Hospice Compassus-Southwest Missouri

“Based on policy review, record review and interview, the hospice provider failed to ensure an allegation involving potential sexual abuse/inappropriate conduct by a hospice employee was immediately reported to the hospice administrator in, one of one applicable patient record reviewed (Record/Patient #1) with an allegation of abuse. This deficient practice has the potential to affect all patients receiving hospice services. Findings included:Review of the provider’s policy titled “Disclosures for Suspected or Confirmed Abuse, Neglect, or Domestic Violence,” last reviewed/updated 06/01/2026, showed sexual abuse was defined as coercing or attempting to coerce sexual contact or behavior without consent and stated that sexual abuse included, but was not limited to, treating an individual in a sexually demeaning manner. The policy further defined elder sexual abuse as non-consensual sexual contact of any kind.Review of the provider’s policy titled, “Patients’ Rights,” last revised 05/02/2026, showed in part, patients had the right be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse. RECORD/PATIENT #1:Review of the hospice complaint documentation showed that on 07/15/2026, Patient #1’s complaint was documented as including an allegation that the licensed practical nurse (LPN) had been “sexually inappropriate” with the patient by rubbing the patient’s leg/arm and making a comment concerning the patient’s buttocks.During an interview on 08/18/2026 at 12:13 PM and 1:21 PM, registered nurse case manager (RNCM) stated that sometime between 07/02/2026 and 07/06/2026, the patient reported that the patient did not want the LPN to visit because the LPN had been sexually inappropriate and the conduct was offensive to the patient’s spouse. The RNCM stated that the patient reported the LPN rubbed the patient’s leg and shoulders and made a comment regarding the patient’s buttocks. The RNCM stated that he/she did not believe the concern reported because he/she had not witnessed inappropriate conduct.During a follow-up interview on 08/19/2026 at 12:31 PM, the RNCM stated that on 07/02/2026, the patient reported the LPN had been inappropriate, made the patient feel uncomfortable, and that the patient did not want the LPN to return. The RNCM stated that the LPN was removed from the patient’s care; however, the RNCM did not report the concern to the hospice administrator because he/she believed the matter had been resolved by removing the LPN from the patient’s case.During an interview on 08/19/2026 at 11:51 AM, the administrator stated that the patient’s allegations did not meet the hospice’s definition of sexual abuse and therefore were not treated as an allegation of sexual abuse.”

“Based on policy review, record review and interview, the hospice provider failed to ensure an allegation of potential abuse/inappropriate conduct by a hospice employee was fully investigated in accordance with established procedures and failed to implement immediate protective measures while the allegation was being verified in, one of one applicable patient record reviewed (Record/Patient #1) with an allegation of abuse. This deficient practice has the potential to affect all patients receiving hospice services. Findings included:Review of the provider’s policy titled, “Patients’ Rights,” last revised 05/02/2026, showed in part, that patients had the right to be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse. The policy further showed the provider would fully investigate reports of such concerns.Review of the provider’s policy titled “Disclosures for Suspected or Confirmed Abuse, Neglect, or Domestic Violence,” last reviewed/updated 06/01/2026, showed that sexual abuse was defined as coercing or attempting to coerce any sexual contact or behavior without consent. The policy further stated that sexual abuse, included, but not limited to, treating an individual in a sexually demeaning manner.Review of the provider’s policy titled, “Complaints and Grievances,” last revised 07/10/2026, showed in part, that the director of clinical services (DCS) or designee was responsible for beginning the initial investigation, determining the nature of the complaint, determining whether escalation to the internal compliance/legal team was necessary, and taking immediate corrective steps to mitigate concerns when appropriate. The procedure further showed that the investigation may include review of documentation and interviews with the complainant, team members, witnesses, and/or others pertinent to the occurrence and directed that the investigation be as thorough and comprehensive as the situation required. Review of the employee roster showed the DCS and administrator were separate positions. RECORD/PATIENT #1:Review of the hospice complaint documentation dated 07/15/2026, showed the administrator initiated an investigation of the