Every finding on record at Companion Hospice, L.L.C.

Based on record review and interview, the hospice failed to ensure:1) Volunteer visits were provided in accordance with the plan of care frequency for two (Patients #7 and 8) of 19 patients.2) Music therapy visits were provided in accordance with the plan of care frequency for three (Patients #8, 17, and 18) of 19 patients.3) Chaplain visits were provided in accordance with the plan of care frequency for one (Patient #10) of 19 patients.4) Skilled Nurse visits were provided in accordance with the plan of care frequency for one (Patient #7) of 19 patients.5) Aide visits were provided in accordance with the plan of care frequency for one (Patient #7) of 19 patients. --- Findings:Patient #7A plan of care dated 01/01/26 - 03/01/26 showed a volunteer frequency of two to six visits a month for three months, a skilled nurse frequency of one to two visits a week for three months, and an aide frequency of one to two visits a week for three months.  A review of the clinical record showed:1) A volunteer visit of 01/14/26 and an unfinished note dated 01/28/26 (one visit conducted), no volunteer visit notes for February (no visit conducted).2) No Skilled Nurse visits the week of 01/01/26 - 01/03/26 (no visit conducted).3) No Aide visit the week of 01/01/26 - 01/03/26 (no visit conducted).The clinical record showed no patient or family refusal of visits and no changes in the ordered frequency.Patient #8A plan of care dated 01/29/26 - 03/29/26 showed a volunteer  frequency of once a month for two months and music therapy worker frequency of one to two visits a month for two months. A review of the clinical record showed:1) No volunteer visit notes from 02/01/26 - 02/28/26 (no visit conducted).2) No music therapy visit notes 01/29/26 - 03/04/26 (no visits conducted).The clinical record showed no patient or family refusal of visits and no changes in the ordered frequency.Patient #10A plan of care dated 01/13/26 - 03/13/26 showed a chaplain frequency of one to two visits a month for three months.  A review of the clinical record showed no chaplain visits from 01/13/26 - 01/31/26 ( no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequency.Patient #17A plan of care dated 01/01/26 - 03/01/26 showed a music therapy frequency of one to two visits a month for three months.  A review of the clinical record showed no music therapy visits from 01/01/26 - 03/01/26 ( no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequency.Patient #18A plan of care dated 02/04/26 - 05/04/26 showed a music therapy frequency of one to two visits a month for four months.   A review of the clinical record showed no music therapy visits from 02/04/26 - 03/04/26 (no visits conducted) and showed no patient or family refusal of visits and no changes in the ordered frequency. On 03/03/26 at 2:10 p.m., Staff A stated there were no notes and they couldn't confirm the visit frequencies were followed:1) By the volunteer for patients #7 and 82) By musical therapy for patients #8, 17, and 183) By the chaplain for patient #104) By the nurse for patient #75) By the aide for patient #7

Based on record review and interview, the agency failed to ensure a home health aide supervisory visit was completed every 14 days for one (Patient #8) of 19 patients. --- Findings:Patient #8A plan of care dated 01/29/26 to 03/29/26 showed orders for aide visits twice for one week and then five times a week for eight weeks.  A review of the clinical record showed during the weeks of:01/29/26 - 01/31/26 home health aide visits were made one time.02/01/26 - 02/07/26 home health aide visits were made three times.02/08/26 - 02/14/26 home health aide visits were made three times. 02/15/26 - 02/21/26 home health aide visits were made three times. 02/22/26 - 02/28/26 home health aide visits were made three times. The clinical record showed supervisory visits on 02/10/26 and 02/25/26 (15 days between supervisory visit).On 03/04/26 at 2:10 p.m., Staff A stated the supervisory visit on 02/25/26 was late.

Based on record review and interview, the hospice failed to ensure: 1. Completion of the initial bereavement assessment no later than 5 calendar days after the election of hospice care for two (Patients #2 and 13) of 19 patients; and 2. Completion of the initial psychosocial assessment no later than 5 calendar days after the election of hospice care for one (Patient #7) of 19 patients. 3. Completion of the initial spiritual assessment no later than 5 calendar days after the election of the hospice care for one (Patients #13) of 19 patients. --- Patient #2 A review of the clinical record showed an election of the hospice benefit on 02/09/23 with no completion of the initial bereavement assessment from 02/09/23 to 03/22/23 (40 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Bereavement Coordinator and no patient or caregiver refusal of Bereavement Coordinator visits. Patient #7 A review of the clinical record showed an election of the hospice benefit on 11/21/22 with no completions of the initial psychosocial assessment from 11/21/22 to 11/28/22 (6 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Medical Social Worker and no patient or caregiver refusal of Medical Social Worker visits. Patient #13 A review of the clinical record showed an election of the hospice benefit on 11/29/22 with no completion of the initial bereavement assessment from 11/29/22 to 02/26/23 (90 days after election of the hospice benefit) and no completion of the initial spiritual assessment from 11/29/22 to 02/26/23 (90 days after election of the hospice benefit) with no documentation of attempts to contact the patient made by the Bereavement Coordinator or Chaplain and no patient or caregiver refusal of Bereavement Coordinator or Chaplain visits. On 03/22/23 at 1:00 pm, Staff A stated: 1. The initial bereavement assessments for were not completed within the first five days after the election of the hospice benefit for Patients #2 and 13. 2. The initial psychosocial assessment was not completed within the first five days after the election of the hospice benefit for Patient #7. 3. The initial spiritual assessment was not completed within the first five days after the election of the hospice benfit for Patient #13.

