Compassus - Vinita

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program, also described below. The hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes: a description of the training and competency evaluation program; the qualifications of the instructor; a statement that distinguishes skills taught in a laboratory using a real person (not a mannequin); indicators of which skills the aide was judged to be competent in; How additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met, as evidenced by a document review, an interview, and a review of the personnel record. Agency Policy titled “Hospice Aide and Homemaker Services HOS-C21 Revised 12/17/2025” stated in relevant parts: “2. Prior to independent care and at least annually, HA (hospice aides) are evaluated for skills proficiency by direct observation in the following areas: Refer to Procedure C-12A for Competency evaluation process. e. Appropriate and safe techniques in performing personal hygiene and grooming tasks (ADLS), including items on the following basic checklist: i. bed bath, ii. sponge, tub, and shower bath, iii. hair shampoo (sink, tub, and bed), IV. nail and skin care, v. oral hygiene, vi. toileting and elimination. f. Safe transfer techniques and ambulation. g. Normal range of motion and positioning.” Agency Procedure C12-A titled “Supervision of Hospice Aides and LP/VN Colleagues Revised 08/18/2022” stated in relevant part: “g. At least annually, the RN must directly observe the hospice aide in the performance of care delivery.” In 1 of 5 (20%) personnel records reviewed, the agency did not ensure that the skills and competencies of hospice aides, including volunteers, prior to providing care were assessed. Personnel Record 3: A joint review of the personnel record was conducted with the Administrator on 06/25/2026. The record review for Personnel Record 3, an employee (Hospice Aide), hired on 10/28/2025, revealed her initial skills competency checklist dated had been checked off using “pseudo patients” for all tasks, including bathing, shampoo, transferring, ambulation, oral care, toileting, which was not in accordance with agency policy, which requires direct observation/actual patients on multiple skills/tasks. The skills checklist dated 01/21/2026 did not include the type of observation (patient or pseudo-patient) for the following skills: toileting, assisting with bedpan/urinal, safe transfers from bed to chair/commode, ambulation, passive range of motion, body positioning/alignment. An interview was conducted with the Administrator on 06/25/2026, and she confirmed the tasks “should have been marked as completed with a patient per policy.””

“It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program, also described below. The hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes: a description of the training and competency evaluation program; the qualifications of the instructor; a statement that distinguishes skills taught in a laboratory using a real person (not a mannequin); indicators of which skills the aide was judged to be competent in; How additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provide in-service training and education programs where required. This standard was not met, as evidenced by a document review, an interview, and a review of the personnel record. Agency Policy titled “Hospice Aide and Homemaker Services HOS-C21 Revised 12/17/2025” stated in relevant parts: “2. Prior to independent care and at least annually, HA (hospice aides) are evaluated for skills proficiency by direct observation in the following areas: Refer to Procedure C-12A for Competency evaluation process. e. Appropriate and safe techniques in performing personal hygiene and grooming tasks (ADLS), including items on the following basic checklist: i. bed bath, ii. sponge, tub, and shower bath, iii. hair shampoo (sink, tub, and bed), IV. nail and skin care, v. oral hygiene, vi. toileting and elimination. f. Safe transfer techniques and ambulation. g. Normal range of motion and positioning.” Agency Procedure C12-A titled “Supervision of Hospice Aides and LP/VN Colleagues Revised 08/18/2022” stated in relevant part: “g. At least annually, the RN must directly observe the hospice aide in the performance of care delivery.” In 1 of 5 (20%) personnel records reviewed, the agency did not ensure that the skills and competencies of hospice aides, including volunteers, prior to providing care were assessed. Personnel Record 3: A joint review of the personnel record was conducted with the Administrator on 06/25/2026. The record review for Personnel Record 3, an employee (Hospice Aide), hired on 10/28/2025, revealed her initial skills competency checklist dated had been checked off using “pseudo patients” for all tasks, including bathing, shampoo, transferring, ambulation, oral care, toileting, which was not in accordance with agency policy, which requires direct observation/actual patients on multiple skills/tasks. The skills checklist dated 01/21/2026 did not include the type of observation (patient or pseudo-patient) for the following skills: toileting, assisting with bedpan/urinal, safe transfers from bed to chair/commode, ambulation, passive range of motion, body positioning/alignment. An interview was conducted with the Administrator on 06/25/2026, and she confirmed the tasks “should have been marked as completed with a patient per policy.””

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice, including expiration date. This standard was not met as evidenced by interview and observation. In 1 of 3 (33%) home visits revealed the agency did not ensure that medications were checked for expiration dates in accordance with accepted standards of practice. Home Visit 2/Clinical Record 2: A home visit was conducted with Personnel Record 2 (RN) on 06/25/2026. During the home visit, the patient’s husband advised the nurse he hadn’t used the “Ativan and Morphine in a while, actually since the patient was first admitted in 2025.” Requested to see the medications and noted the labels on the Ativan and Morphine bottles showed they both expired on 02/04/2026. Showed them to the RN, who then destroyed them with the husband per agency policy. An interview was conducted with the Director of Patient Care on 06/25/2026, who advised, “The nurse called and reported the medications were expired, and she had destroyed them. We should have noticed it and replaced them before they expired.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group, and written patient care instructions for a hospice aide are prepared by an 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 14 (7%) clinical records reviewed of patients who accepted Hospice Aide services, the agency did not ensure that the Registered Nurse (RN) provided proper infection control instruction for the Hospice Aide (HA). Clinical Record 9: The patient elected the hospice benefit on 10/13/2023 with the diagnosis of malignant neoplasm of the right breast. The patient resided in a nursing facility (NF). The plan of care for the benefit period dated 02/04/2025 to 04/04/2025 ordered HA services twice (2) a week. The Licensed Practical Nurse (LPN) visit note dated 02/07/2025 documented, “NH has COVID outbreak. Proper PPE utilized. Hospice team notified... nasal congestion and dry cough noted. New order for Mucinex 600mg BID x5 days. Negative for COVID...” On 02/10/2025, the LPN visit note documented, “Spoke with facility nurse. Patient tested positive for COVID Saturday. New orders obtained by facility for ZPAK...” The hospice Social Worker (SW) visit note dated 02/11/2025 documented, “Facility is under COVID protocol. Hospice offices have been alerted...Pt is visibly tired. Pt has a cough through most of visit...” On 02/10/2025, the physician ordered a ZPAK “to be taken as directed due to COVID.” On 02/11/2025, the Hospice Aide missed visit note documented, “Pt refused. She is COVID-positive and stated she is not feeling good and did not want a shower or cleaned up. Floor staff nurse notified. Registered Nurse Case Manager (RNCM) notified.” On 02/13/2025, a Hospice Aide missed visit note documented, “Pt refused all personal care. Very sick and cold. Wants to rest. Floor nurse (name) and (name) RNCM notified.” Although the HA did not perform a complete visit, contact was made between the HA and the patient. The Hospice Aide care plan dated 02/05/2025 documented standard infection control precautions. On 02/11/2025, the care plan was updated to include standard infection control precautions. The HA care plan was not updated to alert the Hospice Aide to COVID-19 transmission-based precautions. During a joint clinical record review and interview on 03/07/2025, the Executive Director of Area Clinical Operations/RN and the Director of Clinical Services confirmed that the Hospice Aide Care Plans dated 02/05/2025 and 02/11/2025 included standard-based precautions and not transmission-based precautions related to the patient having COVID-19. No additional information was provided at the end of the site visit.”