Hospice Compassus-Joplin

“Based on policy review, record review, and interview, the hospice failed to ensure physician authorization and oversight for invasive nursing interventions; failed to appropriately assess, coordinate, and report a Foley catheter (a sterile tube placed in the bladder to drain urine) related complication; failed to ensure interdisciplinary and supervisory awareness of significant clinical changes; and failed to ensure follow-up and availability of ordered medication in one of three patient records reviewed (Record/Patient #1). The cumulative effect of these failures resulted in the hospice’s inability to consistently ensure safe and effective provision of core nursing services. Findings included: Review of the provider’s policy titled “Core Services,” revised 01/22/2026, showed in part:- Hospice must ensure nursing services are provided by qualified personnel;- Hospice is responsible for ensuring services meet patient needs;- Supervisory staff must be available to provide oversight; and- Hospice retains responsibility for management and coordination of care. Review of the provider’s policy titled, “Nursing Services,” revised 12/09/2025, showed in part, nursing services must be provided in accordance with physician orders, accepted standards of practice, and with appropriate documentation and supervision. Review of the provider’s policy titled, “Indwelling Urinary Catheter (Foley) Care and Management,” reviewed 12/15/2025, showed in part:- Physician direction for catheter use;- Ongoing assessment and monitoring for complications;- Documentation of care and clinical findings;- Removal of catheter when clinically indicated; and- Compliance with infection prevention practices. Review of the provider’s policy titled, “Patient Adverse Event Reporting,” revised 10/20/2020, showed in part:- Adverse event defined as deviation from normal expected outcome;- Events must be assessed and reported within 24 hours;- Physician and IDT (interdisciplinary team) notification required as indicated;- Events tracked and reviewed through QAPI (Quality Assurance and Performance Improvement); and- Written report required for documentation and trending. Review of the provider’s policy titled, “Management and Staff Training,” revised 01/20/2022, showed in part:- Direct care staff must receive competency evaluation;- Competency must be discipline-specific;- Competency validation occurs during onboarding and periodically thereafter; and- The provider was responsible for evaluating proficiency in completion of specific skills. Review of the provider’s policy titled, “Medication Reconciliation and Management,” revised 10/28/2025, showed in part:- Medication reconciliation required at admission and with changes;- Ensure ordered medications are available in the home;- Confirm refills and delivery of medications;- Provide patient and caregiver education; and- Document effectiveness and follow-up. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 12/31/2025 with a terminal diagnosis of end stage renal disease (ESRD, a permanent condition in which the kidneys no longer function adequately to sustain life without dialysis or transplant). The record showed dialysis (treatment for kidney failure) was discontinued two days prior to hospice admission. The record showed generalized edema (swelling of the tissues). The patient resided at home with family members. Review of registered nurse (RN) - C’s patient information note dated 01/07/2026 at 2:02 PM, showed an urgent call was received reporting seizure activity. The caregiver was instructed to administer lorazepam (anti-anxiety medication used to treat seizures) 2 mg. Upon arrival, the patient had intermittent arm spasms, was incontinent of bowel and bladder, and had 4+ edema (a clinical classification of fluid retention) in all extremities with significant edema to the scrotum and penis, with edema documented as “moving further up.” The record failed to show physician notification or interdisciplinary group (IDG) coordination following this significant clinical change. The record failed to show documentation of reassessment or an updated plan of care following the documented seizure activity or worsening edema. Review of RN C’s visit note dated 01/08/2026 at 5:03 PM, showed an 18 French catheter (a larger sized urinary tube used to drain urine from the bladder) was inserted with no urine return and the balloon (a small part at the end of the catheter that is filled with sterile water to keep the catheter in place) would not inflate. RN C documented inability to remove the Foley catheter due to suspected bladder spasms and administered lorazepam 2 mg. RN C, a PRN (as needed) nurse who worked across branches, documented intent to return in 30–45 minutes following unsuccessful catheter insertion. The clinical record failed to reflect a physician order authorizing Foley catheter insertion prior to RN C’s attempt. The clinical record failed to reflect notification of the assigned patient care manager, the patient’s parent branch supervisory staff, or documented physician consultation prior to leaving the patient with an unresolved complication. Review of a physician order dated 01/08/2026 at 6:56 PM, showed an emergency PRN visit for Foley catheter needs, signed by RN coordinator B. The timing indicated the order was obtained after RN C’s insertion attempt. Review of RN coordinator B’s visit note dated 01/08/2026 at 7:11 PM, showed a PRN visit and orders to place the Foley catheter. RN coordinator B attempted placement of the Foley catheter with no urine return. The record failed to reflect physician notification that the initial insertion attempt was unsuccessful prior to the second attempt and failed to include documentation that the complication was reported as an adverse clinical event. While competency documentation was present in personnel files, the record failed to reflect procedure-specific validation related to Foley catheter insertion or documented review following the unsuccessful attempts described above. Review of a physician order dated 01/08/2026 at 8:35 PM showed morphine concentrate was ordered every two hours, as needed. During an interview on 02/17/2026 at 12:49 PM, RN coordinator A stated that RN C performed the 01/08/2026 visit and attempted Foley catheter insertion. RN coordinator B assisted. RN coordinator A stated that he/she was not aware of the Foley catheter complication until the chart was audited. He/she further stated that morphine was not followed up after being called in by the physician and was not delivered prior to revocation. During an interview on 02/17/2026 at 1:38 PM, case manager D stated that he/she was not present during the Foley catheter attempt and was not directly notified of the complication. He/she stated that staff were expected to call the physician with each catheter insertion attempt. He/she further stated that he/she would not leave a patient with a Foley catheter in place if there were complications or if he/she was unable to remove it. During an interview on 02/18/2026 at 11:41 AM, RN coordinator B stated that RN C informed him/her that he/she had inserted a Foley catheter without urine return and that it was stuck. RN coordinator B attempted placement but did not receive urine return. He/she stated that there were no additional physician orders addressing reinsertion following complication or removal of a non-functioning catheter. During an interview on 02/18/2026 at 11:57 AM, RN C stated that he/she attempted Foley catheter insertion due to urinary incontinence and agitation. He/she stated that he/she did not receive urine return and believed bladder spasms were the cause. He/she administered lorazepam for agitation and possible bladder spasm relief and did not recall a specific order for lorazepam related to bladder spasms. During an interview on 02/18/2026 at 12:39 PM, the administrator stated that Foley catheter insertion was considered a basic nursing skill and competency validation may include verbal explanation rather than demonstration. The administrator stated that he/she was unsure whether the Foley catheter complication qualified as an incident.”