patient’s complaint by contacting involved staff and documenting their responses. The complaint included an allegation that the licensed practical nurse (LPN) had been “sexually inappropriate” by rubbing the patient’s leg/arm and making a comment concerning the patient’s buttock. The involved staff denied the reported comments/actions. Review of the corporate investigation documentation, with a date received of 07/24/2026, identified the nature of the incident as “Potential Patient Abuse.” The documentation showed that on 07/24/2026, Compliance, Legal, Program Leadership, and the “People” Team met to review the reported concern and recommended the LPN be placed on paid leave for the duration of the investigation. The LPN was removed from patient care on 07/24/2026, nine days after the allegation was brought to the administrator’s attention on 07/15/2026. Additional investigative activity was documented on 07/28/2026, and a final review was conducted on 07/30/2026. The LPN was permitted to return to patient care effective 07/31/2026.Review of the hospice complaint documentation dated 07/15/2026 and the corporate investigation documentation, with a date received of 07/24/2026, failed to show that protective measures regarding the LPN’s contact with other hospice patients were implemented between 07/15/2026, when the detailed allegation was documented, and 07/24/2026, when the LPN was removed from patient care. Although the LPN had been removed from the Patient #1’s care, documentation failed to demonstrate that the potential risk of other patients was assessed or that additional protective measures were implemented while the allegation was being verified.Further review of the corporate investigation documentation failed to demonstrate that Patient #1 was interviewed regarding the specific allegations as part of the corporate investigation prior to reaching its conclusion. The corporate investigation documentation contained inaccurate dates regarding the LPN’s visit and the date the complaint was reported to the administrator. The documented date of the LPN’s visit was corrected from 07/10/2026 to 07/01/2026, and the date of the complaint was reported to the administrator was corrected from 07/14/2026 to 07/15/2026 following clarification of the underlying documentation.During an interview on 08/19/2026 at 11:43 AM and 11:51 AM, the administrator stated that the patient’s allegations did not meet the hospice’s definition of sexual abuse. The administrator stated that the LPN was suspended after the patient filed a police report and corporate wanted to ensure an action plan was in place. The administrator further stated decisions regarding the LPN’s removal from and return to patient care were made by the corporate compliance team.”

“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; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects.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, observation and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s comprehensive assessment included a drug profile that included the patient’s current medications. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The Registered Nurse’s (RN) admission visit dated 06/21/2025 documented that the patient’s respiratory rate was 26 breaths per minute and that the patient had recently been hospitalized for 14 days for a COPD exacerbation, requiring BiPAP support during the first week of hospitalization. On 01/28/2026, the RN documented that the patient was receiving 4 liters per minute (LPM) of continuous oxygen via nasal cannula (N/C), with an oxygen saturation of 89%....” During a Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026, the patient was documented as alert and oriented ×4 but tachypneic and dyspneic at rest, with an oxygen saturation of 85% on 4 LPM of continuous oxygen...” The NP Face-to-Face visit dated 04/10/2026, documented the patient’s oxygen saturation as 84% on 4 LPM via nasal cannula...” The patient’s medication profile did not document oxygen administration. CLINICAL RECORD 19: The RN admission visit note dated 08/15/2025 documented that the patient was alert and oriented ×3, short of breath, with a dyspnea score of 2/10, and that oxygen therapy was initiated. On 09/05/2025, the skilled nurse (SN) visit note documented a respiratory rate of 32 breaths per minute, crackles auscultated in the lung fields, and intermittent oxygen requirement. On 10/06/2025, the RN documented that the patient continued to have diminished lung sounds throughout all lung fields and now required 2 liters per minute of continuous oxygen via nasal cannula. The patient’s medication profile did not document oxygen administration. During a joint clinical record review and interviews on 04/23/2026, the Area Executive of Clinical Operations confirmed that patient medication profiles include the oxygen or medications the patients were receiving.”

