Compassus-Hattiesburg

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: 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, document review, observation, and interview. Agency procedure “Medication Reconciliation” (revised 01/30/2019) stated in part, “For patients in their own residence, it is the responsibility of the hospice nurse to perform the following steps at each scheduled nursing visit... Nurse obtains the most current copy of the medication list...Nurse visually reviews the patients’ medications list in the home, comparing it to the medication list from the medical record...If the medication lists do not match, the nurse ensures the incorrect list is promptly updated to reflect the correct orders and the medication reconciliation process is completed.” In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure a medication reconciliation occurred per agency policy. Clinical Record 1/Home Visit 1: The patient elected hospice care on 04/21/2025 with diagnoses of unspecified systolic (congestive) heart failure, atherosclerotic heart disease, and chronic kidney disease, stage 3. The patient resided in a home with their spouse, who was the primary caregiver. During the home visit with the Chaplain (SC) [Personnel Record 3] on 07/22/2025, the patient’s medications were reviewed with their spouse. The spouse stated, “The clonidine was discontinued because he (the patient) was having blood pressure problems, and the doctor added the hydralazine. I think it was back in May when the nurse called the doctor about his blood pressure.” The skilled nurse (SN) visit note dated 05/27/2025 documented, “ Blood pressure (BP) has been consistently elevated. SN contacted Dr. (name). Dr. (name) ordered hydralazine 100 mg tid, and take 1/2 clonidine for 2-3 days, and then take 1/2 clonidine every other day for 2-5 days.” A clinical record review revealed no evidence that the medication profile was updated when the nurse obtained the order to change the clonidine. During an interview on 07/23/2025, the Director of Clinical Services stated, “I spoke to the nurse, and she stated she had called the doctor, received the new orders for clonidine, included the information in her narrative note for the visit, however, had forgotten to update the medication profile.”

“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: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C_09A “Individualized Plan of Care” (reviewed 12/27/2024) stated in part, “Content of the Plan of Care...All services needed to manage the terminal illness and related conditions... A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs...Scope = what services are part of the plan of care.” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the patient’s plan of care included the scope and frequency of services necessary to meet the patient’s needs. CLINICAL RECORD 1: The patient elected hospice care on 04/21/2025 with diagnoses of unspecified systolic (congestive) heart failure, atherosclerotic heart disease, and chronic kidney disease, stage 3. The patient resided at home. A review of the plans of care established by the Interdisciplinary Team (IDG) for the benefit periods dated 04/21/2025 through 07/19/2025 and 07/20/2025 through 10/17/2025 revealed Hospice Aide (HA) services were ordered three (3) times a week. The plans of care did not document the scope of services the HA was to provide. The HA was providing a bed bath, dressing, shampoo, skin care, peri-care, and shave each visit. CLINICAL RECORD 2: The patient elected hospice care on 04/30/2025 with diagnoses of chronic kidney disease, unspecified atrial fibrillation, and urinary tract infection. The patient resided in an assisted living facility (ALF). A review of the plan of care established by the Interdisciplinary Team (IDG) dated 04/30/2025 through 07/28/2025 revealed Medical Social Worker (MSW) services ordered one (1) time a month and the Hospice Aide (HA) services ordered effective 05/04/2025 two (2) times a week for twelve weeks. The plan of care did not document the scope of services the HA and the MSW were to provide. CLINICAL RECORD 4: The patient elected hospice care on 03/11/2025 with diagnoses of atherosclerotic heart disease of the native coronary artery without angina pectoris, sepsis, unspecified organism, chronic respiratory failure with hypoxia, and chronic kidney disease, stage 4. The patient resided in a skilled nursing facility (SNF). A review of the plan of care established by the Interdisciplinary Team (IDG) dated 03/11/2025 through 06/08/2025 and 06/09/2025 through 09/06/202 revealed HA services ordered three (3) times a week for 13 weeks. The plans of care did not document the scope of services the HA was to provide. The HA was providing a bed bath, dressing, shampoo, skin care, peri-care, and shave each visit. CLINICAL RECORD 5: The patient elected hospice care on 06/23/2025 with diagnoses of malignant neoplasm of overlap sites of right female breast, estrogen receptor positive, nausea, and other pulmonary embolism without acute cor pulmonale. A review of the plan of care established by the Interdisciplinary Team (IDG) dated 06/23/2025 through 09/30/2025 revealed HA services ordered three (3) times a week for 13 weeks and MSW services ordered one (1) time a month. The plan of care did not document the scope of services the HA and the MSW were to provide. The HA was providing a shower, turning and positioning, shampoo, hair care, skin care, and peri-care. The MSW was counseling on death and dying. CLINICAL RECORD 7: The patient elected hospice care on 05/03/2025 with diagnoses of chronic obstructive pulmonary disease with (acute) lower respiratory infection, primary spontaneous pneumothorax, essential (primary) hypertension, and unspecified sequelae of cerebral infarction. A review of the plan of care established by the Interdisciplinary Team (IDG) dated 05/03/2025 through 07/31/2025 revealed HA services ordered three (3) times a week for twelve weeks, two (2) times a week for one (1) week. The plans of care did not document the scope of services the HA was to provide. The HA was providing a shower, shampoo, hair care, skin care, peri-care, foot care, and shaving. CLINICAL RECORD 11: The patient elected hospice care on 06/06/2025 with diagnoses of hypertensive heart disease with heart failure and essential (primary) hypertension. A review of the plan of care established by the Interdisciplinary Team (IDG) dated 06/06/2025 through 09/03/2025 ordered HA services two (2) times a week for twelve weeks, one (1) time a week for one (1) week. A physician order dated 06/08/2025 increased the hospice aide to three (3) times a week. The plan of care did not document the scope of services the HA was to provide. The HA was providing a shower, shampoo, hair care, skin care, perineal care, shaving, and oral care. During the joint record review on 07/23/2025, the Area Director of Quality Outcomes stated, “That is correct, there are no orders with the scope of services for the aide services or for the Social Worker.””