Based on record review and interview, the hospice failed to ensure: 1.Psychosocial services (social worker) were provided in accordance with the plan of care frequency for one (Patients #1) of 19 patients; 2. Hospice aide services were provided in accordance with the plan of care frequency for two (Patients #6 and 14) of 19 patients and; 3. Spiritual services (Chaplain) were provided in accordance with the plan frequency for one (Patient #14) of 19 patients. --- Patient #1 A plan of care dated 12/26/22 to 02/23/23 and plan of care updates dated 12/28/22, 01/11/23, 01/25/23, 02/08/23 and 02/15/23 showed a social worker frequency of one to two visits per month for three months. A review of the clinical record showed no social worker visits from 12/26/22 to 02/23/23 (no completed visits). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. Patient #6 A plan of care dated 01/15/23 to 03/15/23 and plan of care updates dated 01/19/23, 02/02/23, 02/16/23 and 03/02/23 showed a hospice aide frequency of two visits per week for nine weeks and a Chaplain frequency of one visit per week for nine weeks. A review of the clinical record showed the following: A hospice aide visit dated 01/30/23 during the week of 01/29/23 to 02/04/23 (one of two visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A hospice aide visit dated 03/02/23 during the week of 02/26/23 to 03/04/23 (one of two visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. The week of 02/19/23 to 02/25/23 no Chaplain visits were made (zero of one visit completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. The week of 03/05/23 to 03/11/23 no Chaplain visits were made (zero of one visit completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. Patient #14 A review of the plan of care dated 12/07/22 to 02/04/23 and plan of care updates dated 12/28/22, 12/21/22, 01/05/23, 01/19/23 and 02/02/23 showed a hospice aide frequency of three visits per week for one week and three visits per week for eight weeks. A review of the clinical record showed: A hospice aide visit dated 12/12/22 and 12/16/22 for the week of 12/11/22 to 12/17/22 (two of three visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A hospice aide visit dated 01/02/23 and 01/04/23 for the week of 01/01/23 to 01/07/23 (two of three visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. A hospice aide visit dated 01/11/23 and 01/12/23 for the week of 01/08/23 to 01/14/23 (two of three visits completed). Documentation showed no patient or family refusal of visits and no changes in the ordered frequency. On 03/22/23 at 1:50 pm, Staff A stated; 1. The social worker frequency was not met for Patient #1; 2. The hospice aide frequencies were not met for Patients #6 and 14; and 3. The Chaplain frequency was not met for Patient #14.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for fifteen (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 19) of 19 patients reviewed. --- Patient #1 A review of the plan of care dated 12/26/22 to 02/23/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 02/09/23 to 05/09/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 12/26/22 to 02/23/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 01/31/23 to 03/31/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 01/32/23 to 04/30/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 01/15/23 to 03/15/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 11/21/22 to 02/19/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A review of the plan of care dated 01/12/23 to 03/12/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 02/13/23 to 05/13/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 01/06/23 to 04/05/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 01/30/23 to 04/29/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #12 A plan of care dated 01/24/23 to 04/23/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #13 A plan of care dated 11/29/22 to 02/26/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #14 A plan of care dated 12/07/22 to 02/04/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #19 A plan of care dated 12/17/22 to 02/14/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 03/22/22 at 12:58 pm, Staff A stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 ,14 and 19 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the hospice aide notified the supervising nurse of missed visits for two (Patients #6 and 14) of 19 patients. --- Patient #6 A review of the plan of care dated 01/15/23 to 03/15/23 and plan of care updates dated 01/19/23, 02/02/23, 02/16/23 and 03/02/23 showed a hospice aide frequency of two visits per week for nine weeks. A review of the clinical record showed: A hospice aide visit dated 01/30/23 for the week of 01/29/23 to 02/04/23 (one of two visits completed) with no documentation of a missed visit or notification to the supervising nurse of a missed visit. A hospice aide visit dated 03/02/23 for the week of 02/26/23 to 03/04/23 (one of two visits completed) with no documentation of a missed visit or notification to the supervising nurse of a missed visit. Patient #14 A review of the plan of care dated 12/07/22 to 02/04/23 and plan of care updates dated 12/28/22, 12/21/22, 01/05/23, 01/19/23 and 02/02/23 showed a hospice aide frequency of three visits per week for one week and three visits per week for eight weeks. A review of the clinical record showed: A hospice aide visit dated 12/12/22 and 12/16/22 for the week of 12/11/22 to 12/17/22 (two of three visits completed) with no documentation of a missed visit or notification to the supervising nurse of a missed visit. A hospice aide visit dated 01/02/23 and 01/04/23 for the week of 01/01/23 to 01/07/23 (two of three visits completed) with no documentation of a missed visit or notification to the supervising nurse of a missed visit. A hospice aide visit dated 01/11/23 and 01/12/23 for the week of 01/08/23 to 01/14/23 (two of three visits completed) with no documentation of a missed visit or notification to the supervising nurse of a missed visit. On 03/22/23 at 1:30 pm, Staff A stated there was no documentation of the supervising nurse being notified of hospice aide missed visits or the reasons for missed visits.