Hospice Compassus - the Woodlands

“It is required that the comprehensive assessment include an initial bereavement assessment of the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement risk assessment. Clinical Record 16: The patient elected the hospice benefit on 11/08/2024. The initial Registered Nurse (RN) comprehensive assessment was documented on 11/08/2024, the initial Social Work (SW) assessment was documented on 11/11/2024, and the initial Spiritual Counseling (SC) assessment was documented on 11/12/2024. The RN, SW, and SC assessments and visit notes did not include evidence of an initial bereavement risk assessment. The initial bereavement risk assessment was completed on 12/06/2024, with 28 days outstanding. Clinical Record 18: The patient elected the hospice benefit on 02/18/2024. The initial RN comprehensive assessment was documented on 02/18/2024, and the initial Spiritual Counseling visit was documented on 02/20/2024. The RN and SC assessment and visit notes did not include evidence of an initial bereavement risk assessment. The initial SW assessment was completed on 02/26/2024, which was past the initial five-day requirement; however, there were documented calls by the SW with attempts to contact the family. The initial bereavement risk assessment was completed on 02/27/2024, with nine (9) days outstanding. During interviews on 07/02/2025 and 07/03/2025, the Director of Clinical Services confirmed the late initial bereavement risk assessments. The Director of Clinical Services stated that a process needed to be developed for such situations.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included patient and family goals for identified problems. Clinical Record 4: The patient elected hospice care on 05/27/2025 with diagnoses of malignant neoplasm of bronchus or lung and sarcoidosis. On 06/19/2025, an ‘as needed’ (PRN) visit was completed by the Registered Nurse (RN) because the patient was experiencing increased congestion, shortness of breath, and an oxygen saturation reading of 86% on room air. On 06/20/2025, the RN visit note documented that the patient’s oxygen reading on room air was 90-91% and with oxygen administered at 2 liters per minute via nasal cannula, the readings rose to 92-94%. The RN visit note dated 06/23/2025 documented that the patient was lethargic and exhibited a productive cough, which the patient described as painful. The RN documented recommending that the patient’s daughter administer cough syrup and a nebulizer treatment to the patient. A physician’s order dated 06/23/2025 ordered “Lactulose 10gm/15ml - take 30ml by mouth daily as needed for constipation” and “Albuterol 1.25mg/3ml - 3ml inhalation/nebulized every 4 hours as needed for shortness of breath or wheezing.” On 06/25/2025, the skilled nurse (SN) documented that the patient’s daughter reported that her mother’s oxygen readings the previous night were 86-87%, so she placed oxygen on the patient, which raised their oxygen level to 98% and that the patient had not had a bowel movement in 5 days. The SN instructed the patient’s daughter to administer Lactulose to her mother as ordered. The RN visit note dated 06/27/2025 documented that the patient’s last bowel movement had been on 06/20/2025, so the patient’s daughter was instructed to give Lactulose during the day and 2 Senna tablets at bedtime until the patient has a bowel movement. A physician’s order dated 06/27/2025 ordered “Geri-Tussin DM 10mg-100mg/5ml - take 10ml by mouth every 4 hours as needed for cough or congestion.” The patient was assessed for impaction during the RN’s visit on 06/29/2025, and the patient allowed the nurse to remove stool from the rectal vault. The RN documented that a 10mg Bisacodyl suppository was administered during the visit and noted that the patient’s usual bowel habits were every three days. The patient’s medication profile included an order dated 05/28/2025 for Miralax 17gm by mouth daily, Bisacodyl 10mg suppository per rectum as needed daily for constipation, and Senna Laxative 8.6mg tablets - two (2) tablets by mouth each night at bedtime. During the Interdisciplinary Group Meetings (IDG) documented on 06/10/2025 and 06/24/2025, the RN did not report the patient’s problems with constipation or respiratory congestion, including decreased oxygen saturations. The medications ordered were accompanied by their respective indications. A problem was identified on admission regarding comfort, which included setting a goal for the patient or caregiver to understand symptom scales, learn how to manage symptoms, and report changes to the hospice when symptoms occurred. Interventions included medication reconciliation, assessment of signs and symptoms of death, and instruction on symptom management throughout the dying process, as well as monitoring of shortness of breath level using the appropriate shortness of breath scale. The identification of the patient’s constipation problem was documented on the plan of care with the medication order. There were no goals documented for the patient’s identified problems and treatments for the respiratory and constipation problems the patient was experiencing. Clinical Record 8: The patient elected hospice care on 02/10/2025 with diagnoses of cerebral infarction, unspecified, and moderate protein-calorie malnutrition. The SN visit note dated 04/17/2025 documented that, per the caregiver report, the patient had been having a bowel movement every 3 days but also experienced some complaints of abdominal discomfort. The physician was consulted, and an order was received for “Senna 8.6mg tablets, one (1) tablet daily as needed for constipation.” The SN visit note dated 05/01/2025 documented that the caregiver reported the patient’s urine had a strong odor, and the patient complained of burning and pain with urination. The patient was also experiencing intermittent hallucinations, so the physician was contacted and an order was received for “Cipro 250mg by mouth twice daily for 5 days” for a urinary tract infection (UTI). The SN visit note dated 05/07/2025 documented that the caregiver reported that the patient