Every finding on record at Compassionate Care Hospice

Upon patient record review, 8 of 14 (Patient #1,2,4,6,7,8,9,10) 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: Patient 1: The hospice medication list contains an order for Tramadol prn initiated 5/28/25, the facility profile does not have this listed. The facility MAR has Acetaminophen 325mg 2 BID ordered in May 2025 the hospice medication profile does not have this listed. These are not new since the last SN visit. Corrected on site, profile updated. Patient 2: The medication profile contains orders for Acetaminophen 650mg PO TID and Acetaminophen 650 mg rectally every 4 hours prn pain. There is no directive to not exceed 4000 mg daily of Acetaminophen. Corrected on site, profile updated. Patient 4: The medication profile contains orders for Acetaminophen 650 mg PO every 6 hours prn and 650 mg suppositories every 6 hours prn. There is no directive to not exceed 4000 mg daily. Corrected on site, profile updated. Patient 6: The medication profile contains an order for Nitroglycerin 0.4mg 1 tab every five minutes until pain is relieved and no instructions what to do if pain not relieved after 3rd dose. In addition, Acetaminophen 650 mg PO 3 times daily and Acetaminophen 650 rectal suppository every 6 hours prn with no directive not to exceed 4000 mg daily. Corrected on site, profile updated. Patient 7: The medication profile contains Acetaminophen PO 325 2 tabs 3 times daily and Acetaminophen 650 rectally Q6 hours prn with no directive not to exceed 4000 mg daily. Corrected on site, profile updated. Patient 8: The medication profile contains orders for Acetaminophen 650 rectal Q6 hours prn and Acetaminophen 325 mg 2 tabs PRN/as needed for pain. There is no frequency to the PO tablet and no directive not to exceed 4000 mg daily. Corrected on site, profile updated. Patient 9: The medication profile contains an order for Acetaminophen 500 mg 2 tabs every 6-8 hours prn and Acetaminophen rectally 650 mg suppository 4 times daily prn. There is no directive not to exceed 4000 mg daily. Corrected on site, profile updated. Patient 10: The medication profile contains an order for Polyethylene Glycol with no diluent. Corrected on site, profile updated.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: Agency policy 4-043.2 "if a wound is present, orders should be placed and wound should be observed weekly by hospice nurse." There were visits 9/3 and 9/4 for this week and the wound was not assessed by the hospice nurse.

Upon patient record review, 3 of 14 (Patient #2,3,5) 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: The POC contains orders for ASA daily, there is no risk for bleeding care plan with goals and interventions initiated. Corrected on site, goals and interventions updated. Patient 3: Upon home visit finding, patient's right arm is in a cast. There are no goals or interventions for the cast initiated. Corrected on site, goals and interventions updated. Patient 5: The POC 3/19/25 contains orders for ASA, there is no risk for bleeding care plan with goals and interventions initiated. Corrected on site, goals and interventions updated.

Upon patient record review, 8 of 14 (Patient #1,2,4,6,7,8,9,10) 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 1: The facility MAR has Acetaminophen 325mg 2 BID orders the hospice POC does not have this order. Corrected on site, order updated. Patient 2: The POC 9/26/25 contains order for Acetaminophen 650 mg PO TID and Acetaminophen 650 mg rectally every 4 hours prn pain. There is no directive to not exceed 4000 mg daily of Acetaminophen. The SN documented on 10/1/25 that barrier cream is being applied to buttocks with each brief change. This item is not on the POC. Corrected on site, order updated. Patient 4: Acetaminophen is ordered for 650 mg PO every 6 hours prn and 650 mg suppositories every 6 hours prn. There is no directive to not exceed 4000 mg daily. The SN documented on 10/19/25 the patient is on a puree diet and using Calmoseptine cream. These were not included on the POC. Corrected on site, orders updated. Patient 6: The POC 9/1/25 contains an order for Nitroglycerin 0.4mg 1 tab every 5 min until pain is relieved and no instructions what to do if pain not relieved after 3rd dose, Acetaminophen 650 mg PO 3 times daily and Acetaminophen 650 rectal suppository every 6 hours prn with no directive not to exceed 4000 mg daily. Corrected on site, orders updated. Patient 7: The POC 9/14/25 contains an order for Acetaminophen PO 325 2 tabs 3 times daily and Acetaminophen 650 rectally Q6 hours prn with no directive not to exceed 4000 mg daily. Corrected on site, orders updated. Patient 8: The POC 10/15/25 contains orders for Acetaminophen 650 rectal Q6 hours prn and Acetaminophen 325mg 2 tabs PRN/as needed for pain. There is no frequency to the PO table and no directive not to exceed 4000 mg daily. Corrected on site, orders updated. Patient 9: The POC 10/15/25 contains an order for Acetaminophen 500 mg 2 tabs every 6-8 hours prn and Acetaminophen rectally 650mg suppository 4 times daily prn. There is no directive not to exceed 4000 mg daily. Corrected on site, orders updated. Patient 10: The POC contains an order for Polyethylene Glycol with no diluent. The SN documented patient wearing compression stockings 9/10, there is no order for compression stockings. Corrected on site, orders updated.

Upon patient record review, 1 of 14 (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 equipment and supply needs. Patient 4: The SN documented on 10/19/25 patient uses Hoyer lift, there is not an order for the Hoyer lift on the POC. Corrected on site, orders updated.