“It is required that a hospice aide provides services: ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed for patients receiving Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services ordered by the interdisciplinary group. CLINICAL RECORD 8: The patient elected hospice care on 01/24/2024 with diagnoses of Parkinson’s disease without mention of fluctuations and essential (primary) hypertension. The plan of care established by the Interdisciplinary Team (IDG) dated 05/06/2025 through 07/04/2025 ordered HA services two (2) times a week for one (1) week and three (3) times a week for eight (8) weeks. On 06/06/2025, the physician ordered HA services, “effective Medicare week 06/01/2025, .... 3Q2wk2, 3WK3.” The week of 06/01/2025, there were no documented hospice HA visits. The week of 06/08/2025, there were three (3) documented HA visits. The HA documented visits for the week of 06/15/2025 on 06/15/2025, 06/16/2025, and 06/18/2025, and during the week of 06/22/2025 on 06/23/2025, 06/25/2025, and 06/27/2025. A clinical record review revealed no communication or physician’s order for the HA to visit the patient during the weeks of 06/15/2025 and 06/22/2025. During the joint record review on 07/23/2025, the Area Director of Quality Outcome stated, “The aide performed visits that did not include an order.””

“It is required that a hospice aide provides services: consistent with the hospice aide training. This standard was not met as evidenced by document review and observation. Agency procedure “Bed Bath” (revised 05/19/2025), stated in part, “Equipment for bathing using water, skin cleanser, and washcloths...For bathing using water, skin cleanser, and washcloths. Clean the patient’s face......clean rinse and dry the patient’s abdomen, and then then the groin and perineum. Remove and discard your gloves. Perform hand hygiene. Put on new pair of gloves. Clean, rinse, and dry the patient’s left leg, left foot.” In 1 of 4 (25%) home visits observed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services consistent with the hospice aide training. Home Visit 3: The patient elected hospice care on 09/25/2024 with diagnoses of Alzheimer’s disease, unspecified, and senile degeneration of the brain, not elsewhere classified. During the home visit with the HA [Personnel Record 5] on 07/23/2025, the HA washed the patient’s face and ears, bathed the patient’s upper body, rinsed the cloth in the water basin, washed the patient’s midsection (abdomen, groin, perineum, rinsed the cloth, then washed the patient’s lower extremities. Once this was completed, the patient was turned on their right side, and the patient’s back, buttocks, and in between the buttocks were washed. The cloth was rinsed, and then the lower extremities were washed. The patient was bathed using multiple washcloths. After the HA washed the patient’s abdomen, groin, and perineum, the HA did not change gloves or perform hand hygiene per the agency’s bath procedure.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C-31 “Clinical Records” (revised 02/04/2025) stated in part, “The clinical record contains complete and accurate information... All entries into the clinical record are legible, clear, accurate, complete, and authenticated...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s clinical record contained a plan of care including accurate information regarding the care and services to meet the patient’s needs. CLINICAL RECORD 6: The patient elected hospice care on 07/17/2025 with diagnoses of malignant neoplasm of overlap sites of right female breast, estrogen receptor positive, secondary malignant neoplasm of brain, and other seizures. The patient resided at home. A review of the plan of care established by the Interdisciplinary Team (IDG) dated 07/17/2025 through 10/14/2025 revealed an order for Hospice Aide (HA) services, “hospice aide to assist with personal care and hygiene.” During an interview on 07/23/2025, the Director of Clinical Services stated, “This patient does not have an aide; that must be an error.” CLINICAL RECORD 9: The patient elected hospice care on 06/27/2024 with diagnoses of senile degeneration of the brain, not elsewhere classified, essential (primary) hypertension, sarcopenia, and abnormal weight loss, unspecified. The patient resided in an ALF. A review of the plan of care established by the Interdisciplinary Team (IDG) dated 06/22/2025 through 08/20/2024 ordered HA services to assist with ADLs and personal care needs. During an interview on 07/23/2025, the Director of Clinical Services stated, “This patient doesn’t have an aide; that must have been an error.””