Hospice Compassus - the Highland Rim

“Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by clinical record review, and observation. 1 of 6 (17%) home visit observations revealed that the agency did not ensure that the clinician followed the plan of care. HOME VISIT 3/CLINICAL RECORD 3: The patient was admitted on 09/16/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 09/16/2025 to 12/14/2025 included an order to “Assess upper quadrant, mickey button placement, cleanse with NS and apply dressing as needed, assess for signs and symptoms of skin breakdown.” During the home visit with the RN (PERSONNEL RECORD 3) on 10/14/2025, observed the nurse ask the patient and the caregiver questions about the patient’s appetite and volume of intake. The nurse did not ask about the mickey button to ensure there were no complications and did not assess the area. The nurse did listen to bowel sounds over the patient’s clothing. The nurse did not assess the patient’s skin except what was exposed fully clothed.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 1 of 27 (4%) clinical record reviewed revealed that the agency did not ensure the individual plan of care included all of the necessary interventions for concerns identified in the initial assessment. CLINICAL RECORD 16: 79 year old elected hospice on 07/14/2025 with a diagnosis of COVID-19, unspecified protein-calorie malnutrition, Chronic kidney disease, hypertension, type 2 diabetes, and hyperlipidemia. SN admission assessment on 07/14/2025 revealed that upon initial assessment, the patient had a documented loss of 8 pounds and had a history of trigeminal neuralgia, which created pain issues at times; she required maximum assistance and a Hoyer lift for mobility. Patient was incontinent, requiring total care with a stage 1 pressure ulcer to the coccyx. The skilled nurse documented that the patient had a drastic decline in appetite, hence the weight loss, and was taking Metformin BID without checking the patient’s blood sugars. Oxygen ordered. The plan of care dated 07/14/2025 through 10/11/2025 did not include interventions for skin integrity, pain, diet, or respiratory status. The only interventions on the plan of care were “Admission RN will complete a medication inventory at time of admission, within 48 hours of admission will complete a medication reconciliation including: evaluate ESIDL for meds, discuss with physician possible de-prescribing of non-therapeutic meds, discuss purpose of each medication with patient or caregiver, evaluate that the patient/caregiver is capable of administering medication and ensure that patient has a minimum 7 day supply of medication. The Director of Quality Outcomes reviewed the clinical record on 10/17/2025 and confirmed the findings and stated, “I am kind of glad you cited that because it gives us more evidence for what we have been working with the admission nurses about.””

“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. 3 of 22 (14%) clinical records with a hospice aide reviewed, revealed that the agency did not ensure that the written care plan for the aide included required specific instructions to the aide to meet the individual patient needs. CLINICAL RECORD 3: The patient was admitted on 09/16/2025 with a mickey button in place. The SN assessment on 09/16/2025 also indicated that the patient had a history of seizures. The plan of care dated 09/16/2025 included orders to assess the upper left abdominal quadrant around the mickey button for signs and symptoms of skin breakdown and included seizure precautions. A hospice aide was ordered on 09/21/2025 for twice per week. The aide care plan initiated on 09/24/2025 and updated on 10/13/2025, did not include notification or instruction to the aide that the patient had a mickey button or that the patient was on seizure precautions. CLINICAL RECORD 7: Patient elected hospice on 10/02/2025 with a diagnosis of chronic obstructive pulmonary disease and chronic respiratory failure. The The plan of care dated 10/02/2025 included significant interventions, safety measures and education related to oxygen safety. An aide was ordered 2 times a week for 12 weeks effective 10/05/2025. An aide care plan was developed on 10/02/2025 and updated 10/03/2025. The SN assessment described that the patient has a colostomy and ostomy supplies are included on the plan of care. The aide care plan did not mention colostomy care. CLINICAL RECORD 15: The patient elected hospice on 07/07/2025 with a diagnosis of heart failure and chronic obstructive pulmonary disease. The SN assessment noted that the patient became short of breath while talking and required oxygen. Oxygen orders and supplies were noted on the plan of care dated 07/07/2025. There was no notation related to oxygen on the aide care plan. The Director of Quality Improvement, reported “OK” and confirmed the findings in an interview and review on 10/14/2025 and stated, “We will be doing a lot of education about aide care plans again.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview, observation, and personnel record review. 1 of 10 (10%) personnel records reviewed revealed that the agency did not ensure documented competency of skills that were provided by a registered nurse. PERSONNEL RECORD (PR) 3: This RN was hired on 03/31/2025 as a case manager. Observed the RN on home visit 3 on 10/14/2025. Per clinical record 3, and home visit 3, the patient has a mickey button. PR 3 did not include any documented evidence of a competency assessment related to feeding tubes of any type. In an interview on 10/16/2025 with the Administrator and Director of Quality Outcomes, it was confirmed that the competency skills checklists did not include any competency reviews for feeding tubes. The Administrator stated, “Feeding tubes are pretty common, I can’t believe we don’t have a competency for that but we don’t, we even checked with corporate. We will put one together and everyone will be competencied by the end of the month.””

