Every finding on record at Compassus of Indiana I, LLC

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: Medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed the agency did not ensure that all medical supplies and appliances necessary to meet the needs of the patient were included in the patient's individualized written plan of care. CLINICAL RECORD 9: The patient elected the hospice benefit on 12/07/2023. A physician's order dated 11/11/2024 read in part "Oxygen 2 liters via nasal cannula as needed for comfort". The plans of care dated 12/01/2024 through 01/29/2025, 01/30/2025 through 03/30/2025, 03/31/2025 through 05/29/2025, 05/30/2025 through 07/28/2025, and 07/29/2025 through 09/26/2025 did not include documentation of the patient's oxygen supplies. The plan of care dated 09/27/2025 through 11/25/2025 was updated on 10/07/2025 to include the patient's oxygen supplies. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/08/2025. The plan of care dated 04/08/2025 through 07/06/2025 included an order for a foley catheter. The plan of care lacked documentation of the patient's foley catheter supplies. During joint record reviews and interview on 10/06/2025 and 10/08/2025, the Area Executive of Clinical Operations (Personnel Record 1) confirmed the above findings that foley catheter supplies and oxygen supplies were not included in the patients plans of care.

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. In 1 of 8 (12%) clinical records reviewed with hospice aide services provided the agency did not ensure that all written patient care instructions were included in the hospice aide care plan. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. A physician's order dated 09/20/2025 read in part "Place 18Fr foley catheter". The plan of care dated 09/19/2025 through 12/17/2025 ordered "Hospice Aide (HA) 2x per week starting week of 09/21/2025". The first Hospice Aide visit was dated 09/22/2025. The Hospice Aide care plan dated 09/19/2025 was not updated to include foley catheter care instructions. During a joint record review and interview on 10/08/2025, the Area Executive of Clinical Operations (Personnel Record 1) confirmed the above finding that the hospice aide care plan did not include foley catheter care instructions.

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 a review of clinical records and interviews. 4 of 11 (36%) records reviewed revealed that the agency did not ensure that medication profiles were complete and updated. Clinical Record 5: The patient was admitted 11/10/2022 with the diagnosis of Senile Degeneration of the Brain. The comprehensive assessment documents in part, "Oxygen at 2.5L per nasal cannula." The plan of care dated 11/10/2022 includes oxygen supplies and equipment, assessment of respiratory status, and orders to obtain O2 saturation levels per pulse oximeter. The medication profile does not include oxygen from 11/10/2022 through 11/15/2022. Orders for oxygen were received on 11/15/2022 and oxygen placed on medication profile on 11/15/2022. Clinical Record 8: The start of care (SOC) comprehensive assessment (4/28/22) documented that patient was using oxygen at 8 L/M (liters per minute) per nasal cannula (NC). Oxygen is not included on the medication list from 4/28/2022 to 5/21/2022 (the patient's date of death) Clinical Record 9: The patient's SOC was 4/18/2022. The nursing visit note on 4/19/2022 documented that patient is using oxygen per NC. Oxygen is not included on medication profile. Clinical Record 10: The comprehensive assessment on the SOC date of 5/24/2022 documented that patient is on continuous oxygen. An order dated 5/26/2022 states, "May increase oxygen to 5L/M per NC for comfort. The medication profile does not include oxygen until 5/28/2022. The Director of Nursing stated in interview on 11/22/2022, " I am starting a PIP (performance improvement project) on that now." 4 of 11 (36%) of clinical records reviewed reveal that the agency did not ensure that medication profile were complete and updated.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (9%) records reviewed revealed that the agency did not ensure that the plans of care specified care and services necessary to meet the patients' specific needs. Clinical Record 5: The patient was admitted on 11/10/2022 with the diagnosis Senile Degeneration of the Brain. The start of care (SOC) comprehensive assessment reads in part, "Oxygen at 2.5L per nasal cannula." The plan of care dated 11/10/2022 includes orders for oxygen supplies and equipment, assessment of respiratory status, and orders to obtain O2 saturation levels per pulse oximeter. The medication profile does not include oxygen. The plan of care does not include the use of oxygen. Clinical Record 10: The comprehensive assessment at the SOC on 5/24/2022 documented that the patient is using a CPAP (Continuous positive airway pressure) machine and oxygen at 2.5 L/M (liters per minute) per NC (nasal cannula). The plan of care dated 5/24/2022 does not include the use of a CPAP machine and does not provide detail related to the amount of oxygen. The plan of care orders, "SN to instruct and monitor use of oxygen" but does not include information related to the rate of flow. Interview Director of Nursing and Administrator stated in interview on 11/26/2022, "We will do some more nurse education." 2 of 11 (9%) of records reviewed revealed that the agency did not ensure that the plan of care specified care and services necessary to meet the patient's specific needs.

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 a review of clinical records and interviews. 4 of 11 (36%) records reviewed of patients with hospice aide services revealed the agency did not ensure the aide care plan was specific and clear to allow the aide to practice within their scope of practice. Clinical Record 5: The skilled nursing (SN) assessment dated 11/10/2022 reads in part, "Oxygen at 2.5 L per nasal cannula". Oxygen is not included on the aide care plan dated 11/10/2022. Clinical Record 4: The patient was admitted on 5/2/2022. The comprehensive assessment notes in part, "Foley catheter to be inserted at next visit." The SN note, dated, 5/3/2022 reads in part, "Foley catheter inserted". The plan of care dated 5/2/2022 prescribes insertion of foley catheter. The aide care plan dated 5/2/2022 does not include foley catheter care. As of the date of review, 11/21/2022, there have been no updates to aide care plan. Clinical Record 10: The comprehensive assessment at the start of care (5/24/2022) documented that the patient is using oxygen at 2.5L/M per nasal cannula. The aide care plan dated 5/24/2022, with an update 5/25/2022, does not include information that patient is on oxygen. Clinical Record 11: The comprehensive assessment at the start of care (3/30/22) documented that patient has a urostomy. The aide plan of care dated 3/30/2022, with updates on 4/9/22 and 4/11/22, does not include any information related to patient having a urostomy. The Director of Nursing stated in interview on 11/22/2022, "We will do more training on this with the nurses." 4 of 11 (36%) of records reviewed with aide services revealed the agency did not ensure the the aide care plan was specific and clear to allow the aide to practice within the scope of practice.