Compassus-Memphis

“It is required that each patient’s individualized written plan of care includes all medical supplies and appliances necessary to meet the needs of the patient. 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 patient’s plan of care included all DME (durable medical equipment) to meet the needs of the patient. CLINICAL RECORD 5: The patient elected hospice care on 03/23/2026 with diagnoses of senile degeneration of the brain, unspecified dementia, unspecified severity, without behaviors/moods. The Registered Nurse (RN) visit note dated 04/23/2026 documented that education was provided on the safe use of the Hoyer lift, including a return demonstration. The Skilled Nursing (SN) visit note dated 06/26/2026 documented that the patient was transferred into their wheelchair using a Hoyer lift. The Plan of Care DME for the benefit periods 03/23/2026 to 06/20/2026 and 06/21/2026 to 09/18/2026 did not document a Hoyer lift. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/11/2026. The Registered Nurse (RN) admission visit dated 04/11/2026 documented “ordered bed, table, Hoyer, and oxygen…,” that the patient was unable to stand, and that transfer from bed to chair was very difficult. The Skilled Nurse (SN) visit note dated 05/15/2026 documented that a Hoyer lift was present in the home and that a caregiver had attempted to transfer the patient using the equipment. The SN documented “spoke with a caregiver who reports that she attempted to get patient up with Hoyer lift to transport wheelchair...” The Plan of Care DME for the benefit period 04/11/2026 to 07/09/2026 did not document a Hoyer lift. During a joint clinical record review and interview on 07/10/2026, the Director of Clinical Services confirmed that the Hoyer was not documented in the plan of care.”

“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 1 of 10 (10%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 10: The Plan of Care (POC) for the benefit period 04/11/2026 to 07/09/2026 ordered Hospice Aide (HA) visits twice weekly for the week of 05/20/2026 and once weekly beginning 05/25/2026.The Registered Nurse’s (RN) admission assessment on 4/11/2026 documented the patient had a 16-Fr Foley catheter. The Hospice Aide care plan dated 04/22/2026, active at the time of record review, did not document instructions or assign tasks to the HA related to the Foley catheter care during personal care. During an interview and a joint record review on 07/10/2026, the Administrator/RN (Personnel Record 2) confirmed that the Hospice Aide care plan contained no instructions or assigned tasks related to the patient’s Foley catheter. The Administrator/RN acknowledged the omission and stated, “It should be there.””

“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 agency did not ensure that the Hospice Aide reported changes related to the plan of care to the Registered Nurse (RN). CLINICAL RECORD 10: The patient’s Plan of Care (POC) for the benefit period 04/11/2026 to 07/09/2026 ordered Hospice Aide (HA) visits twice weekly for the week of 05/20/2026 and once weekly beginning 05/25/2026. The Hospice Aide care plan dated 04/22/2026, active at the time of the record review, assigned the HA the tasks: bed baths, hair care, oral care, perineal care, skin care, dressing assistance, turning and repositioning for comfort, and weekly shampoo and linen changes. The HA visit notes dated 06/18/2026, 06/24/2026, 06/30/2026, and 07/02/2026 documented that the bed bath, shampoo, oral care, and dressing assistance were not completed. A review of the clinical record revealed no evidence that the HA reported the changes to the care plan to the RN. During interviews and joint record reviews on 07/10/2026, the Director of Clinical Services and the Administrator/Registered Nurse (RN) confirmed the findings. They agreed that the care not completed on 06/18/2026, 06/24/2026, 06/30/2026, and 07/02/2026 should have prompted the HA to notify the RN of the change to the care plan.”

“It is required that the Interdisciplinary Group ensure instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family, and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the patient, as appropriate, and the family/caregiver received instruction on the proper handling, storage, and safe utilization of durable medical equipment (DME) and/or supplies. CLINICAL RECORD 10: The patient elected the hospice benefit on 04/11/2026. The Registered Nurse (RN) admission visit dated 04/11/2026 documented “ordered bed, table, Hoyer, and oxygen…,” that the patient was unable to stand, and that transfer from bed to chair was very difficult. The Skilled Nurse (SN) visit note dated 05/15/2026 documented that a Hoyer lift was present in the home and that a caregiver had attempted to transfer the patient using the equipment. The SN documented “spoke with a caregiver who reports that she attempted to get patient up with Hoyer lift to transport wheelchair...” A clinical record review revealed no documentation that the patient, family members, and/or caregivers received instruction on the operation of the Hoyer lift. There was no documentation of competency validation or return demonstration of safe use. During a joint clinical record review and interview on 07/10/2026, the Administrator/RN and the Director of Clinical Services confirmed that no documentation was present to demonstrate that the patient’s family members and/or caregivers received education regarding the safe operation of the Hoyer lift.”