Every finding on record at Compassus Op of Georgia II, LLC

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, document review, and interview. Agency policy # HOS_C21 "Hospice Aide and Homemaker Services" (reviewed 03/20/2025) stated in part, "(Name of agency) provides hospice aide and homemaker services according to the patient's plan of care as determined by the IDT and assigned by the Registered Nurse...The hospice aide follows the assigned activities in the delivery of care and services to the patient." In 2 of 12 (17%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 13: The patient elected the hospice benefit on 02/28/2025. The HA care plan dated 02/28/2025 assigned the HA the relevant tasks: oral care, shampoo, pericare, and shave every visit. On 03/28/2025, the HA documented that tasks were not required for that visit. There was no evidence of a change in the HA care plan. The HA did not follow the care plan. Clinical Record 17: The patient elected the hospice benefit on 04/09/2024. The HA care plan dated 04/09/2024 assigned the HA the relevant task: shampoo and haircare every visit. On 04/15/2024, the HA documented that shampoo and hair care were not required for that visit. There was no evidence of a change in the HA care plan. The HA did not follow the care plan. During interviews on 04/08/2025 and 04/09/2025, the Area Executive of Clinical Operations confirmed that the Hospice Aide did not follow the care plan for tasks assigned.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide reported changes in the patient's personal care needs related to the plan of care to the Registered Nurse (RN). Clinical Record 13: The patient elected hospice benefit on 02/28/2025. The HA care plan dated 02/28/2025 assigned the HA the relevant tasks: oral care, shampoo, pericare, and shave every visit. On 03/28/2025, the HA documented that tasks were not required for that visit. There was no evidence of a change in the HA care plan. There was no documented evidence that the RN was notified of the tasks that were not completed. Clinical Record 17: The patient elected the hospice benefit on 04/09/2024. The HA care plan dated 04/09/2024 assigned the HA the relevant task: shampoo and haircare every visit. On 04/15/2024, the HA documented that shampoo and hair care were not required for that visit. There was no evidence that the Registered Nurse was notified of the tasks that were not completed. During interviews on 04/08/2025 and 04/09/2025, the Area Executive of Clinical Operations confirmed that the aide did not inform the RN with respect to tasks not completed.