Compassioncare Hospice of Reno

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This standard was not met as evidenced by personnel record review, document review, and interviews with the Administrator and Human Resources, which revealed that the agency failed to ensure the hospice professional met the personnel qualification requirements in the following areas: Failed to ensure the Social Worker who provided patient services directly was legally authorized and licensed in accordance with state law and regulation in 1 of 1 (100%) personnel records reviewed of a Social Worker. [HSRM.3.I/L784]. The effect of this deficient practice may pose a risk to patient safety and could result in the agency’s inability to meet the patient’s needs for the condition of participation, CFR 418.114: Personnel Qualifications.”

“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 measures 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 comprehensive assessment included a medication profile that contained the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 07/01/2025 with a diagnosis of myelodysplastic syndrome. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 08/13/2025, the patient’s hospice medication profile (printed on 08/12/2025) and SNF medication profile (printed on 08/13/2025) were compared. The following medications were documented on the hospice medication profile and not documented on the SNF medication profile: lovastatin 20 mg, take one (1) tablet every night (ordered 07/01/2025); hydrocortisone cream 1%, apply topically to rash 2x day for 7 days (ordered on 07/01/2025, was still showing active). Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/07/2025 with a diagnosis of Alzheimer’s disease. The patient resided in an assisted living facility (ALF). During the home visit with the Spiritual Counselor [Personnel Record 6] on 08/13/2025, the patient’s hospice medication profile (printed on 08/12/2025) and ALF medication profile (printed on 08/13/2025) were compared. The following medications were documented on the ALF medication profile and not documented on the hospice medication profile: nystatin cream, apply topically under left breast twice daily (ordered 12/11/2023); Chest congestion DM 10-100, take 10 ml every 4 hours as needed (ordered 06/10/2023); hyoscyamine 0.125 mg, every 6 hours as needed (ordered 05/17/2023); loperamide 2 mg, take two (2) capsules as needed (ordered 05/31/2023); ondansetron 8 mg, take every 8 hours as needed (ordered 07/06/2023). During the wrap-up call on 08/14/2025, the Administrator and Director of Compliance confirmed the findings, and the Director responded that medication reconciliations were “not optional. Should be completed with every comprehensive visit.””

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 1: The patient elected hospice care on 07/01/2025 with a diagnosis of myelodysplastic syndrome. The patient resided in a skilled nursing facility. The plan of care ordered HA services twice weekly. The HA care plan dated 07/01/2025, and updated on 07/03/2025 and 08/06/2025, assigned the HA the relevant tasks: “Bathing-shower, transfer from bed/chair and chair to bed, routine catheter care, shaving, oral care.” All tasks were to be completed on every visit until the 08/06/2025 revision, which changed shaving to weekly. The HA visit note dated 07/07/2025 documented, “Shower: No...Comments: bed bath; transfer from bed/chair and chair to bed, routine catheter care, shaving, oral care: caregiver completed prior to visit.” The HA visit note dated 08/04/2025 documented, “Shower: No. Bed bath-Registered Nurse Case Manager (RNCM) notified. Transfer from bed/chair and chair to bed...not care planned for today... RNCM notified.” The HA visit note dated 08/06/2025 documented, “Shower: No. Bed bath-RNCM notified. Transfer from bed/chair and chair to bed...not care planned for today...RNCM notified.” CLINICAL RECORD 8: The patient elected hospice care on 06/13/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a group home. The plan of care ordered HA services twice weekly. The HA care plan dated 06/13/2025, assigned the HA the relevant tasks: “Bathing-bed bath, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, catheter care, shampoo, shaving, skin care, skin care-apply moisturizer, turn and position in bed, wash dishes, keep oxygen on while bathing, empty trash, provide companionship. All tasks were to be completed on every visit. The HA visit note dated 07/01/2025 documented: “bed bath, shaving, oral care, dressing, empty trash, wash dishes: No...Caregiver completed prior to visit. CLINICAL RECORD 14: The patient elected hospice care on 12/05/2024 with a diagnosis of malignant melanoma of the skin. The patient resided in an assisted living facility (ALF). The plan of care ordered HA services twice weekly. The HA care plan dated 12/05/2024 and updated on 08/06/2025, assigned the HA the relevant tasks: bathing-shower, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, shampoo, shaving, skin care, skin care-apply moisturizer, stand by assist with ambulation, change linens, empty trash, provide companionship. All tasks were to be completed every visit until the update; then, shaving and linens were changed to a weekly schedule. The HA visit note dated 05/01/2025 documented: “Change linens, empty trash-No. Caregiver completed prior to visit.” The HA visit note dated 06/17/2025 documented, “oral care, change linens, empty trash-No. Caregiver completed prior to visit.” The HA visit note dated 08/07/2025 documented, “Change linens, empty trash-No. Caregiver completed prior to visit. RN notified.” CLINICAL RECORD 19: The patient elected hospice care on 07/02/2025 with a diagnosis of heart failure. The patient resided in a SNF. The plan of care ordered HA services twice weekly. The HA care plan dated 07/07/2025, assigned the HA the relevant tasks: “Bed bath, shampoo, hair care, skin care, turn and position in bed, perineal care, shaving, nail care, ear care, dressing, change linens, oral care.” All tasks were to be completed on every visit. Aide frequency of twice weekly. The HA visit note dated 07/09/2025 documented: “Shaving, oral care, nail care: No, caregiver completed prior to visit.” The HA visit note dated 07/14/2025 documented: “Shaving, oral care, nail care: No, caregiver completed prior to visit.” The HA visit note dated 07/16/2025 documented: “Turn and position in bed, oral care, change linens: No, caregiver completed prior to visit.” The HA visit note dated 07/21/2025 documented: “Turn and position in bed, shampoo, shaving: not care planned for today.” During an interview and a joint clinical record review on 08/14/2025, the Administrator stated that “They had recognized issues with aide care plans and instituted a performance improvement plan to work on correcting these.””

