Every finding on record at Compassion Hospice and Palliative Care, Inc.

Observed in HR File Review. In 3 out of 5 applicable HR files, Emergency Preparedness training was not provided at least every 2 years. Examples: In HR#2 (MD), HR#4 (RN), and HR#6 (CH) emergency preparedness training was not provided at least every 2 years. This was confirmed by the Administrator Designee.

Observed in Record Review. In 1 out 2 discharge records, the organization did not involve the patient in making decisions about their care, treatment, or services. Example: In RRDC#1, discharge documentation indicated the patient wanted aggressive treatment and choose to revoke hospice services. However, there's not a revocation form signed by the patient or designee within the patient record validating this choice. This was confirmed by the Administrator.

Observed in Tracer Visit. In 1 out 3 home visit records, the medication profile in the medical record was inaccurate. Example: In RRHV#2, the medication profile was inaccurate in the medical record. The following medications were not included in the profile: Levetiracetam 500 mg tablet; Memantine Hydrochloride 10mg Tablet; Sertraline Hydrochloride 25mg Tablet. This was confirmed with the Administrator who contacted their EMR platform Hospice MD for evaluation of the discrepancy.

Observed in Tracer Activities. In 1 out of 4 records, the plan of care did not clearly define prn medication parameters to meet the patient needs. Example: In RRHV#2, the orders to address pain prn was not clearly defined. The patient plan of care included Acetaminophen 325mg Tablets every 4 hours as needed for pain and Morphine Sulfate 15 mg every 4 hours as needed for pain.. This was confirmed by the Administrator.

Observed in Tracer Visit. In 3 out of 4 records, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. Examples: In RRHV#1, 1 extra nursing visit noted in week 3 of benefit period 2 and 1 missed Aide visit noted in the last week of benefit period 2. In RRHV#2, 1 missed nursing visit noted in the first week of benefit period #2. In RRHV#3 benefit period 1, there were 2 missed Aide visits in week 1 and 2 missed aide visits in week 2. This was confirmed with the Administrator.

Observed in Infection Control System Tracer. In 3 out of 6 HR files, the organization did not provide ongoing infection control education to staff. Examples: In HR#2 (MD), HR#4 (RN), and HR#6 (CH) ongoing infection control education was not provided annually. This was confirmed by the Administrator Designee.

Observed in Tracer Activities. In 2 out of 3 bereavement record reviews, the organization did not develop a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service delivery. Example: In RRBR#2 and RRNHV#5, a bereavement plan of care was not developed. This was confirmed with the Administrator.

Observed in Tracer Activities. In 3 out of 3 bereavement records, the organization did not conduct the post-death reassessment of the bereaved family per policy. Example: The bereavement policy indicates that the post-death bereavement assessment would take place 3-5 weeks after the patient's death. In RRBR#1, the assessment occurred 8 months after the patient passed. In RRBR#2, the post-death bereavement assessment was done 9 months after the patient passed. In RRNHV#5, the post-death bereavement assessment was done 7 months after the patient passed. This was confirmed by the Administrator.

Observed in Tracer Activities. In 1 out of 4 records, the registered nurse did not supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. Example: In RRDC#2, the Aide Supervisory visit was late by 1 day in week 3 of benefit period 4 and by 12 days in week 7 of benefit period 4. This was confirmed by the Administrator.

Observed in Record Review. In 1 out of 5 applicable charts, the hospice did not provide the patient’s attending physician with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. Example: In RRNHV#2, the Hospice did not send a copy of the discharge summary to the Attending MD after the patient was discharged for extended prognosis. This was confirmed by the Administrator.

Observed in Individual Tracer. In 3 of 3 home visits conducted, During Tracer visit 1 and 2 the surveyor noted that the nurses did not follow the organization's bag technique policy. They both failed to wash their hands before entering the nursing bag and only used gel. In visit 3 the CNA did not change her gloves after cleaning the private areas of the resident. This was validated with the Administrator who attended the visits.

Observed in HR File Review. In 5 of 8 licensed files reviewed, During the Competence assesment session, the surveyor noted that in LVN 2, the date of hire was 1/6/2020 and was not primary source verified. The license then expired on 6/30/21 and was not verified until 8/16/21. In CNA 2 the DOH was 6/4/21 and was not verified on hire with a date on the verification. In CNA 1 the DOH was 8/24/20 and was not verified on hire, the license expired on 4/19/2022 but there was no date on the verification. The license was verified on the last day of survey. In the MSW file the license was not verified on DOH 11/11/2019 but was verified on 4/20/2022. IN the DCPS file the license expired on 11/30/2020 and was not verified until 4/12/21. This was validated in a discussion with and observation by the Administrator and the Human Resource Director. Observed in HR File Review. During the Competence assesment session, the surveyor noted that the Chaplain's education was not verified at the time of hire. This was validated in a discussion with and observation by the Administrator and the HR Director.