Every finding on record at Compassus of Kansas I, LLC

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 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; [and] 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 measures 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 and interview. In 1 of 14 (7%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 01/24/2024 with a diagnosis of cerebral infarction. The patient revoked the hospice benefit on 03/15/2025 and was readmitted on 03/17/2025. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse [Personnel Record 3] on 09/02/2025, the hospice medication profile, printed on 09/02/2025, was compared with the SNF medication list (printed on 09/02/2025). Amiodarone 200 mg tablet, take daily (ordered 01/24/2024), which was documented on the hospice medication profile, was not documented on the SNF medication list. The SNF medication list documented the following medications that were not documented on the hospice medication profile: acetaminophen rectal suppository 650 mg, 1 every 4 hours as needed (ordered 03/25/2025); bisacodyl 10 mg suppository, 1 every 24 hours as needed (ordered 03/25/2025); Milk of Magnesia 400 mg/5 ml, 30 ml every 12 hours as needed (ordered 03/25/2025); and multivitamin, 1 tablet daily (ordered 06/04/2025). Additionally, the hospice medication profile documented morphine 0.25 ml every hour as needed (ordered 06/10/2025), and the SNF medication list documented morphine 0.25 ml every two hours as needed (ordered 06/09/2025). The last comprehensive skilled nursing visit was completed five days ago. During a joint clinical record review and interview on 09/04/2025, the Area Clinical Officer confirmed the findings and advised that the medications should be reconciled with every nursing visit.

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 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services and home visits observed, the agency did not ensure that the HA received written patient care instructions from the Registered Nurse (RN) to meet the patient's needs. CLINICAL RECORD 2/HOME VISIT 2: The patient elected hospice care on 01/24/2024 with a diagnosis of cerebral infarction, revoked the hospice benefit on 03/15/2025, and was readmitted on 03/17/2025. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 03/17/2025 assigned the HA the relevant tasks: "Apply moisture barrier to coccyx, bed bath, dressing, HOB (head of bed) elevated, oral care, perineal care, position for comfort, relieve pressure points, shampoo, skin care, write a narrative note, provide comfort and support, RN communication for incomplete tasks, fall precautions, infection control, oxygen." On 03/25/2025, the physician ordered "Left heel wound, cover with foam dressing." On 04/09/2025, the physician ordered "Stage II coccyx covered with bordered foam dressing." On 04/17/2025, the physician ordered "Right Achilles wound, cover with hydrocolloid." On 05/09/2025, the physician ordered "Right Achilles wound, cover with xeroform, adherent bandage wrap." During the home visit with the Registered Nurse (RN) on 09/02/2025, the patient had bilateral heel protectors (moon boots) in place. The HA care plan was not updated to notify the HA of the wounds or to provide specific instructions regarding the wounds should they become soiled, dislodged, or wet during care, and when to notify the RN. Additionally, the HA care plan did not provide the aide with specific instructions for the patient's use of the heel protectors during personal care. A joint clinical record review and interview was conducted with the Area Clinical Officer on 09/04/2025, during which they confirmed that the HA care plan did not contain specific instructions for the wounds or heel protectors.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. CLINICAL RECORD 2: The patient elected hospice care on 01/24/2024 with a diagnosis of cerebral infarction. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 01/25/2024, revised 05/17/2024 and 7/31/2024, assigned the HA the relevant tasks: "assist to toilet, bathing (shower), dressing, hair care, oral care, shampoo, shaving, skin care, stand by assistance with ambulation, provide comfort and support, bleeding precautions, fall precautions, infection precautions." The revision on 05/17/2024 added "nail care." The revision on 07/31/2024 added "electric shaver." All tasks were to be completed on every visit. The HA frequency was twice weekly. The HA visit note dated 02/14/2024 documented: "Patient refused shower. Gave good bed bath instead. Needed help standing up." The HA visit note dated 03/13/2024, documented: "Patient had a good sponge bath." CLINICAL RECORD 8: The patient elected hospice care on 07/20/2025 with a diagnosis of squamous cell carcinoma of the skin, scalp, and neck. The patient resided at home. The HA care plan dated 07/20/2025, assigned the HA the relevant tasks: "fall precautions, stand by assistance with ambulation, assist to toilet, bathing-shower, shampoo, hair care, skin care, oral care, dressing, HOB (head of bed) elevated, provide comfort and support." All tasks were to be completed on every visit. The HA frequency was twice weekly. The HA visit note dated 08/18/2025 documented: "Patient had a good bed bath. Patient couldn't get to the shower, so I gave her a bath while she was on the commode." CLINICAL RECORD 14: The patient elected hospice care on 08/16/2024 with a diagnosis of hypertensive heart disease. The patient resided in a facility. The HA care plan dated 03/03/2025 assigned the HA the relevant tasks: "fall precautions, infection control, bathing-shower, shampoo, hair care, skin care, foot care, oral care, nail care, dressing, position for comfort, apply moisture barrier, transfer from bed to chair, notify RN for incomplete tasks." All tasks were to be completed on every visit. The hospice aide frequency was twice weekly. The HA visit note dated 04/08/2025 documented: "Patient had a TIA yesterday, and she wasn't feeling good, so I gave her a bed bath today because they kept her in bed." During a joint clinical record review and interview on 09/04/2025, the Area Clinical Officer confirmed the aide provided services that were "not included in the plan of care."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that a Registered Nurse supervised the Hospice Aide during an on-site visit to the patient's home, at least every 14 days. CLINICAL RECORD 6: The patient elected hospice care on 04/09/2024 with a diagnosis of hypertensive heart disease. HA services were ordered twice weekly. A clinical record review revealed the HA visit notes dated: 05/26/2025, 06/02/2025, 06/12/2025, 06/16/2025, 06/23/2025, 07/07/2025, 07/14/2025, 07/21/2025, 07/28/2025, 08/05/2025, 08/11/2025, 08/18/2025, and 08/25/2025. The Registered Nurse completed supervisory visits on 05/21/2025, 05/26/2025, 06/4/2025, 06/10/2025, 06/18/2025, 07/02/2025, 07/09/2025, 07/29/2025, 08/11/2025, 08/22/2025, and 08/28/2025. There was no evidence of a RN supervisory visit between 07/09/2025 and 07/29/2025, with 20 days outstanding. A joint clinical record review and interview was conducted with the Area Clinical Officer and Regional Quality on 09/04/2025, in which it was confirmed that the supervisory function had not been completed during that time frame.