“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. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure the Hospice Aide reported changes in the patient’s needs to the Registered Nurse. CLINICAL RECORD 8: The patient elected hospice care on 06/13/2025 with a diagnosis of unspecified protein-calorie malnutrition. The patient resided in a group home. The plan of care ordered HA services twice weekly. The HA care plan dated 06/13/2025, assigned the HA the relevant tasks: “Bathing-bed bath, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, catheter care, shampoo, shaving, skin care, skin care-apply moisturizer, turn and position in bed, wash dishes, keep oxygen on while bathing, empty trash, provide companionship. All tasks were to be completed on every visit. The HA visit note dated 07/01/2025 documented: “bed bath, shaving, oral care, dressing, empty trash, wash dishes: No...Caregiver completed prior to visit. There was no evidence that the Registered Nurse (RN) was notified of the change in the care plan and the patient’s needs. CLINICAL RECORD 14: The patient elected hospice care on 12/05/2024 with a diagnosis of malignant melanoma of the skin. The patient resided in an assisted living facility (ALF). The plan of care ordered HA services twice weekly. The HA care plan dated 12/05/2024 and updated on 08/06/2025, assigned the HA the relevant tasks: bathing-shower, dressing, ear care, hair care, nail care, oral care, pericare, pericare-apply barrier cream to intact skin, shampoo, shaving, skin care, skin care-apply moisturizer, stand by assist with ambulation, change linens, empty trash, provide companionship. All tasks were to be completed every visit until the update; then, shaving and linens were changed to a weekly schedule. The HA visit note dated 05/01/2025 documented: “Change linens, empty trash-No. Caregiver completed prior to visit.” The HA visit note dated 06/17/2025 documented, “oral care, change linens, empty trash-No. Caregiver completed prior to visit.” There was no evidence that the Registered Nurse (RN) was notified of the change in the care plan and the patient’s needs. During an interview and a joint clinical record review on 08/14/2025, the Administrator stated that “They had recognized issues with aide care plans and instituted a performance improvement plan to work on correcting these.””

“It is required that all hospice professionals who provide services directly, under an individualized contract, or under arrangements with a hospice are legally authorized (licensed, certified or registered) in accordance with local, state, and federal law and regulation. This standard was not met as evidenced by document review, interview, and personnel record review. In 1 of 1 (100%) personnel records reviewed of a Social Worker, the agency did not ensure that the Social Worker (SW) who provided patient services directly was legally authorized and licensed in accordance with state law and regulations. The Board of Social Work Examiners Statute: NRS 641B.500 “Representation as social worker without license. It is unlawful for any person to represent himself or herself as a social worker within the meaning of this chapter unless he or she is licensed pursuant to the provisions of this chapter. NRS 641B.505 Practice of social work without required license unlawful. 1. Except as otherwise provided in this chapter, it is unlawful for a person to engage in: (a) The independent practice of social work unless he or she: (1) Holds an active license as a clinical social worker or an independent social worker issued pursuant to this chapter; or (2) Holds an active license as a master social worker issued pursuant to this chapter and is engaging in the independent practice of social work under the conditions prescribed in NRS 641B.225. Agency policy #9-021.1 “Psychosocial Services-(state)” (dated 2003) (revised 10/2019 and 05/2020) stated in part, “The hospice will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and the interdisciplinary team and in accordance with the plan of care. Duties and responsibilities will be identified in appropriate job descriptions.” Agency job description “Social Work” (dated 2003) (revised 12/2023) stated in part: “Position Qualifications. 6. Current licensure according to Medicare guidelines to practice in state of operations.” Personnel Record 5: The SW (a MSW) was hired on 04/08/2024. The SW’s “Initial Competency Skills Checklist-Social Worker” was signed as completed by a Master Social Worker (MSW) (who holds a state license) on 04/26/2024. During an interview and a joint personnel record review on 08/14/2025, the Administrator and the agency’s human resources confirmed that there was no evidence of a current license for the SW, reporting that the SW did not have a license, as “it was not needed in this state.” During an interview on 08/14/2025, the SW [Personnel Record 5] stated that “human resources and compliance advised her that a license was not needed in this state.” A review of Personnel Record 5 (SW) hired on 04/08/2024 was conducted on 08/13/2025 with Human Resources and the Administrator. A copy of their current license was requested. It was reported the social worker did not have a license as “it was not needed in this state.” An interview was conducted with Personnel Record 7 on 08/14/2025 during which time she advised upon hire “there was a lot of back and forth but human resources and compliance advised her a license was not needed in this state.””