“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 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient/family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected hospice care on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN admission visit note dated 06/21/2025 documented the patient’s respiratory rate as 26 breaths per minute and a recent 14-day hospitalization for a COPD exacerbation, which required BiPAP support for the first week. On 01/28/2026, the skilled nurse (SN) visit note documented that the patient’s oxygen saturation was 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula, with visible cyanosis and reports of orthopnea when lying down. A Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026 documented that the patient was alert and oriented ×4 but tachypneic and dyspneic at rest. The NP Face-to-Face visit on 04/10/2026 documented the patient’s oxygen saturation was documented at 84% on 4 LPM via nasal cannula. The Interdisciplinary Group (IDG) documentation dated 03/04/2026, 03/19/2026, 04/01/2026, and 04/16/2026 documented oxygen needs, ranging from 4–8 LPM. The patient’s plans of care for the benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 identified planned interventions for the patient’s respiratory-related problems shortness of breath (SOB) using an appropriate SOB scale, however no patient/family reflected goal for shortness of breath was documented. CLINICAL RECORD 6: The patient elected hospice care on 01/02/2026 with a terminal diagnosis of metastatic pancreatic cancer. On 02/27/2026, the SN visit note documented that the patient reported severe pain rated at 10/10, accompanied by abdominal cramping and nausea, and that the patient was fluctuating between diarrhea and hard stools. New physician orders were obtained for an adjusted pain regimen and ondansetron (Zofran) to address nausea. The IDG meeting dated 03/04/2026 documented a generalized comfort goal of maintaining pain below the patient’s stated goal of 3/10, with reference to an “effective bowel regimen.” Medication changes were noted, including a new order for dicyclomine (Bentyl) for cramping. The same information was repeated during the IDG meeting on 03/18/2026. The SN visit note dated 04/10/2026 documented that the patient reported mild abdominal pain and persistent nausea, stating that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting dated 04/10/2026 documented the new order for simethicone and ondansetron. During a nursing assessment on 04/10/2026, the patient reported mild abdominal pain and persistent nausea, stating that that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting on the same date documented medication changes, including the prior addition of Bentyl on 03/04/2026 and a new order for simethicone. The plans of care for the benefit periods dated 01/02/2026 to 04/01/2026 and 04/02/2026 to 06/30/2026 documented no planned interventions, nor patient/family reflected goals for the patient’s identified problem with nausea. CLINICAL RECORD 8: The patient elected hospice care on 01/20/2026 with a terminal diagnosis of Parkinsonism. On 02/24/2026, the RN documented that the patient was continuing antibiotics for a urinary tract infection and aspiration pneumonia. On 02/27/2026, the SN visit note documented that the patient “continued to not feel very well,” slept most of the time, and had coarse lung sounds, prompting the physician’s approval of another round of antibiotics. The IDG meeting on 03/04/2026 documented intermittent oxygen use for shortness of breath or low oxygen saturation, treatment with Cefdinir for aspiration pneumonia, and Macrobid for urinary tract infection (UTI), with no measurable respiratory, infection-related, or neurological goals identified. The documentation regarding oxygen use was repeated during the IDG meeting on 04/16/2026, with no evidence of updated goals despite continued decline. On 04/17/2026, the RN documented the patient’s staying awake all night after previously sleeping 14–16 hours/day, increased agitation, and worsening neck pain. The hospice physician ordered morphine sulfate extended release, 15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. On 04/21/2026, the SN visit note documented a recurrence of aspiration pneumonia symptoms, with crackles throughout the right lung to the bases, productive cough with yellow-green sputum, confusion, and hallucinations. Cefdinir was restarted. The plans of care for the benefit periods dated 01/20/2026 to 04/19/2026 and 04/20/2026 to 06/18/2026 did not include documentation of patient/family reflected goals for the patient’s recurrent problems with aspiration pneumonia, agitation, hallucinations, confusion, and respiratory symptoms. CLINICAL RECORD 18: The patient elected hospice care on 05/17/2022 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD) and a comorbid condition of malignant neoplasm of the larynx. During the Registered Nurse’s (RN) admission visit on 05/17/2022, the RN documented significant swallowing impairment, including dysphagia, inability to chew and swallow most foods, and coughing with sips of liquid. The RN further documented that the patient had a gastric tube (G-tube) in place and was administered Ensure feedings via G-tube approximately every 2–3 days. The SN visit note dated 11/13/2025 documented that staff assisted the patient with clearing a blockage in the feeding tube. The patient’s plans of care for the hospice benefit periods dated 08/29/2025 to 10/27/2025 and 10/28/2025 to 11/17/2025 did not include interventions or patient/family goals for the feeding tube and management, enteral nutrition, dysphagia, or aspiration risk. During an interview and review of the findings on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients’ plans of care did not include interventions, or goals for the identified patients’ problems.”

