Hospice Compassus

“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, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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, observation, and interview. 3 of 6 (50%) observed home visits revealed the agency did not ensure medication reconciliations were completed and medications updated to the medication profiles. HOME VISIT 1/CLINICAL RECORD 1: The patient’s date of election of the hospice benefit was 12/10/2024. The hospice medication profile, printed on 03/16/2026, listed Hydrocodone 5 mg-Acetaminophen 325 mg tablet, take 1 tablet orally every 6 hours as needed for pain, dated 08/07/2025; and Oxycodone 5 mg tablet, take 1 tablet 2 times daily orally, dated 08/07/2025. During the observed home visit on 03/17/2026 with the Medical Social Worker (Personnel Record 9), the hospice medication profile was compared with the group home medication list. The medication list at the group home included Oxycodone 5 mg tablet, take 1 tablet orally 4 times a day, started 12/03/2025. The group home director reported that Hydrocodone-Acetaminophen was discontinued in December 2025 when Oxycodone was started. The hospice clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when a new medication was added or when changes were made to existing medications. HOME VISIT 4/CLINICAL RECORD 12: The patient’s date of election of the hospice benefit was 12/02/2025. The hospice medication profile, printed on 03/18/2026, listed Levocetirizine 5 mg tablet, take one tablet orally at bedtime dated 03/13/2024; and Montelukast 10 mg tablet, take one tablet orally daily dated 03/13/2024. During the observed home visit on 03/18/2026 with the Registered Nurse (Personnel Record 8), the medications in the home were reviewed. Claritin 10 mg tablet, take one tablet by mouth in the morning, started approximately 3 weeks prior; Azo D-Mannose, take two capsules daily, started 4 months prior; and Azo Cranberry 1 capsule daily, started 4 months prior; these were not listed on the hospice medication profile. The patient’s caregiver stated that the Levocetirizine and Montelukast were stopped 3 months ago. The caregiver also stated that the Claritin was started for seasonal allergies, and the Azo D-Mannose and Azo Cranberry were started after the patient had bladder infections. The clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when new medications was added or when changes were made to existing medications. HOME VISIT 6/CLINICAL RECORD 3: The patient’s date of election of the hospice benefit was 12/10/2024. The hospice medication profile, printed on 03/19/2026, listed Atorvastatin 40 mg tablet, take 1 tablet at bedtime orally, dated 09/02/2025; and Trazadone 50 mg tablet, take 1 tablet at bedtime orally, dated 09/02/2025. During the observed home visit on 03/20/2026 with the Hospice Aide (Personnel Record 15), the medications in the home were reviewed. The patient’s caregiver stated that the Atorvastatin was stopped when the patient went to respite in February 2025. The caregiver stated that they felt it was time to stop the medication. The caregiver stated that they give the patient 2 tablets of Trazodone every other night and that the patient has taken it this way for a while, which seems more effective for him. The clinical record lacked evidence that a medication reconciliation occurred at the time of each comprehensive assessment and/or when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 03/20/2026, the Area Executive for Clinical Operations confirmed that there was no documented evidence the medications were reconciled at the time when new medications were added, or changes were made to existing medications.”

“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. 3 of 6 (50%) home visit observations revealed the agency did not ensure the staff followed the agency’s hand hygiene policy. Agency Policy: “Infection Control: Bag Technique and Standard Precautions”, procedure number IPC.11_A2, last reviewed 09/19/2025, stated in part, “When washing hands with soap and water. Wet your hands with clean running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails for at least 20 seconds. Do you need a timer? Hum the “Happy Birthday” song from beginning to end twice. Rinse your hands well under clean, running water. Dry your hands using a clean paper towel or air-dry them. Faucet to be turned off with paper towel used to dry hands. If the air-dry method is used, turn faucet off with elbows, hands up no contact to face or hair. Repeat process 1-5, before and after patient contact, before and after entering your bag, before and after donning and doffing gloves, before and after any patient procedure, or after contact with inanimate objects in the patient environment.” HOME VISIT 2: During the observed home visit on 03/17/2026 with the Registered Nurse (RN - Personnel Record 7), the RN was observed to wash the hands with soap and water, rinsing the hands, turning off the faucet with wet hands, and dried the hands with paper towels. The RN did not use paper towels to dry hands and then turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. HOME VISIT 4: During the observed home visit on 03/18/2026 with the RN (Personnel Record 8), the RN was observed to wash the hands with soap and water, rising the hands, turning off the faucet with wet hands, and dried the hands with a hand towel that was hanging on the towel holder on the wall. The RN did not use paper towels to dry hands and turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. HOME VISIT 6: During the observed home visit on 03/20/2026 with the Hospice Aide (HA - Personnel Record 15), the HA was observed to wash the hands with soap and water, turn off the faucet with wet hands, open the hall closet with wet hands, remove a clean towel, and dry the hands. The HA did not use paper towels to dry the hands and turn off the water, nor turn off the faucet with the elbow and air-dry the hands in accordance with policy. During an a joint document review and interview on 03/20/2026, the Area Executive for Clinical Operations agreed the staff did not follow the hand hygiene policy.”

“It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by document review, interview and personnel record review. 2 of 2 (100%) personnel records of hospice aides (HA) reviewed revealed the agency did not ensure that competency evaluations were completed prior to the HAs performing care independently. Agency Policy: UNV-P01 “Management and Staff Training” policy number UNV-P01, last reviewed 12/26/2024, stated in part, “Direct Care colleagues will receive a competency evaluation aimed at the discipline-specific skills or behaviors necessary for effective care delivery at the conclusion of the onboarding process...Hospice Aides (HA’s) will also receive observed skills evaluation prior to independent care to verify the aide can satisfactorily provide patient care services.” PERSONNEL RECORD 13: The HA’s date of hire was 05/07/2024. There was no documented evidence that a skills competency evaluation was completed on hire in accordance with policy. An attestation statement had been entered in the HA’s record in December 2025 stating that the initial competency was not found during a mock audit. There was a documented initial competency evaluation, completed on 03/16/2026, and entered in the record. PERSONNEL RECORD 15: The HA’s date of hire was 04/15/2024. There was no documented evidence that a skills competency evaluation was completed on hire in accordance with hospice policy. An attestation statement had been entered in the HA’s record in December 2025 stating that the initial competency was not found during a mock audit. There was an initial competency evaluation, completed on 03/16/2026, and entered in the record. During a joint personnel record and document review and interview on 03/19/2026, the Business Office Manager (BOM) agreed that the employees did not have the initial competency documentation required by hospice policy. The BOM stated that a mock audit discovered the competencies were missing. An attestation was used to document the record audit and the items that were missing in December 2025. The BOM confirmed that the initial competencies for both hospice aides were not completed and entered into the records until 03/16/2026. During a joint record review and an interview on 03/20/2026, the Area Executive of Clinical Operations agreed, there was no documented evidence a hospice aide skills competency evaluation was completed at hire for the 2 hospice aides.”