Every finding on record at Compassion Hospice LLC

Based on record review and interview, the hospice agency failed to ensure the hospice aide was observed performing all the required skills competency checks for 1 of 2 hospice aides reviewed who have cared for patients (CNA 2). Findings include: --- 1. A review of CNA 2s personnel record included a hospice aide skills checklist. The checklist was signed by RN 2 and indicated but not limited to CNA 2 had been checked off verbally in oral, rectal, and axillary temperatures; bed bath; tub/ shower; nail care; skin care; brushing teeth; denture care; chair to standing transfer; assist with ambulating; and assist with ambulating with a cane. This document failed to evidence CNA 2 was observed performing these tasks. During an interview on 6/13/24 at 4:10 PM, the Clinical Director indicated all the skills on the hospice aide skills checklist are to be observed at patients bedsides and that RN 2 should not have checked CNA 2 off on any of the skills verbally.

Upon patient record review, 2 of 6 (Patient #2,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: On admission, there is an order for oxygen to be delivered at 2-4 liters per minute via nasal cannula as needed. The patient's medication profile includes oxygen at 2 liters per minute via nasal cannula as needed. Patient 4: On 2/15/23, the record indicates an order for Diclofenac 2 gm topically four times daily for arthritic pain. There is no evidence of a location for application identified on the medication profile.

Upon patient record review, 1 of 6 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments Patient 4:On 2/15/23, the record indicates an order for Diclofenac 2 gm topically four times daily for arthritic pain. The order did not identify the location for the application of the medication.

Upon patient client record review, 1 of 6 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The initial plan of care includes an order that the agency should anchor the patient's Foley catheter. There is no evidence in the patient record that a Foley catheter is present.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The medication profile for triamcinolone acetonide topical cream did not contain evidence of specific area(s) for application. In addition, the profile listed cipro ordered 10/19/2022 and 11/9/2022 250mg one tab twice a day and cipro ordered 03/16/2023 500 mg 1 tab twice a day as well as diflucan ordered 10/28/2022 250mg 1 capsule one time as active. COS

Upon patient record review, 3 of 5 (Patient #1, #2, #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #1-#3: There was no evidence of a bereavement assessment performed as part of the comprehensive assessment or as of the date of survey.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 5 (Patient #2, #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: Patient admitted with anxiety symptoms which was documented to continue however, the plan of care did not contain problems/interventions/goals related to anxiety. COS Patient #3: Patient admitted with pain and respiratory symptoms which was documented to continue however, the plan of care did not contain problems/interventions/goals related to pain and respiratory symptoms. COS

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The order for triamcinolone acetonide topical cream did not contain evidence of specific area(s) for application. In addition, there were active orders for cipro ordered 10/19/2022 and 11/9/2022 250mg one tab twice a day and cipro ordered 03/16/2023 500 mg 1 tab twice a day as well as Diflucan ordered 10/28/2022 250mg 1 capsule one time. These meds remained on the POC but were no longer to be taken. COS

Upon patient record review, 1 of 5 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: There was documentation patient was experiencing back pain and agitation but refusing medication however, there was no evidence of problems/interventions/goals added to plan of care for these new symptoms. In addition, patient was place on oxygen in February however, there was no evidence that oxygen safety precautions was added to plan of care. COS

Upon client record review, 3 of 5 (Patient #1, #2, #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The social work and spiritual visit frequency was ordered at start of care 2/month however, there was only evidence of one visit for April and May for each discipline. Patient #2: The spiritual visit frequency was ordered 1 low/1 high since start of care however, there was no evidence of a visit in April. Patient #3: The social work visit frequency was ordered 1 low/2 high on 04/03 however, there was no evidence of visit in April.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #5: The patient passed on 10/09/2022 however, the bereavement plan of care was created and closed on 11/15/2022 and bereaved requested 12/30/2022 not to receive communication from agency. The plan of care did not contain specifics of services to be offered.

Upon patient record review 3 of 5 (Patient #1, #2, #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The aide visit frequency was ordered on 05/16/2023 2/week however, the weeks of 05/21, 05/28, 06/04, and 06/11/23 there was only evidence of one visit each week. In addition, the aide plan of care directed aide to clean oxygen filter weekly, clean nails each visit, and record bm each visit however, the week of 06/13/23 there was not evidence these were completed and the aide did not notify the nurse. Patient #2: The aide visit frequency was ordered at start of care 1 low/4 high and on 05/17 1 low/1 high however, there was evidence of visits 04/13, 05/05, and 06/02. In addition, the aide plan of care directed aide to shower, dress, comb/brush hair, and perform perineal care weekly however, there was no evidence these were performed in these visits and the aide did not notify the nurse. Patient #3: The aide visit frequency was ordered 05/02 1 low/0 high and on 05/17 ordered 2/week however, there was only evidence of visit 04/13 with next visit occurring 05/12. In addition, the aide plan of care directed aide to perform oral care, record bm, assist with range of motion every visit however, there was no evidence these were performed on 06/09, 06/13, and 06/19 and the aide did not notify nurse. The aide documented on 06/16 "assisted patient to dye hair" however, there was no evidence this was included on plan of care.

Upon patient client record review, 2 of 5 (Patient #2, #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patients #2-#3: Upon admission, the patient/POA requested the addendum for notice of non-covered items however, there was not evidence this was delivered.