Every finding on record at Compassionate Care Hospice of Marlton, LLC

Upon patient record review 1 of 19 (Patient #1) 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: There is evidence in the medical record the aide plan of care indicated a shampoo every visit. On 10/9/25 the aide documented "shampoo "not completed".

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The annual report of volunteer services was 0.6% for 2024. The hospice has a PIP for volunteer improvement.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records. In 4 of 16 (25%) clinical records reviewed, the plan of care did not reflect patient and family goals and identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 8: The Medical Social Worker identified and documented in the social assessment dated 10/12/22 that the patient's spouse was upset over the cost of the patient is in an Assisted Living facility. There was no goal or intervention found in the plan of care addressing the patient's financial issues and the need for support. Clinical Record 6: The patient was ordered O2@2liters prn on 11/26/22. There was no planned intervention for oxygen safety education for the patient and/or caregiver with no established goal. Clinical Record 15: The patient was ordered O2 @2liters prn on 9/18/22. There was no planned intervention for oxygen safety education for the patient and/or caregiver with no established goal. Clinical Record 16: Patient was ordered O2@2liters prn on 10/11/22. There was no planned intervention for oxygen safety education for the patient and/or caregiver with no established goal.