“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 2 of 17 (12%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide care plan included all written patient care instructions. CLINICAL RECORD 6: The patient elected the hospice benefit on 08/11/2025 with a diagnosis of malignant neoplasm of the lung. The patient resided in a long-term care facility (LTC). On 08/18/2025, the physician ordered wound care with a dressing for a stage 2 pressure ulcer wound to the patient’s coccyx. The plan of care dated 08/11/2025 through 11/08/2025 ordered “HHA 2x/week.” The HA care plan dated 08/11/2025 assigned the HA the relevant task: “Bed bath every visit.” The HA care plan was not updated to document instructions for the HA related to the wound dressing on the patient’s coccyx, should it become wet or dislodged during the bed bath. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/24/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a long-term care facility (LTC). On 09/24/2025, the physician ordered wound care with a dressing for a wound to the patient’s right lateral ankle. The plan of care dated 09/24/2025 through 11/22/2025 ordered “HHA 2x/week.” The HA care plan dated 09/24/2025 assigned the HA the relevant task: “shower every visit.” The HA care plan did not document instructions for the HA related to the wound dressing on the patient’s right lateral ankle, should it become wet or dislodged during the shower. During a joint record review on 10/30/2025, the Area Executive of Clinical Operations confirmed that the wound dressing instructions were not included in the Hospice Aide care plan.”

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the facility failed to identify a system of medical documentation that secures and maintains the availability of patient records in case of an emergent event. This failure had the potential to affect 64 of 64 residents receiving care from the agency. Findings include: Review of the agency’s EPP, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM), revealed no policy or procedure that identified the system of medical documentation that preserves resident information; provides for the confidentiality of resident information; and secures, maintains, the availability of resident records in the case of an emergent event. During an interview 02/05/25 at 8:45 AM, the BOM confirmed the EPP does not identify the medical record documentation system.”

