Compassus - Fort Worth

“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 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, interview, and observation. In 1 of 14 (7%) clinical record reviews and home visits observed, the hospice did not ensure the patient’s comprehensive assessment included a drug profile containing the patient’s current medications. CLINICAL RECORD 6/HOME VISIT 2: The patient elected the hospice benefit on 11/01/2024 with a diagnosis of unspecified sequelae of nontraumatic subarachnoid hemorrhage. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 08/05/2026, the patient’s hospice medication profile was compared to the ALF medication profile. The hospice medication profile documented Eliquis 5mg, twice daily. The ALF medication profile documented Eliquis 2.5mg once daily, effective 03/01/2025-current. The hospice medication profile documented fluconazole 200mg tablet, once daily. The ALF medication profile did not document fluconazole as an active medication. The RN [Personnel Record 7] was interviewed during the home visit and stated, “We should have caught that. We are supposed to reconcile their list with ours every visit.” During a joint record review and interview on 08/06/2026, the Administrator agreed that there was no documented evidence that the Registered Nurse reconciled the medications and updated the medication profile. Additionally, during an interview on 08/06/2026, the Administrator stated, “We started a PIP for this.””

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visits observed, the hospice did not ensure the Registered Nurse (RN) coordinated care with the facility. HOME VISIT 2/CLINICAL RECORD 6: The patient elected the hospice benefit on 11/01/2024 with a diagnosis of unspecified sequelae of nontraumatic subarachnoid hemorrhage. The patient resided in an assisted living facility (ALF).The Registered Nurse comprehensive assessment dated 04/17/2026 documented a stage 2 pressure ulcer on the patient’s mid-upper back. During the home visit with the RN [Personnel Record 7] on 08/05/2026, wound care for the wound was observed. The Hospice and Facility Coordinated Plan of Care located in the patient’s hospice binder at the ALF did not include documentation of the wound. The wound section was blank. During an interview, the RN [Personnel Record 7] stated, “The facility doesn’t do wound care; we do.” A review of the ALF treatment orders revealed that the ALF provided wound care to the patient’s mid-upper back wound, scheduled twice weekly and as needed. The ALF RN was interviewed and stated, “I am not sure if the hospice does wound care; we do, though.” The RN [Personnel Record 7] stated during an interview, “We need to collaborate with the facility. This would explain why it was already done when I came recently. This is outdated. I can get it updated.” During a joint record review and interview on 08/06/2026, the Administrator agreed that there was no documented evidence that a Registered Nurse coordinated care related to the wound care needs. Additionally, during an interview on 08/06/2026, the Administrator stated, “We’ve had such a change in staff I don’t think all nurses understood how and when to update the form.””

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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, observation, and interview. In 4 of 13 (31%) clinical records reviewed and home visits observed, the hospice did not ensure that the patient’s plan of care reflected patient and family goals and included planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 4/HOME VISIT 1: The patient elected the hospice benefit on 09/17/2024 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). The Registered Nurse (RN) comprehensive assessment dated 05/13/2026 documented a blood blister on the patient’s right posterior foot. During the home visit with the Hospice Aide [Personnel Record 8] on 08/05/2026, the patient had an approximately quarter-size open blister. The plans of care (POC) dated 05/13/2026 through 08/05/2026 did not identify goals for the wound identified in the comprehensive assessment. CLINICAL RECORD 6/HOME VISIT 2: The patient elected the hospice benefit on 11/01/2024 with a diagnosis of unspecified sequelae of nontraumatic subarachnoid hemorrhage. The patient resided in an assisted living facility (ALF). The RN comprehensive assessment dated 04/17/2026 documented a stage 2 pressure ulcer on the patient’s middle upper back. During the home visit with the RN [Personnel Record 7] on 08/05/2026, wound care was observed for the wound. The POCs dated 04/17/2026 through 08/05/2026 did not identify goals for the wound identified in the comprehensive assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/14/2025 with a diagnosis of senile degeneration of the brain. The plan of care ordered volunteer visits 2-4 times monthly starting 12/08/2025. Three visits were completed in December 2025, and two in January 2026. The POCs dated 12/01/2025 through 01/31/2026 did not include interventions or goals for volunteer services. CLINICAL RECORD 13: The patient elected the hospice benefit on 07/29/2025 with a diagnosis of unspecified sequelae of cerebral infarction. The RN comprehensive assessment dated 07/29/2025 documented that the patient was a high fall risk. The POCs dated 07/29/2025 through 09/17/2025 (death) did not identify planned interventions to address the patient’s high risk for falls. During a joint record review and interview on 08/06/2026, the Administrator agreed that there was no documented evidence that the plans of care included the problems identified with planned interventions and goals. Additionally, during an interview on 08/06/2026, the Administrator stated, “We started a PIP for this.””

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy “Infection Control: Bag Technique and Standard Precautions” stated in part, “When to use hand gel (sanitizer): Before donning gloves and after removing gloves, moving between clean and contaminated body surfaces/sites, after contact with inanimate objects in the patient’s environment, before and after entering your bag.” In 1 of 3 (33%) home visits observed, the hospice did not ensure that hand hygiene was performed when indicated per the agency’s policy. HOME VISIT 2: During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 08/05/2026, the RN donned gloves, removed the soiled wound dressing from patient’s middle upper back, entered their nursing bag and removed a measuring tape, removed their gloves, reached into their nursing bag, put on new gloves, sprayed the patient’s wound and wiped it off with gloved hands and gauze, and applied the border dressing, The RN did not wash or sanitize their hands after removing their gloves and before donning new gloves. The RN did not wash or sanitize their hands when moving from the dirty wound to the clean wound. The RN did not wash or sanitize their hands prior to reentering their nursing bag. During a joint review of the Bag Technique and Standard Precautions policy and interview on 08/06/2026, the Administrator agreed that the RN did not follow the agency policy for hand hygiene.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the hospice did not ensure that the discharge summary was sent to the patient’s attending physician. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/30/2025 and discharged, no longer terminally ill, on 11/03/2025. There was no documented evidence that the discharge summary was sent to the patient’s attending physician. During a joint record review and interview on 08/06/2026, the Administrator agreed that there was no documented evidence that the discharge summary was sent to the patient’s attending physician.”