Every finding on record at Compassus Op of Texas, LLC

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C_09A.1 "Missed Visits" (effective/last revised 07/08/2022) (reviewed 12/27/2024) stated in part, "When a visit is returned in the EMR from the assigned clinician to the scheduler, one of the following may apply... No answer at the door/no answer on the phone...A Coordination Note documenting the reason for the missed visit is required from the clinician. The visit should be rescheduled, if possible, within the Medicare Week (Sunday to Saturday)." Agency policy #HOS-C15 "Nursing Services" (effective 11/01/2017) and ( reviewed 07/28/2025) stated in part, "defines a nursing assessment as the holistic evaluation of an individual's response to changes in health status...and the evaluation of the effectiveness of these interventions..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the IDG continuously assessed the patient's needs. Clinical Record 18: The patient elected hospice care on 10/30/2024 with a primary diagnosis of unspecified protein-calorie malnutrition. The patient resided at home. The Registered Nurse (RN) visit note dated 04/08/2025 documented that the patient reported burning with urination, the feeling of frequency occurring about every twenty minutes, and urine with an abnormal color. On 04/08/2025, the Hospice Medical Director ordered "ciprofloxacin 500mg by mouth twice daily for seven days." A Nurse Practitioner (NP) face-to-face encounter completed (on paper) on 04/10/2025 at 1500 documented that the patient's temperature was 97.8 degrees (F) and her blood pressure was 95/45. The NP documented the patient was "alert and oriented to person and place but was confused with the time and date" and was "incontinent but voiding without difficulty...Her sleeping had increased from 8-10 hours per day in January to 14-16 hours per day in April"..."Patient alone for the visit. Took 10 minutes to come to the door..." The patient's blood pressure was documented as 149/66 during the skilled nursing visit dated 04/01/2025 and 129/77 on 04/08/2025. The Chaplain's visit note dated 04/14/2025 at 1320, documented that the patient was conversant, that the patient stated she had not received her morning medications, and that the patient's spouse confirmed the medications were not received by the patient. The Chaplain's visit included a Registered Nurse (RN) orienting to the agency. The Chaplain documented that the patient's medication profile was accessed with the RN and the spouse. The spouse then brought the medications to the patient to take. The Chaplain documented that the patient's RN Case Manager (RNCM) was informed of this information. The next scheduled skilled nursing visit was scheduled for 04/16/2025, which was eight (8) days after the RN visit on 04/08/2025 and six (6) days after the NP visit, however the Licensed Vocational Nurse documented in a coordination note that the visit was missed after attempting to reach the patient/spouse by phone twice with no answer and waiting at the door for fifteen minutes with no response. A clinical record review revealed no evidence documenting that the RN was notified of the missed visit or that another SN visit was attempted. The hospice received a call from the patient's daughter on 04/18/2025 at 1613 reporting that her mother may have passed away. The RN noted in the visit at 1528 that the police and fire departments were on scene when she arrived and that Emergency Medical Services (EMS) pronounced the patient's death at 04/18/2025 at 1619. The patient had an "Out of Hospital Do Not Resuscitate (DNR)" dated 01/03/2025. A secure message from the orienting RN to the patient's RNCM on 04/14/2025 stated in part, "Hey, this is (RN name), one of the nurses. I'm shadowing (Chaplain name) today, and we went and saw (patient name). She hadn't been given her morning meds, so (Chaplain) asked me to give them to her...She also had more Cipro left than she likely should if her meds should be ending today..." There was an acknowledgement by the RNCM that the message was received. During a joint clinical record review and interviews on 08/06/2025 and 08/07/2025, the Director of Clinical Services (DCS) confirmed that the patient should have had another nursing visit attempted on Thursday or Friday after the Licensed Vocational Nurse (LVN) documented a missed visit on 04/16/2025 and that they could find no documentation by any nurse that a phone call was made or that another visit was attempted. The DCS stated that there was no follow-up, and there should have been some communication of a follow-up or another attempt to visit. The patient's RNCM was no longer employed with this hospice.