“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: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient/family goals with measurable outcomes. CLINICAL RECORD 1: The patient elected hospice care on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. On 03/06/2026, the Registered Nurse (RN) documented slurred speech, mumbling, and slowed, effortful word finding, episodes of choking when drinking liquids, and observed to be visibly frustrated and distressed by their declining ability to communicate. On 04/08/2026, the Licensed Practical Nurse (LPN) documented bowel incontinence, lethargy, and orientation only to person and place. On 04/15/2026, the LPN documented both bowel and bladder incontinence, with the patient sleeping throughout the visit and not awakening. The patient’s mother reported administration of Ativan and pain medication, and that anti-nausea medication was required that morning. On 04/17/2026, the RN documented that the patient’s last bowel movement occurred on 04/14/2026, that the patient was sleeping 22–23 hours per day, taking only small sips of fluids with medications and a few bites of food daily, and that a priest had visited to administer the Sacrament of the Sick. The plans of care for the benefit periods dated 01/20/2026 to 03/20/2026 and 03/21/2026 to 05/19/2026, documented the patient’s comfort goal: maintain a pain score below SIT 3, with assessment for signs and symptoms of death and dying; and a sensory/neurological goal: changes will be identified promptly and interventions initiated to minimize discomfort, with success defined as patient/caregiver acceptance of comfort at each visit. These goals did not include documentation of measurable outcomes. CLINICAL RECORD 5: The patient elected hospice care on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The RN admission visit note dated 06/21/2025 documented the patient’s respiratory rate as 26 breaths per minute and a recent 14-day hospitalization for a COPD exacerbation, which required BiPAP support for the first week. On 01/28/2026, the skilled nurse (SN) visit note documented that the patient’s oxygen saturation was 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula, with visible cyanosis and reports of orthopnea when lying down. A Nurse Practitioner (NP) Face-to-Face visit on 02/02/2026 documented that the patient was alert and oriented ×4 but tachypneic and dyspneic at rest. The NP Face-to-Face visit on 04/10/2026 documented the patient’s oxygen saturation was documented at 84% on 4 LPM via nasal cannula. The Interdisciplinary Group (IDG) documentation dated 03/04/2026, 03/19/2026, 04/01/2026, and 04/16/2026 documented oxygen needs, ranging from 4–8 LPM. The patient’s plans of care for the benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 documented the patient’s goals: “comfort” the patient and caregiver will understand symptom scales, symptom management, and when to report changes to hospice. The plans of care did not include documentation of a comfort goal with measurable outcomes. CLINICAL RECORD 6: The patient elected hospice care on 01/02/2026 with a terminal diagnosis of metastatic pancreatic cancer. The RN admission visit note dated 01/02/2026 documented that the patient was alert and oriented to person, place, time, and situation, and reported moderate, generalized abdominal aching pain rated at 4/10. The patient complained of constipation. On 01/23/2026, the physician ordered Senna Plus 8.6 mg–50 mg, two (2) capsules twice daily, to address constipation. During the IDG meeting dated 02/04/2026, the patient’s pain level was documented as 3/10, with a stated goal of 3/10. The SN documented a two-week goal to maintain pain below the stated level and to achieve an effective bowel regimen. The same goals were documented during the IDG meeting dated 02/18/2026. On 02/27/2026, the SN visit note documented that the patient reported severe pain rated at 10/10, accompanied by abdominal cramping and nausea, and that the patient was fluctuating between diarrhea and hard stools. New physician orders were obtained for an adjusted pain regimen and ondansetron (Zofran) to address nausea. The IDG meeting dated 03/04/2026 documented a generalized comfort goal of maintaining pain below the patient’s stated goal of 3/10, with reference to an “effective bowel regimen.” Medication changes were noted, including a new order for dicyclomine (Bentyl) for cramping. The same information was repeated during the IDG meeting on 03/18/2026. On 03/30/2026, the SN visit note documented that the patient had no bowel movement on 03/29/2026, followed by three episodes of diarrhea on 03/30/2026. During the IDG meeting on 04/01/2026, the plan again reflected the goal of maintaining pain below the pain scale score through effective medication management and bowel regimen. The SN visit note dated 04/10/2026 documented that the patient reported mild abdominal pain and persistent nausea, stating that they were taking simethicone for gas and ondansetron for nausea. The IDG meeting dated 04/10/2026 documented the new order for simethicone. The plans of care for the benefit periods dated 01/02/2026 to 04/01/2026 and 04/02/2026 to 06/30/2026 documented the comfort problem with the patient’s goal: caregiver to identify gastrointestinal changes within 3 days of symptom onset and to initiate interventions promptly to minimize discomfort. The plans of care did not include measurable outcomes for the patient’s comfort goals related to the identified gastrointestinal problems. During an interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients’ plans of care did not include goals with measurable outcomes.”