“Based on interview and review of the facility’s Emergency Operations Plan (EPP), the facility failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect 64 of 64 patients receiving care from the facility. Findings include: Review of the facility’s EPP, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM) revealed no policy regarding the use of State and/or Federal healthcare professional volunteers in an emergency as a staffing strategy. Review of page 11 of 45 of the facility’s EPP showed:”K. Volunteers (i.e. individuals who volunteer to help you, not your hospice volunteers)i. The program should identify the activities or tasks volunteers can perform during an emergency.1. Task: Supply Runs2. Task: Phone Calls3. Task: Sit with Patientii. Before suspending service to patients, seek guidance from the home office, seek volunteers from local program partners or determine if accessing the state’s volunteer database is possible for delivery of services or administrative support.” During an interview on 02/05/25 at 8:48 AM, the BOM stated, “I’m not sure we address use of state and federal designated healthcare volunteers.””

“Based on interview and a review of the facility’s Emergency Preparedness Plan (EPP), the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect 64 of 64 patients receiving care and services from the organization and hindered the organization’s ability to provide care and services and keep patients safe during an emergency. Findings include: Review of the facility’s EPP Communication Plan, last reviewed by the Governing Body on 03/12/24, with Business Office Manager (BOM) did not reveal any policy or procedure regarding the role of the facility if the Health and Human Services Secretary should declare a section 1135 waiver. During an interview on 02/05/25 at 8:56 AM, the BOM confirmed the facility role under an 1135 waiver was “not in there [EPP].””

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the Hospice failed to maintain a current list of names and contact information in the “Emergency Preparedness Communication Plan” that included all patients’ physicians. This failure had the potential to affect 64 of 64 patients receiving care from the organization and could delay the facility’s ability to respond to an emergency. Findings include: Review of the facility’s EPP Communication Plan, last reviewed by the Governing Body on 03/12/24, with the Business Office Manager (BOM) revealed no inclusion of a list of patient physicians and their contact information. In an interview on 02/05/25 at 8:59 AM, the BOM confirmed no patient physician names or contact information was contained in the communications plan.”

“Based on interview and review of the facility’s Emergency Preparedness Plan (EPP), the facility failed to ensure the EPP communication plan addressed the means of communicating with the federal and state emergency management agencies. This failure had the potential to affect 64 of 64 patients receiving care from the facility and hinder the facility’s ability to respond to any potential emergency situations. Findings include: Review of the facility’s EPP Communications Plan, last reviewed by the Governing Body on 03/12/24, with the facility Business Office Manager revealed an identified alternate form of communication identified in the EPP was an analog phone for use with a land phone line on page 11. In an interview on 02/04/25 at 9:10 AM, the BOM stated, “There is no landline non-electric phone in the facility.” During a follow-up interview on 02/04/25 at 10:17 AM, the Administrator confirmed there was no analog phone in the facility for use with the telephone land line.”

“Based on interview, record review, and policy review, the Hospice agency failed to ensure that the plan of care was reviewed and updated for three of 19 patients (Patients (P) 6, P9, and P16) whose records were reviewed. This failure had the potential to affect the care provided to the patients. Findings include: 1. Review of P6’s “Patient Information Report,” provided by the facility revealed P6 was admitted to hospice services on 12/27/23 with diagnoses that included protein calorie malnutrition, senile degeneration of the brain, and chronic obstructive pulmonary disease (COPD). Review of P6’s “Plan of Care Update Report,” provided by the facility and dated 05/02/24, revealed, “. . . Review of P6’s “Plan of Care Update Report,” dated 12/27/23, revealed, “. . . Caregiver(s) verbalize understanding of lack of appetite and/or dehydration in the dying patient and express comfort with the natural course of the disease process within next 4 visits . . .” Review of P6’s “Plan of Care Update Report,” dated 05/02/24, revealed, “. . . Patient/Caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled teaching.” The intervention was, “ SN [Skilled Nursing] – instruct patient caregiver in administration of inhalation therapy including equipment care.” Review of P6’s “Plan of Care Update Report” revealed no documented evidence that the instruction on inhalation therapy was successful or that P6 demonstrated independence with inhalation therapy. There was no documented evidence that the caregiver’s understanding of P6’s appetite/dehydration status was achieved within four visits. 2. Review of P9’s “Patient Information Report,” provided by the facility, revealed P9 was admitted to hospice services on 03/08/24 diagnoses that included cancer of the face, head, neck, lungs, and lymph system, and stage four chronic kidney disease. Review of P9’s “Comprehensive Care Plan Report,” provided by the facility, revealed a goal of “Personal business problems will be resolved as evidenced by obtaining in-home caregivers and a life alert system.” Another goal, dated 05/08/24, was, “Patient/caregiver will demonstrate independence in administration of ordered inhalation therapy and care for equipment as a result of skilled teaching.” Another goal, dated 05/08/24, was “Patient/caregiver will verbalize understanding of safe and effective use of oxygen.” Review of P9’s “Comprehensive Care Plan Report” revealed no documented evidence that the life alert system, inhalation therapy/equipment teaching, or verbalization of safe use of oxygen had been provided or received. 3. Review of P16’s “Patient Information Report,” provided by the facility, revealed P16 was admitted to hospice services on 04/18/22 with diagnoses that included senile degeneration of the brain and vascular dementia. During a site visit on 02/03/25 at 3:40 PM, Licensed Practical Nurse (LPN) 1 stated that the wound on P16’s right shin was healed and the dressing was a protective covering because he/she crossed his/her legs. Review of P16’s “Plan of Care Update Report,” dated 02/29/24, revealed, “. . . Patient/Caregiver(s) demonstrates proper care for decubitus wound and verbalize/demonstrate preventative measures to include pressure relief, nutrition, skin care, and S/S [signs/symptoms] to report to Hospice as evidenced by teach back by visit number [no number was included].” The intervention was, “SN – Instruct patient/caregiver(s) on symptoms to report including changes in wound size, odor, drainage and/or pain.” Review of P16’s “Plan of Care Update Report” revealed no documented evidence the plan of care was updated to include healing of the wound. During an interview on 02/05/25 at 3:30 PM, the Administrator confirmed the care plans should have been updated. Review of the facility’s policy titled, “Written Interdisciplinary Plan of Care,” reviewed 12/24/24, revealed, “. . . The hospice IDG [Interdisciplinary Group], in collaboration with the hospice physician and the patient’s attending physician (if the patient has one), reviews and updates the plan of care at least every 15 days or more often as needed as dictated by the patient’s condition and this review is documented . . .””