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected patient and family goals and planned interventions based on problems identified in the updated comprehensive assessment. CLINICAL RECORD 10: The patient elected hospice care on 05/12/2025with diagnoses of malignant neoplasm of unspecified part of bronchus/lung, malignant neoplasm of the brain, chronic obstructive pulmonary disease, and seizures. The Registered Nurse (RN) visit note dated 07/15/2025 documented, "Pt reports that he had episode of headache and chest pain yesterday...He is reporting episode of mid-sternal chest pain. He used his PRN oxygen and Tylenol for relief with good results..." The skilled nurse (SN) visit note dated 07/18/2025 documented that the patient had "non-pitting bilateral lower extremity edema." The SN visit note dated 07/22/2025 documented that the patient had bilateral lower leg swelling in the patient's feet and ankles. On 07/25/2025, the SN visit note documented that the patient evidenced "2+ bilateral lower extremity edema," and noted that education was provided to the patient on the use of compression stockings and to elevate his legs. On 07/29/2025, the SN visit note documented, "He reports experiencing shortness of breath and intermittent chest pain. The chest pain is described as mid-sternal, lasting about 5 minutes, and is relieved by oxygen use. He also complains of left arm pain, specifically in the shoulder and upper arm. The patient notes swelling in his feet, which improves with elevation at night..." The patient's plan of care did not document planned interventions or goals for the patient's identified problems with chest pain and edema. During the joint record review and interview on 08/06/2025, the Director of Clinical Services (DCS) (Personnel Record 3) confirmed the new assessment findings were not addressed on the patient's plan of care or in Interdisciplinary Meetings. The clinical record was brought into compliance on 08/06/2025.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C09 "Written Interdisciplinary Plan of Care" (effective 08/01/2017) (reviewed 12/24/2024) read in part, "The content of the plan of care includes...An identification of the services to be provided, including management of symptoms...Designation of the discipline...who will provide the intervention..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the IDG revised the patient's plan of care to include information from the patient’s updated comprehensive assessment. CLINICAL RECORD 10: The patient elected hospice care on 05/12/2025 with diagnoses of malignant neoplasm of unspecified part of bronchus/lung, malignant neoplasm of the brain, chronic obstructive pulmonary disease, and seizures. The Registered Nurse (RN) visit note dated 07/15/2025 documented, "Pt reports that he had episode of headache and chest pain yesterday...He is reporting episode of mid-sternal chest pain. He used his PRN oxygen and Tylenol for relief with good results..." The skilled nurse (SN) visit note dated 07/18/2025 documented that the patient had "non-pitting bilateral lower extremity edema." The SN visit note dated 07/22/2025 documented that the patient had bilateral lower leg swelling in the patient's feet and ankles. On 07/25/2025, the SN visit note documented that the patient evidenced "2+ bilateral lower extremity edema," and noted that education was provided to the patient on the use of compression stockings and to elevate his legs. On 07/29/2025, the SN visit note documented, "He reports experiencing shortness of breath and intermittent chest pain. The chest pain is described as mid-sternal, lasting about 5 minutes, and is relieved by oxygen use. He also complains of left arm pain, specifically in the shoulder and upper arm. The patient notes swelling in his feet, which improves with elevation at night..." A review of the Interdisciplinary Meeting dated 07/22/2025, revealed no evidence that the IDG revised the patient's plan of care to include the patient's reported chest pain and edema. During the joint record review and interview on 08/06/2025, the Director of Clinical Services (DCS) (Personnel Record 3) confirmed the new assessment findings were not addressed on the patient's plan of care or in Interdisciplinary Meetings. The clinical record was brought into compliance on 08/06/2025.