“Based on policy review, medical record review and interview, the agency failed to provide symptom control for 1 patient (#1) of 3 patients reviewed. The findings included: Review of the Patient Bill of Rights updated January 2021 revealed “;...to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness...” Medical record review revealed Patient #1 was admitted to the agency on 8/3/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Medical record review of the Hospice Certification and Plan of Care dated 8/3/2023 to 10/31/2023 revealed a physicians order for Morphine 100 mg/5 ml (milliliters) 0.25 ml every 4 hours as needed for pain or shortness of breath. Continued review revealed a goal which included skilled nurse (SN) to assess patient for respiratory changes and promptly initiate interventions to quickly minimize associated uncomfortable symptoms. Medical record review of Patient #1’s medication profile dated 8/3/2023, revealed the Morphine Sulfate was listed as a current medication. Medical record review of the Hospice Recertification Plan of Care Update dated 10/18/2023 for the certification period dated 11/1/2023 to 1/29/2024 revealed the physician ordered a “;Comfort Kit” which included Morphine Sulfate 20mg/ml – may take 0.25 ml by mouth or under the tongue every 4 hours as needed for moderate to severe pain or shortness of breath. Medical record review of the medication profile provided to the physician on 10/18/2023 revealed the Morphine Sulfate was listed on the medication profile as current. Medical record review of the SN (skilled nurse) note dated 11/15/2023 revealed the patient had 7 days of medications on hand and no refills were needed. Further review revealed the patient resided in a nursing facility and the facilitys current medication list was accurate. Continued review revealed the facility managed all controlled drugs. Further review revealed the patient was in bed with the oxygen off, curled into a fetal position, responded slowly to verbal/tactile stimuli, and complained of shoulder pain but was unable to rate the pain level. Her hands were cool, and fingertips were dusky. Oxygen turned on and applied at 3 liters/minute via nasal cannula. The patient had a persistent non-productive cough during visit. The oxygen saturation increased to 87% then to 93% with a pulse of 100. The patient had very poor air movement in the left lung lobes and diminished in the right lobes. The patient dozes off during the visit. The patient continues to smoke cigarettes and lung sounds were decreased in the mornings. Medical record review of Patient #1’s physician order dated 11/16/2023 revealed the facility requested a Hospice visit on 11/17/2023 due to increased lethargy and pain. Medical record review of a Patient #1’s physician order dated 11/17/2023 revealed the a nursing visit order due to patients decline. Medical record review of a SN visit dated 11/17/2023 revealed the patient was lying in bed, using accessory muscles for breathing and oxygen saturation was 90% on 3 liters of oxygen. Lung sounds were “;wet with crackles”. The patient had “;thick sputum white/yellow in color caking mouth and teeth”. The SN provided oral care. Heart rate was 133. The patient was encouraged to take slow deep breaths. A request was made to the physician for antibiotics. Medical record review of a Client Coordination Note dated 11/18/2023 revealed a call was received to notify Hospice that the patient was “;imminent” and morphine needed to be ordered. The facility was notified a skilled nurse visit would be made to assess the patient. Medical record review of a physicians order dated 11/18/2023 revealed the agency requested Morphine Sulfate on 11/18/2023 at 7:53 AM. Further review revealed the physician signed the order on 11/18/2023 at 10:51 AM. Medical record review of a SN note dated 11/18/2023 at 12:26 PM revealed a late entry was added for 7:45 AM. Continued review revealed the facility contacted the hospice and stated the patient needed Morphine and was imminent. The physician was notified, and the medication was to be pick up at approximately 11:45 AM and delivered to the facility. Upon the SNs arrival to the facility the patient had expired at 8:45 AM and the Morphine Sulfate was not available to the patient. Medical record review of a Client Coordination Note dated 11/18/2023 revealed the patient had expired before the nurses arrival. The funeral home had retrieved the body. The facility registered nurse declared the patient expired at 8:45 AM. The Morphine Sulfate did not arrive prior to patients death. Review of documentation provided by the agency dated 11/18/2023 revealed the comfort kit was not available at the facility at the time of active decline. Facility stated they requested a comfort kit on 11/17/2023 but the nurse who made the visit denied the facility requested a comfort kit. On the medication profile Morphine Sulfate was listed but the order was never sent to the pharmacy to be filled. Further review revealed this was a service failure and processes were not followed at admission to ensure medications were at the facility post admission. Review of documentation provided by the agency dated 11/20/2023 revealed the governing body and QAPI (quality assurance performance improvement) was notified of the service failure for Patient #1 due to the comfort kit not available to patient. Review of documentation provided by the agency dated 1/4/2024 revealed the agency administration met with Patient #1s family to discuss the service failure related to medications not available at the facility. Continued review revealed the agencys case manager (registered nurse) did not ensure medications ordered by the physician was at the facility. The SN who saw the patient on 11/17/2023 did not ensure the Morphine Sulfate was available after noting active decline. The agency provided re-education one on one to both staff and entire team. Interview with the Director of Clinical Services on 4/23/24 at 11:30 AM, in the conference room, revealed the RN who admitted the patient did not send the prescription for Morphine or Comfort Kit to the pharmacy. Continued interview revealed the patient was on PO (by mouth) pain medications and did not need the Morphine until 11/17/2023. Further interview revealed no one checked with the facility to ensure Morphine was available if needed. The SN who saw the patient on 11/17/2023 and noted the decline did not check with the facility to ensure the Morphine was available. The patient had been diagnosed with Covid 19 approximately 1 week before death. Further interview revealed the patient had been active until 11/17/2023 and continued to go outside to smoke cigarettes. During an interview on 4/23/2024 at 11:45 AM, the Director of Clinical Services confirmed the facility did not have access to the patient’s Morphine due to the pharmacy never received the order.”

