Compassus - Muskogee

“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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C09 “Written Interdisciplinary Plan of Care” (effective 08/01/2017) (revised 04/22/2024)stated in part, “The Interdisciplinary Group (IDG/IDT) ensures the provision of care and services according to the plan of care.” Agency policy #HOS-C15 “Nursing Services” (effective 11/01/2017) (revised 08/29/2025) stated in part, “Nursing services include...Implementation of the individualized plan of care and recommendations for revision to the plan of care based on assessment/evaluation data...Initiation of appropriate rehabilitative and preventative nursing procedures, documentation of assessment/evaluation outcomes, interventions...planning for additional needs...” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included all treatments necessary to meet the patient’s needs. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/22/2025 with diagnoses of Merkel cell carcinoma and malignant neoplasm of the meninges. The Registered Nurse’s (RN) initial assessment dated 08/22/2025 documented that the patient had “developed debilitating chronic complications requiring trach placement with vent assist and peg tube placement with continuous feedings...Foley catheter was placed by urology due to difficult insertion...nonverbal due to cuffed trach and vent dependency...tube feeds Osmolite 1.5cal...” The RN initial assessment also documented that the patient had a “Shiley 6 cuffed tracheostomy tube, with oxygen via the ventilator at 30% FiO2.” Ventilator settings were not included in the assessment note. The RN visit note dated 08/27/2025, documented that the patient had a 16 French (Fr) Foley catheter with a 10mL balloon, which was placed on 08/01/2025, with the next scheduled catheter change due on 09/01/2025. The hospital discharge instructions dated 08/21/2025 (scanned into the clinical record on 08/22/2025) documented “tracheostomy Shiley 6 cuffed, trach care per facility (NF) protocol, ventilator settings of (Assist-Control/Volume-Controlled) AC/VC mode, 30% FiO2 (Fraction of Inspired Oxygen), set respiratory rate of 20 with a tidal volume of 400mL and a PEEP of 5.” A clinical record review revealed that no Foley size was included in the summary, and Foley care was directed according to facility protocol. There was no facility protocol scanned into the patient’s clinical record. The plan of care for the benefit period dated 08/22/2025 to 11/19/2025 and the Interdisciplinary Group Meetings/plan of care updates dated 08/28/2025, 09/07/2025, and 09/18/2025 did not include documentation of the size of tracheostomy, care for the tracheostomy, or the ventilator settings; also not included was the Foley catheter/size or frequency of catheter changes. During a joint clinical record review and interview with the Area Executive of Clinical Operations on 09/19/2025, the evidence was confirmed.”

“It is required that a hospice aide provide services: ordered by the Interdisciplinary Group; included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services ordered by the Interdisciplinary Group (IDG) and included in the plan of care. CLINICAL RECORD 6: The patient elected hospice care on 03/09/2025 with a diagnosis of Parkinsonism. The plans of care for the benefit periods dated 06/07/2025 to 09/04/2025 and 09/05/2025 to 11/03/2025 ordered Hospice Aide (HA) services twice weekly, effective 07/12/2025. The Interdisciplinary Group Meeting (IDG)/plan of care update dated 08/28/2025, documented HA services twice a week. The IDG/plan of care updates dated 09/04/2025 and 09/18/2025, the Registered Nurse (RN) documented no changes in the HA visit frequency. The last HA visit was dated 08/28/2025. The Hospice Aide completed missed visits on 09/04/2025 and 09/11/2025 (no other HA visit or missed visit was documented for either week), which documented “no aide visits.” During a joint clinical record review and interview on 09/19/2025, the Area Executive of Clinical Operations/RN confirmed that there was no order to discontinue Hospice Aide visits.”

“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. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C30 “Hospice Written and Verbal Orders” (effective 04/15/2017) (revised 12/26/2024) stated in part, “(Agency) ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, treatments ...all orders specify an exact...frequency...” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s record included physician orders for patient care and services. CLINICAL RECORD 14: The patient elected hospice care on 08/22/2025 with diagnoses of Merkel cell carcinoma and malignant neoplasm of the meninges. The patient resided in a nursing facility (NF). The initial assessment completed by the Registered Nurse (RN) on 08/22/2025 documented an unstageable sacral wound. On 08/24/2025, the RN visit note documented a stage 2 pressure wound to the sacrum, with “treatment/dressing to clean the wound using saline or wound cleanser, employing aseptic technique. Then apply Medi Honey to the wound and cover with a bordered Mepilex dressing.” Additionally, the RN visit note documented that wound care would be provided by facility staff on Mondays, Wednesdays, and Fridays, as needed. The physician’s order for wound care dated 08/24/2025, did not include documentation of the frequency of dressing changes or whether the care was being provided by facility staff, the hospice nurse, or both. During a joint clinical record review and interview on 09/19/2025, the Area Executive of Clinical Operations/RN confirmed that there was no frequency for wound care or delineation of responsibility for Clinical Record 14.”