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. Agency policy #IPC.11_A2 "Infection Control: Bag Technique and Hand Hygiene with Competency" (effective 08/29/2022) (reviewed 07/30/2025) read in part, "Appropriate hand hygiene is the gold standard and primary method of basic infection control practice...When to Use Hand Gel (Sanitizer): ...After contact with body fluids where they are not visibly soiled...Moving between clean and contaminated body surfaces/sites...After contact with inanimate objects in the patient's environment..." In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. HOME VISIT 1: During the home visit with the Hospice Aide (HA) [Personnel Record 8] on 08/06/2025, the HA completed the patient's bed bath, ending with the perineal area and bottom, removed the dirty sheets from the bed, and placed them in the dirty laundry, and without changing their gloves, the HA grabbed the clean linens to make the bed. The HA did not remove the dirty gloves and complete hand hygiene after transitioning from "dirty" to "clean" areas/linen as per the agency's policy.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 12 (17%) applicable clinical records of patients accepting Chaplain services identified that the initial comprehensive assessment was not completed within five days. Clinical Record 13: The patient elected the hospice benefit on 1/4/2022 with a primary diagnosis of Protein Calorie Malnutrition. The initial spiritual assessment was completed on 1/10/2022, six days after admission. There was no documentation explaining why the assessment was later than five days. Clinical Record 8: The patient elected the hospice benefit on 8/3/2021 with a primary diagnosis of Parkinson's Disease. The initial spiritual assessment was attempted on 8/12/2021, nine days after admission, with a note stating that the caregiver refused the visit. There was no documentation explaining why the assessment was later than five days. The Administrator was interviewed on 10/19/2022 and agreed that there was no explanation for why the assessment was late.

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. 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 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 a 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. 5 of 13 (38%) clinical records reviewed identified that the hospice did not update the drug profile. Clinical Record 7: The patient elected the hospice benefit on 4/1/2022 with a primary hospice diagnosis of Heart Disease. A Nursing Assessment completed on 10/11/2022 stated that the patient was on intermittent O2 @ 2LPM. Oxygen was not on the drug profile. Clinical Record 4: The patient elected the hospice benefit on 1/21/2022 with a primary hospice diagnosis of Heart Disease. A Nursing Assessment completed on 10/13/2022 stated that the patient was on intermittent O2 @ 2LPM. Oxygen was not on the drug profile. Clinical Record 5: The patient elected the hospice benefit on 8/2/2022 with a primary hospice diagnosis of Heart Disease. The Admission Assessment completed on 8/2/2022 stated that the patient was on O2 @ 4LPM. Oxygen was not on the drug profile. Clinical Record 6: The patient elected the hospice benefit on 10/15/2021 with a primary hospice diagnosis of Senile Degeneration of the Brain. A Nursing Assessment completed on 10/10/2022 stated that the patient remained on O2 @ 2LPM. Oxygen was not on the drug profile. Clinical Record 11: The patient elected the hospice benefit on 7/7/2022 with a primary hospice diagnosis of Heart Disease. A Nursing Recertification Assessment completed on 9/19/2022 stated that the patient remained on intermittent O2 @ 2LPM. Oxygen was not on the drug profile. The Administrator was interviewed on 10/19/2022 and agreed that the drug profile's had not been updated. She had no additional information to provide.

