to the patient’s attending physician. CLINICAL RECORD 12: The patient elected the hospice benefit on 06/13/2025 and was discharged (revocation) on 07/07/2025. The discharge summary was provided to the patient’s attending on 07/22/2025, with 11 business days outstanding. The hospice did not send the discharge summary to the patient’s physician within five business days as required by agency policy. During a joint record review and interview on 10/09/2025, the Director of Quality Outcomes (DQO) agreed there was no evidence that the discharge summary was sent for clinical record 11. Additionally, the DQO agreed there was no documented evidence that the discharge summary was provided as required for clinical record 12.”