“Based on medical record review and interview, the agency failed to provide 24 hour nursing services for 1 patient (#1) of 3 patients reviewed. The findings included: Medical record review revealed Patient #1 was admitted to the agency on 8/3/2023 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure. Medical record review of a skilled nurse (SN) note dated 11/15/2023 revealed the patient resided in a nursing facility Further review revealed the patient was in bed with the oxygen off. She was curled into a fetal position. She responded slowly to verbal/tactile stimuli. She complained of shoulder pain but was unable to rate the pain level. Her hands were cool, and fingertips were dusky. Oxygen turned on and applied at 3 liters/minute via nasal cannula. The patient had a persistent non-productive cough during visit. The oxygen saturation increased to 87% then to 93% with a pulse of 100. The patient had very poor air movement in the left lung lobes and diminished in the right lobes. The patient dozes off during the visit. The patient continues to smoke cigarettes and lungs were usually decreased in the mornings. Medical record review of a SN visit dated 11/17/2023 revealed the patient was lying in bed, using accessory muscles for breathing. The oxygen saturation was 90% on 3 liters of oxygen. Lung sounds were “;wet with crackles”. The patient had “;thick sputum white/yellow in color caking mouth and teeth”. The SN provided oral care. Heart rate was 133. The patient was encouraged to take slow deep breaths. A request was made to the physician for antibiotics. Medical record review of a Client Coordination Note dated 11/18/2023 revealed a call was received to notify Hospice that the patient was “;imminent” and morphine needed to be ordered. The facility was notified a skilled nurse visit would be made to assess the patient. Medical record review of a physicians order dated 11/18/2023 revealed the SN requested an order for Morphine on 11/18/2023 at 7:53 AM. Further review revealed the physician signed the order on 11/18/2023 at 10:51 AM. Medical record review of a SN note dated 11/18/2023 at 12:26 PM revealed a late entry was added for 7:45 AM. Continued review revealed the facility contacted the hospice and stated the patient needed Morphine and was imminent. The physician was notified, and the medication was to be pick up at approximately 11:45 AM and delivered to the facility. Upon the SNs arrival on 11/18/2023 at 12:26 PM to the facility the patient had expired at 8:45 AM and the Morphine Sulfate was not available to the patient. Medical record review of a Client Coordination Note dated 11/18/2023 revealed the patient had expired before the nurses arrival. The funeral home had retrieved the body. The facility registered nurse declared the patient expired at 8:45 AM. The Morphine Sulfate did not arrive prior to patients death. The family contacted the agency via telephone and condolences given. The daughter vocalized extremely upset with situation due to facility and self being unable to get through to answering service. Review of documentation provided by the agency dated 11/18/2023 revealed the nursing home facility was unable to contact the On-Call registered nurse to report patients death due to transition from one answering service to another answering service. Review of documentation provided by the agency dated 11/20/2023 revealed the governing body and QAPI (quality assurance performance improvement) was notified of the service failure for Patient #1 due to the change in the answering service. Continued review revealed Emergency Operations Plan Activated which included all patients were contacted and provided an alternate contact to the on-call RNs direct cellular number. Review of documentation provided by the agency dated 1/4/2024 revealed the agency administration met with Patient #1s family to discuss the service failure related to the new answering service. Interview with the Executive Director on 4/23/2024 at 11:30 AM, in the conference room, revealed the answering service started having problems on Friday 17, 2023. The problems included long wait times, no answer to telephone calls and contacting staff members who were not on call. Continued interview revealed the agency became aware of the problems approximately 5 hours after the problems started. She stated the emergency action plan was put into place at that time which included calling all of the patients and giving them the on-call cell phone numbers to contact the on-call nurse if the answering service was unable to help them. The answering service concerns were taken to the Governing Body and QAPI (quality assurance performance improvement). The answering service has been monitored by the staff by calling at all hours to make sure they are answering the telephones in a timely manner. Further interview revealed no other complaints have been brought to her attention since 11/18/2023 with the answering service. Interview with the Executive Director on 4/23/2024 at 11:45 AM confirmed the on call answering service was not taking all calls for approximately 5 hours and resulted in Patient #1 not receiving her medication or support.”