Compassus-Mid-Mississippi

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. 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 the Interdisciplinary Group (IDG) updated the individualized care plan as frequently as the patient’s condition changed. CLINICAL RECORD 1: This patient elected the hospice benefit on 12/07/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). An emergent skilled nursing (SN) visit was completed on 01/19/2025, documenting that the patient was experiencing shaking and trembling. Physician orders were received on 01/20/2025 for Levaquin 750 mg every day for seven days to treat a respiratory infection and a possible urinary tract infection (UTI). The SN visit note dated 02/04/2025 documented that the patient had a wet cough and wheezing in all lobes bilaterally, and that a call was made to the physician, resulting in an order for a “Z-pack for a productive cough.” A clinical record review revealed a physician’s order dated 02/04/2025 for a “Z-pack for a productive cough with an end date of 02/09/2025.” The SN visit note dated 02/07/2025 documented that the Patient Care Assistant (PCA) picked up the patient’s antibiotics and antidiarrheal medications. The plans of care were reviewed for the dates of 01/19/2025 through 8/19/2025 and revealed that no updates were added to the plan of care to include interventions and goals related to the infection. CLINICAL RECORD 10: This patient elected the hospice benefit on 03/26/2024 with a terminal diagnosis of Huntington’s Disease. The SN visit note dated 07/09/2025 documented that the liquids were changed from nectar to honey consistency due to the patient coughing, and aspiration precautions were in place. The plans of care were reviewed for the dates of 07/09/2025 through 08/19/2025 and revealed that no updates were added to the plan of care to include interventions for the change in liquid consistency to address the patient’s coughing. During an interview and joint review of records on 08/19/2025, the Area Executive of Clinical Operations/Administrator stated that the plan of care should have been updated to reflect the patient’s change in condition.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; [and] safe handling of soiled items in the patient’s care environment This standard was not met as evidenced by clinical record review, document review, and observation. Agency policy and procedure #IPC.11_A2 “Infection Control: Bag Technique and Standard Precautions” stated, in part: “When to use hand gel (sanitizer): before direct patient contact and after direct patient contact, before donning gloves and after removing gloves, moving between clean and contaminated body surfaces/sites, after contact with inanimate objects in the patient’s environment. Before and after entering your bag.” In 2 of 3 (67%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 02/27/2025 with a terminal illness of senile degeneration of the brain. A home visit was conducted with the Hospice Aide (HA) [Personnel Record 2] on 08/19/2025, to observe personal care. The Hospice Aide provided a bed bath. The HA washed their hands, donned gloves, bathed the patient, and then left the patient to retrieve clean linen from another room in the home without sanitizing their hands or changing gloves. HOME VISIT 3/CLINICAL RECORD 3: This patient elected the hospice benefit on 03/01/2024 with a terminal diagnosis of severe protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 08/19/2025, the RN sanitized their hands, donned gloves, cleaned the blood pressure monitor, thermometer, measuring tool, and pulse oximeter, and returned the equipment to the nursing bag without changing gloves or sanitizing their hands. During an interview and joint review of records on 08/19/2025, the Area Executive of Clinical Operations/Administrator stated that the agency provided annual infection control education, which instructed employees to observe proper hand hygiene, and that staff would be re-educated on the hand hygiene policy.”