It is required that the supervising registered nurse assesses an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but are not limited to: following the patient’s plan of care for completion of tasks assigned by the RN; creating successful interpersonal relationships with the patient and family; demonstrating competency with assigned tasks; complying with infection control policies and procedures; [and] reporting changes in the patient’s condition. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the supervising Registered Nurse (RN) assessed the HA's ability to follow the patient’s plan of care for completing tasks assigned by the RN. CLINICAL RECORD 6: The patient elected hospice care on 04/09/2024 with a diagnosis of hypertensive heart disease. A hospice physician's order and Skilled Nursing (SN) visit note dated 05/13/2025, documented the placement of a Foley catheter in the patient. On 05/14/2025, the physician ordered, and the SN visit note documented the discontinuation of the Foley catheter. HA services were ordered twice weekly. The HA care plan was updated on 05/13/2025 assigning the HA the relevant tasks: "bathing-shower, dressing, hair care, perineal care, position for comfort, routine catheter care, shampoo, skin care, stand by assistance with ambulation, empty trash, empty urinary drainage bag, companionship, provide comfort and support, bleeding precautions, fall precautions, infection control, oxygen." All tasks were to be completed on every visit. The HA care plan was not revised following the discontinuation and removal of the Foley catheter. A clinical record review revealed the HA visit notes dated: 05/26/2025, 06/02/2025, 06/12/2025, 06/16/2025, 06/23/2025, 07/07/2025, 07/14/2025, 07/21/2025, 07/28/2025, 08/05/2025, 08/11/2025, 08/18/2025, and 08/25/2025 documented "Yes (Y)" to the tasks of routine catheter care and emptying the urinary drainage bag. The Registered Nurse supervisory visits dated 05/21/2025, 05/26/2025, 06/4/2025, 06/10/2025, 06/18/2025, 07/02/2025, 07/09/2025, 07/29/2025, 08/11/2025, 08/22/2025, and 08/28/2025, the RN documented that "the plan of care was reviewed and aide was following the plan of care." During joint clinical record reviews and interviews on 09/03/2025 and 09/04/2025, the Area Clinical Officer and Regional Quality agreed that the supervisory visits "missed the removal of the Foley."