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, interviews , and observations. 4 of 13 (31%) clinical records reviewed identified that the hospice did not include all of the hospice care and services necessary to meet the specific needs of the patient and family. Clinical Record 2: The patient elected the hospice benefit on 2/23/2022 with a primary hospice diagnosis of Senile Degeneration of the Brain. The initial Chaplain assessment was completed on 2/24/2022 with a current visit frequency documented as one visit every month. There were no problems, goals, or interventions for the Chaplain on the plan of care. During a home visit with the RNCM on 10/19/2022, it was observed that the patient had a skin tear on the right thigh. The primary caregiver and RNCM reported that the patient had very fragile skin and frequent bruising and skin tears. There was no integumentary problem opened on the current plan of care. The Administrator was interviewed on 10/19/2022 and agreed that the plan of care was missing the required elements. Clinical Record 7: The patient elected the hospice benefit on 4/1/2022 with a primary hospice diagnosis of Heart Disease. The Chaplain assessment was completed on 4/5/2022 with a current visit frequency documented as one visit every month. There were no problems, goals, or interventions for the Chaplain on the plan of care. The Administrator was interviewed on 10/19/2022 and agreed that the plan of care was missing the required elements. Clinical Record 8: The patient elected the hospice benefit on 8/3/2021 with a primary hospice diagnosis of Parkinson's Disease. A current visit frequency for the Chaplain is documented as one visit every month. There were no problems, goals, or interventions for the Chaplain on the plan of care. The Administrator was interviewed on 10/19/2022 and agreed that the plan of care was missing the required elements. Clinical Record 12: The patient elected the hospice benefit on 7/29/2022 with a primary hospice diagnosis of Alzheimer's Disease. The initial Chaplain assessment was completed on 8/2/2022 with a current visit frequency documented as one visit every month. There were no problems, goals, or interventions for the chaplain on the plan of care. The Administrator was interviewed on 10/19/2022 and agreed that the plan of care was missing the required elements. She had no additional information to add.

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 a review of documents, interviews, and observations. Procedure C_11G: Infection Control Bag: Bag Technique i Home Care and Standard Precautions. Revision Date: 4/22/2020. stated in part: "Hand Hygiene. 2. Follow the recommended steps for healthy hand hygiene according to the Guidelines for Hand Hygiene i Health Care Settings, CDC Morbidity and Mortality Weekly Report (MMWR) 2002, Volume 51 (RR16). a. Follow these five steps every time. https://www.cdc.gov/handwashing/when0how-handwashing.html . v. Dry your hands using a clean towel or air-dry them." 1 of 3 (33%) observations during a home visit identified that Hand hygiene was not performed by the RNCM as defined in the agency policy. Home Visit 2: The patient elected the hospice benefit on 2/23/2022 with a primary hospice diagnosis of Senile Degeneration of the Brain. The RNCM washed hands in the patient's bathroom and then used the patient towel hanging in the bathroom to dry hands. The Administrator was interviewed on 10/19/2022 and discussed the observation and finding with her. She referred to the Bag Technique and Standard Precaution Procedure that had been utilized to provide education and training to all employees.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 12 (8%) applicable clinical records of patients receiving Chaplain services identified that services were not provided as ordered in the plan of care. Clinical Record 9: The patient elected the hospice benefit on 11/9/2021 with a primary hospice diagnosis of Lung Cancer. The initial Chaplain assessment was completed on 11/11/2021 with a defined visit frequency of one time each month. The last documented Chaplain visit was on 6/28/2022. The visit frequency remains one time each month on the current plan of care. There were no Chaplain visit notes for July, August, or September 2022. There was a communication note on 9/30/2022 stating "Declines services. The order created." There was no physician order for Chaplain services discontinued noted on the chart. The Administrator was interviewed on 10/19/2022 and agreed that the visit frequency was incorrect on this record.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary, the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) applicable clinical records of live discharges reviewed identified that the discharge summary was not forwarded to the patient's attending physician. Clinical Record 13: The patient elected the hospice benefit on 1/4/2022 with a primary diagnosis of Protein Calorie Malnutrition. The patient was discharged from Hospice services on 10/4/2022 for no longer meeting eligibility requirements. There was no evidence in the clinical record that the discharge summary was forwarded to the patients attending physician. Clinical Record 11: The patient elected the hospice benefit on 7/7/2022 with a primary diagnosis of Heart Disease. The patient was discharged from Hospice services on 9/19/2022 after being admitted to the hospital. There was no evidence in the clinical record that the discharge summary was forwarded to the patients attending physician. The Administrator was interviewed on 10/19/2022 and agreed that there was no documentation of the discharge summary's being forwarded to the attending physician or facility.