“Based on interview, record review, and policy review, the Hospice agency failed to ensure that the plan of care contained measurable goals for two of 19 patients (Patients (P) 6 and P9) whose records were reviewed. This failure had the potential to affect the patient’s receipt of necessary care and determination if care plan goals have been met or if a plan of care revision was required. Findings include: 1. Review of P6’s “Patient Information Report,” provided by the facility, revealed P6 was admitted to hospice services on 12/27/23 with diagnoses that included protein calorie malnutrition, senile degeneration of the brain, and chronic obstructive pulmonary disease (COPD). Review of P6’s “Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report,” provided by the facility and dated 05/02/24, revealed a problem of “ Patients [sic] dyspnea/shortness of breath will be within a desired range of comfort as stated by the patient.” The intervention was, “SN [Skilled Nursing] – monitor dyspnea/shortness of breath using the appropriate scale of 1-10.” The plan of care did not identify a goal of what P6 found acceptable to ensure the goal was being met. Another problem was recorded as “Patient will have an effective bowel program as evidenced medications [sic] ordered for scheduled or PRN [as needed] use. The intervention was, “SN – Instruct bowel protocol as needed.” The plan of care did not identify what was anormal bowel routine for P6 to ensure the goal the bowel program was effective. 2. Review of P9’s “Patient Information Report,” provided by the facility, revealed P9 was admitted to hospice services on 03/08/24 with diagnoses that included cancer of the face, head, neck, lungs, and lymph system, and stage four chronic kidney disease. Review of P9’s “Comprehensive Care Plan Report,” provided by the facility and dated 03/18/24, revealed a problem of “ Sensory/neurological changes are identified promptly and interventions initiated quickly to minimize associated uncomfortable symptoms.” The plan of care did not identify a baseline sensory/neurological status to ensure all providers knew what might constitute a change. Another problem was recorded as, “Skin integrity will be assessed, potential skin issues addressed and measures to prevent breakdown implemented promptly as evidenced by assessment of skin breakdown on each visit.” The plan of care did not provide a baseline of skin status to ensure changes could be assessed. During an interview on 02/05/25 at 3:20 PM, the Administrator stated that the agency had identified a concern related to care plan goals being unmeasurable. The Administrator stated a Quality Assurance Performance Improvement Project (PIP) was initiated on 01/02/25, and training had been provided to staff on 01/10/25 and 01/15/25. The Administrator stated it was a work in progress. Review of the facility’s policy titled, “Written Interdisciplinary Plan of Care,” reviewed 12/24/24, revealed, “. . . The content of the plan includes at minimum . . . Measurable goals and outcomes for planned interventions . . .””