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. The volunteer program was reviewed on 09/04/2025 with the Area Clinical Officer and Volunteer Coordinator. The volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged 3.74%. The Volunteer Coordinator advised that they had "lost two high-performing volunteers who had recently returned to school but were hoping to replace them soon." A review of the volunteer program was conducted with the Area Clinical Officer and Volunteer Coordinator on 09/04/2025, during which time the volunteer percentage for the last twelve (12) months (September 2024 to August 2025) averaged to 3.74%. The Volunteer Coordinator advised he had "lost two high performing volunteers who had recently returned to school but was hoping to replace them soon."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. (L670) The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide visit notes contained documentation of the services provided. CLINICAL RECORD 6: The patient elected hospice care on 04/09/2024 with a diagnosis of hypertensive heart disease. A hospice physician's order and Skilled Nursing (SN) visit note dated 05/13/2025 documented the placement of a Foley catheter in the patient. On 05/14/2025, the physician ordered, and the SN visit note documented the discontinuation of the Foley catheter. HA services were ordered twice weekly. The HA care plan was updated on 05/13/2025 assigning the HA the relevant tasks: "bathing-shower, dressing, hair care, perineal care, position for comfort, routine catheter care, shampoo, skin care, stand by assistance with ambulation, empty trash, empty urinary drainage bag, companionship, provide comfort and support, bleeding precautions, fall precautions, infection control, oxygen." All tasks were to be completed on every visit. The HA care plan was not revised following the discontinuation and removal of the Foley catheter. A clinical record review revealed the HA visit notes dated: 05/26/2025, 06/02/2025, 06/12/2025, 06/16/2025, 06/23/2025, 07/07/2025, 07/14/2025, 07/21/2025, 07/28/2025, 08/05/2025, 08/11/2025, 08/18/2025, and 08/25/2025 documented "Yes (Y)" to the tasks of routine catheter care and empty urinary drainage bag..." During joint clinical record reviews and interviews on 09/03/2025 and 09/04/2025, the Area Clinical Officer and Regional Quality confirmed the findings. They advised that they would "Call the aide in immediately to do M&M (mentoring and monitoring) to rectify this situation, and the aide's care plan will be adjusted to remove the tasks regarding the Foley.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by a review of documents and interviews. Upon review of the agency volunteer program, it was identified that there are no active volunteers. Agency policy C20 Volunteer Services states in part, "Agency provides volunteer services under the supervision of a designated hospice colleague. Volunteers, under the supervision of the Volunteer Coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs while ensuring a minimum cost savings of 5% of the total patient care hours provided by the program's paid and contract colleagues annually." The agency has one application for a volunteer on file with no evidence of beginning onboarding. The agency does have documentation of recruitment efforts. In an interview with the Volunteer Coordinator and the Hospice Administrator, it was confirmed that there were currently no volunteers. Documents were presented that proved the agency has held community events in different locations to recruit volunteers. In August of 2022, the agency started active recruitment efforts and held 1 community event. In September 2022 the agency held 5 events, and in October 2022, three events. At these events, the volunteer coordinator gives a presentation that describes volunteer opportunities and onboarding processes, and flyers and contact information is given to the participants. Documentation was presented that showed evidence that the volunteer is required to go through orientation, and complete specific education and competencies. Clinical Record 4: SOC 9/14/2022, Dx. Hypertensive Heart Disease; while interviewing the Administrator, and talking about volunteer roles, she mentioned that the family had recently requested volunteer services. This request was not documented in the clinical record and no volunteer services were provided as of 11/2/2022. Upon review of the agency volunteer program, it was discovered that there are no active volunteers documented. Agency policy C20 Volunteer Services states in part, "Compassus provides volunteer services under the supervision of a designated hospice colleague. Volunteers, under the supervision of the volunteer coordinator, provide both patient support and administrative support in a manner and amount consistent with the program's identified needs while ensuring a minimum cost savings of 5% of the total patient care hours provided by the program's paid and contract colleagues annually." The agency has one application for a volunteer on file with no evidence of beginning onboarding. The agency does have documentation of recruitment efforts. In an interview with the Volunteer Coordinator and the Hospice Administrator it was confirmed that there were currently no volunteers. Documents were presented that proved the agency has held community events in different locations in efforts to recruit volunteers. In August of 2022 the agency started active recruitment efforts and held 1 community event. In September of 2022 the agency held 5 events, and in October 2022, three events. At these events the volunteer coordinator gives a presentation that describes volunteer opportunities and onboarding processes, flyers and contact information is given to the participants. Documentation was presented that showed evidence that the volunteer is required to go through orientation, complete specific education and competencies.

It is required that a patient clinical record containing past and current findings are maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by a review of clinical records, documents, and interviews. Agency policy C30 Written and Verbal Orders states in part, "if the order is verbal the individual receiving the order much record and sign it immediately and have the prescribing person sign it by State and Federal regulations." 1 of 11 (9%) clinical records reviewed revealed that extra visits were made by the interdisciplinary team outside of the visits ordered on the plan of care without documentation of a physician's order. Clinical Record 9: The Chaplain visit frequency documented on the plan of care dated 10/5/2022 was 1 time a month. A Chaplain visit was made on 10/9/2022 and an extra visit was on 10/13/2022. There was no documentation of a physician's order for the additional visit. In an interview with the Chaplain and the Administrator, there were extra visits made due to patient and family circumstances. The physician gave verbal orders for the visit, but there was no documented evidence of a physician order for a change of visit frequency for the Chaplain visits provided. Agency policy C30 Written and Verbal Orders states in part; if the order is verbal the individual receiving the order much record and sign it immediately and have the prescribing person sign it in accordance with State and Federal regulations. In the two clinical records below the agency failed to provide documentation of written orders for visits made outside of the Plan of Care orders.