Every finding on record at Compassion Care Hospice, LLC

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 clinical record review and interview. In 3 of 7 (43%) clinical records reviewed, the agency did not ensure that all members of the Interdisciplinary Group completed their initial comprehensive assessment within 5 calendar days after the patient elected their hospice benefit. Clinical Record 1: The patient elected hospice care on 7/25/2023. The consent for care signed by the legal guardian on 7/25/2023 documented that the spiritual counselor would provide an evaluation. The initial hospice orders documented that the spiritual counselor was declined on 7/25/2023. The social worker (SW) assessment dated 7/27/2023 documented that the patient's caregivers were open to spiritual support for the patient. A clinical record review revealed no evidence of follow-up related to a spiritual counselor. No spiritual counselor/chaplain assessment was completed and documented in the clinical record. Clinical Record 4: The patient elected hospice care on 12/16/2021. A review of the clinical record revealed the "Medical Social Services (SW) Assessment" dated 12/20/2021 contained no documentation within the form except pre-filled data. A document attached to the form for signature documented "unable to obtain an electronic signature at the time of the visit." There was no documented evidence that a SW assessment was completed. Clinical Record 5: The patient elected hospice care on 11/22/2021. On 11/22/2021, the physician ordered the SW and chaplain to assess the patient. A clinical record review revealed no documented evidence of the social worker or chaplain assessments. During an interview on 12/13/2023, the Quality and Compliance Administrator confirmed the findings.

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 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 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 2 of 7 (29%) clinical records reviewed, the agency did not ensure that the medication profile was updated when new medications were ordered to identify drug side effects and actual or potential drug interactions. Clinical Record 1: The patient elected hospice care on 7/25/2023. A review of the clinical record revealed the medication "Keflex 500mg TID (3 times a day) for 7 days" was ordered by the physician on 11/7/2023. The medication profile was not updated to include documentation of Keflex. There was no evidence that Keflex was reviewed during the patient's medication regimen review. Clinical Record 5: The patient elected hospice care on 11/22/2021. A review of the clinical record revealed the medications Roxanol 0.5ml q3h (every 3 hours) ATC (Around the clock) and Ativan 1mg q3h ATC were ordered by the physician on 11/30/2021. The medication profile was not updated to include documentation of Roxanol and Ativan. There was no evidence that Roxanol and Ativan were reviewed during the review of the patient's medication regimen. During an interview on 12/12/2023, the Quality and Compliance Administrator/Alternate Administrator confirmed that the medication profile was not updated with new medication orders.

It is required that the individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program. The hospice maintains documentation that each hospice aide has met the requirements. This standard was not met as evidenced by interview and personnel record review. In 1 of 2 (50%) personnel records reviewed of hospice aides, the hospice did not ensure that a competency assessment was completed upon hire. Personnel Record 7: The Certified Nurse Aide/Hospice Aide was hired on 4/19/23. A clinical record review revealed no documented evidence that the hospice aide completed a competency evaluation upon hire. The Human Resources Director confirmed the findings in an interview on 12/13/2023.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice must have written policies and procedures describing the method(s) of assessing competency and maintain a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by document review, interview, and personnel record review. In 4 of 10 (40%) personnel records reviewed, in which assessment of skills and competencies were required, the agency did not ensure that the records contained documented evidence of completion. Agency policy #3-003, "Competency Assessment," dated November 2022, stated in part, "As part of the orientation process, the preceptor/Clinical Supervisor will be assigned to each new person.... Using a Competency Skills Performance Checklist, and the Orientation Checklist, the preceptor/Clinical Supervisor will observe the new personnel performing the required skills and activities." Personnel Record 3: The Bereavement Coordinator was hired on 11/28/23. A personnel record review revealed no evidence of a competency or skills checklist completed at hire. Personnel Record 4: The Licensed Practical Nurse was hired on 9/12/23. A personnel record review revealed no evidence of a competency or skills checklist completed at hire. Personnel Record 5: The Registered Nurse (RN) was hired on 6/19/23. A personnel record review revealed no evidence of a competency or skills checklist completed at hire. Personnel Record 6: The Chaplain was hired on 6/6/23. A personnel record review revealed no evidence of a competency or skills checklist completed at hire. The Human Resources Director confirmed the findings during an interview on 12/13/2023.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, the agency did not ensure that physician orders contained correct clinical information regarding medications. Clinical Record 5: The patient elected hospice care on 5/9/2023. The physician order dated 11/30/21 read in part "loves and 0.25mg Q3HR ATC"). The physician order did include documentation of the name of the medication ordered for "breathing treatment/nebulizer QID." During an interview on 12/12/2023, the Quality and Compliance Administrator/Alternate Administrator confirmed that the physician's order was not written with correct spelling and specific medication for the breathing treatment. Clinical Record 6: The patient elected hospice care on 8/16/2022. The "Hospice Admission Order" dated 8/16/2022 ordered skilled nursing services two times a week for one week, followed by one time a week for 12 weeks. A review of the clinical record revealed that for the week of 08/21/2022, visits were documented on 8/22/2022 and 8/24/2022, and for the week of 10/16/2022, visits were documented for 10/19/2022 and 10/21/2022; actual frequency was two times a week for each week. There was no evidence of communication with the physician or order to support the increased frequency. During an interview on 12/12/2023, the Quality and Compliance Administrator/Alternate Administrator confirmed that the skilled nursing visits were provided on 8/24/2022 and 10/21/22 without a physician order.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. The agency did not ensure that the Medical Director contract included language requiring that contracted employees with direct patient contact or access to patient records obtain a criminal background check. Personnel Record 5/Contract 5: The Medical Director contract was effective 10/11/2022. A personnel record review revealed no evidence of a criminal background check completed at the time of hire. During an interview on 12/12/2023, the Administrator that the contract "Hospice Medical Director Agreement" confirmed that the Medical Director contract did not include language related to criminal background checks.