“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, observation, and interview. In 1 of 4 (25%) home visits observed and clinical records reviewed, the agency did not ensure that the patient’s plan of care included medical supplies needed to meet the patient’s needs. HOME VISIT 1/CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. The skilled nurse (SN) visit notes dated 04/08/2026 and 04/15/2026, documented the patient’s bowel and bladder incontinence. During the home visit with the Hospice Aide (HA) on 04/22/2026, the HA utilized wipes, chux, and a brief due to the patient’s incontinence. The plans of care for the benefit period dated 03/21/2026 to 05/19/2026 did not include documentation of incontinence supplies (briefs, wipes, chux pads). The finding was confirmed following a joint clinical record review and interview on 04/23/2026 with the Area Executive of Clinical Operations.”

“It is required that the Interdisciplinary Group (IDG), in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan no less frequently than every 15 calendar days. A revised plan of care must include information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the IDG reviewed, revised, and documented the patient’s plan of care no less frequently than every 15 calendar days CLINICAL RECORD 1: The patient elected the hospice benefit on 07/24/2025 with a terminal diagnosis of malignant neoplasm of the frontal lobe. The Registered Nurse (RN) visit note dated 03/06/2026, documented that the patient was experiencing significant neurological changes, including slurred speech, mumbling, and difficulty finding and articulating words, and was having episodes of choking when drinking liquids. Additionally, the RN documented that the patient was visibly frustrated and distressed by their decline in the ability to communicate, and the patient reported constipation, having gone up to five days without a bowel movement. On 04/08/2026, the Licensed Practical Nurse (LPN) visit note documented bowel incontinence, lethargy, and orientation only to person and place. On 04/15/2026, the LPN visit note documented bowel and bladder incontinence, with the patient sleeping through most of the visit and not awakening. The patient’s mother reported administering Ativan and pain medication, and that nausea medication was required that morning. On 04/17/2026, the Skilled Nursing (SN) visit note documented that the patient’s last bowel movement had occurred on 04/14/2026, that the patient was sleeping 22–23 hours per day, taking only small sips of fluids with medications and a few bites of food daily, and that a priest had visited and administered the Sacrament of the Sick. A review of the patient’s plans of care revealed that the problems, interventions, and goals (P/I/G) were not updated since 07/2025, except for a revised comfort goal specifying a measurable pain score of =3. The plans of care for the benefit periods dated 01/20/2026 to 03/20/2026 and 03/21/2026 to 05/19/2026 were not updated to were not updated to include the patient’s identified problems with dysphagia and choking with liquids, nausea requiring medication, constipation, and subsequent bowel and bladder incontinence, patient frustration, anxiety, and emotional distress related to communication loss. CLINICAL RECORD 8: The patient elected hospice care on 01/20/2026 with a terminal diagnosis of Parkinsonism. On 02/24/2026, the RN documented that the patient was being treated with antibiotics for both a urinary tract infection (UTI) and aspiration pneumonia. On 02/27/2026, the SN visit note documented that the patient “continued to not feel very well,” slept most of the time, and had coarse lung sounds, prompting the physician’s approval of another round of antibiotics. The IDG meeting on 03/04/2026 documented intermittent oxygen use for shortness of breath or low oxygen saturation, treatment with Cefdinir for aspiration pneumonia, and Macrobid for urinary tract infection (UTI), with no measurable respiratory, infection-related, or neurological goals identified. On 04/17/2026, the RN documented the patient’s staying awake all night after previously sleeping 14–16 hours/day, increased agitation, and worsening neck pain. The hospice physician ordered morphine sulfate extended release, 15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. The hospice physician ordered morphine sulfate extended release,15 mg twice daily, and directed the SN to contact the attending physician regarding agitation and hallucinations. The IDG meeting dated 04/21/2026, documented that the patient exhibited signs and symptoms of aspiration pneumonia, was oriented to person and place, was confused, and was experiencing hallucinations. The patient’s plans of care for the benefit periods dated 01/20/2026 to 04/19/2026 and 04/20/2026 to 06/18/2026 were not updated to include the patient’s identified problems with aspiration, aspiration pneumonia, agitation, confusion, or hallucinations. During a joint clinical record review and interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the patients’ plans of care were not revised to reflect changes in patient condition, acknowledging that newly identified problems, planned interventions, and patient-specific goals were neither added nor updated.”