Upon patient record review, 5 of 14 (Patient #4,5,6,9,11) 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 4: The updated POC contains orders for wound care to a pinkie from SOC 2/10/25 and contains the same care plans from SOC. There is no evidence the agency is updating the POC and no evidence of documentation of progress towards outcome/goals from the POC. Corrected on site, POC updated. Patient 5: There is not evidence the POC has been updated since 3/19/25 or evidence of progress toward goals. One example is "Patient will verbalize understanding of cardiac medications and treatments to manage symptoms during care, within the certification period start effective date 3/19/25." There has been no documentation regarding progress toward this goal and patient is in their 3rd certification period. Corrected on site, POC updated. Patient 6: Pt has a wound to left lower leg with twice weekly wound care, received an order for an antibiotic on 9/30/25 for this wound. No risk for infection care plan with goals and interventions developed. Corrected on site, goals and interventions updated. Patient 9: The POC 10/15/25 contains an order for Clindamycin 300mg 1 cap 4 times daily for 7 days. There was no risk for infection care plan initiated with goals and interventions. Corrected on site, goals and interventions updated. Patient 11: Pt was a live discharge from hospice, last SN visit made 10/11/24, there is no indication patient is discharging. The next note is the discharge HIS which has documented patient is no longer terminally ill and is seeking an alternate Parkinson's program. No evidence of discharge planning.

Upon patient record review, 4 of 14 (Patient #1,6,10,11) 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 POC 9/3/25 contains an order for SN twice weekly, the SN made only 1 visit the week of 9/21/25. There is no missed visit documentation or evidence of refusal. Patient 6: A new order was obtained on 9/30/25 to cleanse wound with wound cleanser, pat dry with gauze, apply medihoney to wound bed, cover with 4x4 foam bordered dressing. The SN documented on 9/30/25 "Wound to LLE cleansed with wound cleanser, has a foul smell to it, picture sent to NP". There is no evidence the rest of the order was followed. There was no previous order to perform wound care this way. On 10/2/25 the SN documented at the end of wound care wrapping the foot leg in gauze and secured with tape and there is no order to wrap with gauze. The order on 10/7/25 for wound care is to wash with soap and water, pat dry, apply betadine, calcium alginate to wound bed, wrap with gauze and apply border foam. On 10/09/25, the SN documented wound care as "washed with wound cleanser, pat dry with gauze, apply calcium alginate with wound bed, cover with gauze, ABD, wrap with gauze daily". The SN did not document applying Betadine as ordered. Patient 10: The current POC has orders for SN visits twice weekly. The week of 9/14 the SN made 1 visit and there is no missed visit documentation or evidence of refusal. Patient 11: The medical record contains an order to hold SN visits twice weekly beginning 10/6/25. There was a SN visit made on 10/11/25. There was no order written for this visit to be made after visits were put on hold.

Upon patient record review, 3 of 14 (Patient #4,7,9) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 4: The aide assignment 4/6/25 contains the following tasks ordered PRN: assist with ambulation, patient/family support, laundry. There is no evidence patient is cognitively able to make decisions. Corrected on site, aide assignment updated. Patient 7: The aide assignment 4/6/25 contains the following tasks PRN: Pt/family support, laundry, clean/file nails every visit/PRN. There is no evidence patient is cognitively able to make decisions. Corrected on site, assignment updated. Patient 9: The aide assignment 4/6/25 contains the following tasks ordered as PRN: clean/file nails every visit/PRN, shave facial hair every visit/PRN, family support PRN, assist with toileting PRN, laundry PRN. There is no evidence patient is cognitively able to make decisions. Corrected on site, assignment updated.

Upon patient record review 5 of 14 (Patient #1,2,6,9,11) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: The RN performed an aide supervisory visit on 9/4/25, there has not been an RN supervisory visit since. The agency has been having LPN performing supervisory visits. Patient 2: There have been no aide supervisory visits completed. The aide is seeing the patient twice weekly. Agency has LPN's doing aide supervisory visits. Patient 6: The RN made an aide supervisory visit on 9/1/25 the next aide supervisory visit is due 9/15/25. There was not one completed until 9/22/25. Patient 9: The RN made an aide supervisory visit on 9/19/25 the next aide supervisory visit is due 10/3/25 it was not done until 10/4/25, this is greater than 14 days. Patient 11: The RN made an aide supervisory visit on 9/26/24 the next one was not completed until 10/11/24, that is greater than 14 days.

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 7: The physical therapist competency assessment was completed by the RN Clinical Manager, not by another physical therapist. Corrected on site, competency performed with another PT.

Upon patient record review, 4 of 14 (Patient #1,3,6,7) 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 1: The aide did not electronically sign their aide visit notes on 9/11/25 and 9/4/25. The SN documented on 9/10/25 "pt/cg" and "d/t" these are not approved abbreviations. Personnel 3: The RN made an aide supervisory visit on 9/12/25. It is unclear which discipline is being supervised as it states supervision of LPN with name and aide with no name there is not a separate supervision for each discipline. Patient 6: SN documented on 10/13/25 "started ABX Saturday". This is not an approved abbreviation. Patient 7: The SN performed a supervisory visit 9/13 though it does not indicate who or which discipline was supervised.

Upon patient record review, 1 of 11 (Patient #8) 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. Pt # 8 - RN visit note dated 9/29/22 indicated Keflex 500mg. TID x 5 days was added. No evidence of an order. (COS)

Upon personnel record review, 1of 11 (Personnel #3) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel #3 - job description requirements says the RN needs a Bachelors degree in Nursing from an accredited program by the National League for Nurses. The staff member has an Associate in nursing degree. Job description was modified and signed on site visit. (COS)