was more confused and was attempting to get out of bed due to restlessness. The physician was contacted, and an order received for “Lorazepam 0.5mg by mouth every 4 hours as needed for anxiety was recorded. On 06/07/2025, the SN visit note documented that the patient had not had a bowel movement in 4-5 days. When the physician was notified, an order was received for “Bisacodyl 10mg suppository to be given per rectum daily as needed for constipation.” The problems of the patient’s constipation, anxiety, and the patient’s urinary tract infection were identified on the plan of care within the medication indications on the physician’s orders. During the Interdisciplinary Group Meeting (IDG) on 05/13/2025, the SN documented that lorazepam had been added to the plan of care for anxiety and that since the last IDG, the patient experienced a UTI. The patient’s bowel problems were addressed during the IDG on 06/10/2025, with the SN documenting that they encouraged the patient’s caregiver to “administer Senna due to an unknown date of the last bowel movement. There were no goals documented for the patient’s identified problems and treatments for constipation, the urinary tract infection, and anxiety. Clinical Record 13: The patient elected hospice care on 01/25/2025 with diagnoses of Alzheimer’s Disease and vascular dementia without behaviors/mood. The RN visit note dated 04/10/2025 documented that the patient’s last bowel movement was on 04/06/2025. The physician was notified. A physician’s order dated 04/10/2025 ordered “Lactulose 10gm/15ml - 15ml daily as needed for constipation, Senna Plus 2 tablets by mouth twice a day, and Bisacodyl 10mg suppository rectally daily as needed for no bowel movement in 3 days.” The RN visit note dated 04/15/2025 documented that the patient’s usual bowel pattern was every 3 days, and per the patient’s caregiver, the patient had not had a bowel movement in more than 4 days. Additionally, the RN documented that a suppository was administered during the visit, and the patient’s urine had a strong smell. The physician was notified, and an antibiotic order was received on 04/16/2025 for Macrobid 100mg by mouth twice daily for 5 days for a urinary tract infection. The SN visit note dated 05/01/2025 documented that the patient’s left shoulder was red and warm. The physician was notified, and an order for Keflex 250mg by mouth three times daily for cellulitis was received. On 06/07/2025, the SN visit note documented that the patient’s husband reported that the patient had “another” episode of diarrhea the previous night. A physician’s order dated 06/07/2025 ordered loperamide 2mg tablets, one (1) tablet by mouth twice a day as needed for diarrhea. The SN documented that another dose of loperamide 2mg was recommended. During the Interdisciplinary Group Meeting (IDG) 04/15/2025, the RN reported an increase in the patient’s Senna, and a new order for Lactulose was added to the plan of care. During the IDG Meeting on 04/29/2025, the RN noted that the patient’s husband was not administering the stool softener and laxative as ordered. On 05/13/2025, during the IDG Meeting, the RN noted only a “skin infection”. The IDG Meetings for 05/27/2025 and 06/11/2025 did not include a discussion regarding the patient’s bowel habits or infections. A problem labeled as comfort was identified in the patient’s plan of care dated 01/25/2025, with the goal of assessing the patient’s skin integrity for potential problems, addressing measures to prevent skin breakdown, and implementing interventions promptly, as evidenced by assessments of skin breakdown at each visit. The patient’s problems with constipation and urinary tract infection on were identified with the medication indications on the physician order and the note in the IDG Meeting dated 04/29/2025, in which the nurse addressed that the spouse was not administering the bowel regimen as ordered. Cellulitis was noted as an indication for the medication ordered, and “skin infection” was identified during the IDG Meeting on 05/15/2025. There were no goals documented for the patient’s identified problems and treatments for constipation,/diarrhea, or the two infections: urinary tract and cellulitis. During a joint clinical record review and interview on 07/03/2025, the Director of Clinical Services confirmed that there were no goals identified for the problems listed in Clinical Records 4, 8, and 13 in the patients’ plans of care.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the 2024 volunteer program revealed an average volunteer contribution of 3.73% for the calendar year of 2024. Due to volunteer percentages falling below the 5% threshold, a Volunteer QAPI Performance Improvement Project was initiated in February 2025, following the January and February 2025 percentages of 2.63% and 3.08%, respectively. During the joint document review and interviews conducted on 07/01/ 2025 and 07/02/2025, the Volunteer Coordinator (hired in 08/2024) and the Hospice Executive of Clinical Operations confirmed the evidence and the implementation of strategies and ongoing efforts to support volunteer engagement. A review of the 2024 volunteer program revealed an average volunteer contribution of 3.73% at year’s end. Due to volunteer percentages falling below the 5% threshold, a Volunteer QAPI Performance Improvement Project was initiated in February 2025, following the January and February 2024 percentages of 2.63% and 3.08%, respectively. Since its inception, the QAPI PIP and volunteer metrics have been monitored monthly, with documented efforts to enhance recruitment through outreach to seminaries, participation in career fairs, posting flyers at libraries and churches, and collaborating with a pet therapy program. Retention activities included face-to-face encounters, phone calls, and educational initiatives. Interviews conducted on July 1, 2025, with the Volunteer Coordinator, hired in August 2024, and on July 2, 2025, with the Hospice Executive of Clinical Operations, confirmed the evidence and implementation of these strategies, as well as ongoing efforts to support volunteer engagement.”