“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 an 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 3 of 15 (20%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 5: The patient elected the hospice benefit on 06/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided at home. On 01/28/2026, the Registered Nurse (RN) visit note documented that the patient had an oxygen saturation of 89% on 4 liters per minute (LPM) of continuous oxygen via nasal cannula and was cyanotic. The plans of care (POC) for the hospice benefit periods dated 02/16/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 ordered HA services twice weekly. The HA care plans dated 04/03/20260 and 09/16/2025 did not provide the HA with instructions regarding the patient’s use of continuous oxygen during personal care. CLINICAL RECORD 14: The patient elected the hospice benefit on 03/25/2026 with a terminal diagnosis of Huntington’s disease. The patient resided at home. During the Registered Nurse’s (RN) admission visit on 03/25/2026, the RN documented that the patient had a gastric tube (G-tube) in place for nutrition and medication administration. The plans of care (POC) for the hospice benefit periods dated 03/25/2026 to 04/16/2026 and 04/17/2026 to 06/15/2026 ordered HA services twice weekly. The HA care plan dated 03/25/2026 did not provide the HA with instructions related to the G-tube during personal care activities. CLINICAL RECORD 19: The patient elected the hospice benefit on 08/15/2025 with a terminal diagnosis of heart failure, unspecified. On 09/22/2025, the RN documented an unstageable coccyx wound measuring 1 cm x 2.2 cm x 1 cm. On the same date, the physician ordered wound care, including cleansing with wound cleanser, application of Medihoney gauze to the wound bed, and covering with a foam dressing on Monday, Wednesday, Friday, and as needed. The RN visit note dated 10/01/2025, documented that the patient required continuous oxygen at 2 liters per minute via nasal cannula (N/C) and had venous stasis ulcers on the bilateral lower extremities (BLE). The physician ordered wound care: “application of Silvadene cream from the knees to the ankles, cover with Telfa, wrap with Kerlix, and secure with tape.” For the hospice benefit period dated 08/15/2025 to 10/17/2025, the physician ordered HA visits twice weekly. The HA care plan dated 08/29/2025 assigned the HA to provide a partial sponge bath, shower, and shampoo at every visit. The HA care plan dated 08/29/2025 did not document instructions for the HA regarding the wounds or dressings should they become wet, soiled, or dislodged during bathing and personal care activities. The care plan did not include instructions for the HA regarding the patient’s use of continuous oxygen during personal care. During a joint clinical record review and interview on 04/23/2026, the Area Executive of Clinical Operations confirmed that the HA care plans did not include instructions to meet the patient’s needs.”

“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 day-to-day administrative or direct patient care services in an amount that equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of Volunteer Program documentation and interviews with the Volunteer Coordinator on 04/23/2026, revealed that the average percentage of total patient care hours for all paid hospice employees and contract staff attributable to volunteers was 3.45% for 01/01/2025 through 12/31/2025. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. During the review of Volunteer Program documentation and interviews with the Volunteer Coordinator (Personnel Record 7) on 04/23/2026, it was determined that the average percentage of total patient care hours for all paid hospice employees and contract staff attributable to volunteers was 3.45% in 2025 and 1.86% year-to-date in 2026. These rates remain significantly below the targeted 5% volunteer requirement. As a result of continued noncompliance, a Performance Improvement Project (PIP) was initiated and remained active at the time of the site visit. The Volunteer Coordinator began with the organization in September of 2025 and has monthly meetings with the Area Executive of Clinical Operations to monitor progress. Documented recruitment strategies include posting opportunities on the Volunteer Match and Idealist websites, utilizing social media platforms, distributing flyers, outreach to local colleges, and participation in career and health fairs. Documented retention efforts include individualized phone calls and text messages to volunteers, inclusion of volunteers in staff gatherings, provision of small appreciation gifts, and one-on-one meetings to promote engagement through face-to-face interaction.”

“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. CONTINUED REQUIRED ACTION This standard was not met, as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed, the hospice did not ensure that the written plan of care included the medical supplies necessary to meet the patient’s needs. Clinical Record 1: The patient elected hospice care on 12/06/2023 with the diagnosis of Unspecified Protein-Calorie Malnutrition. The initial assessment completed by the Registered Nurse (RN) on 12/06/2023 documented that the patient was incontinent of bowel and bladder, refused to wear Depends, and was cleaned with wipes. The plan of care dated 12/06/2023 did not include the Depends and wipes. Clinical Record 4: The patient elected hospice on 12/01/2023 with the diagnosis of malignant neoplasm of the pancreas. The initial assessment completed by the RN on 12/01/2023 documented that the patient was incontinent of bowel and bladder and that the patient wears size 8 Depends. The plan of care dated 12/01/2023 did not include the Depends. The Director of Clinical Services was interviewed on 03/07/2024 and confirmed that the medical supplies necessary to meet the needs of the patient were not included in the plan of care. REOCCURING REQUIRED ACTION.”