Every finding on record at Compassionate Care Hospice of Miami Dade and the Florida Keys, Inc.

Upon patient record review, 2 of 5 (Patient #1, #2) 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 #1: Patient SOC diagnosis Malignancy of Lung with metastasis, had craniotomy with mets to brain during hospitalization prior to SOC. There was no evidence of Problem/interventions/goals for neuro on POC. Patient #2: Patient had diagnosis of dysphagia, SN SOC assessment included "dysphagia leading to aspiration", and fall risk of 14 (>10- high risk). There was no evidence on the POC of a problem/interventions/goals for risk of aspiration or falls. Corrected on site.

Upon patient client record review, 1 of 5 (Patient #1) 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: Note on 10/7/2023 included "instructed to call Madison Hospital with any needs or concerns" Per SN "auto correct issues".

Upon patient record review, 6 of 19 (Patient #2, #3, #4, #5, #6, #15) 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 included lantaprost eye drops without evidence of directions for specific eye(s) and oxygen at 2lpm continuous without evidence of a route. corrected on site Patient #3: The medication profile listed ativan 0.5mg PRN anxiety as directed, clopidogrel 75mg per instruction daily as directed, eliquis 2.5mg per instruction daily as directed, isosorbide ER 30mg tab daily per instruction daily as directed. Patient #4: The medication profile listed ipratropium 0.5mg-albuterol 3mg (2.5mg base) per instruction Q12 hours however, there was no evidence of a route and quantity/dose. corrected on site Patient #5: The medication profile listed maxitrol eye drops without evidence of directions for specific eye(s), miralax powder without evidence of mixing directions, oxygen at 3lpm continuous without evidence of a route, and Z-pack 250mg daily per instructions as directed. corrected on site Patient #6: The medication profile listed percocet 5-325mg 1 tab every 6 hours PRN pain and acetaminophen suppository every 4 hours PRN fever without evidence of maximum dosing. corrected on site Patient #15: The medication profile included acetaminophen 325mg every 4 hours PRN pain and acetaminophen 650mg every 4 hours fever without the maximum allowable dosing.

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

Upon patient record review, 1 of 19 (Patient #4) 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 #4: The patient had a documented wound which was assessed initially 05/11 then again 07/12 and 08/08. Per agency wounds are to be assessed weekly and photos (if permitted by patient/family) obtained monthly.

Upon patient record review, 1 of 19 (Patient #1) 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 #1: The patient admitted on 02/03/2023 a stage 2 wound on back however, there was no evidence of problems/interventions/goals for wound or skin integrity. There was no evidence on problems/interventions/goals to manage pain and symptoms. corrected on site

Upon patient record review, 1 of 19 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4: The NP visit frequency was ordered PRN on 05/28/2023.

Upon patient record review, 6 of 19 (Patient #2, #3, #4, #5, #6, #15) 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 medication profile included lantaprost eye drops without evidence of directions for specific eye(s) and oxygen at 2lpm continuous without evidence of a route. corrected on site Patient #3: The medication profile listed ativan 0.5mg PRN anxiety as directed, clopidogrel 75mg per instruction daily as directed, eliquis 2.5mg per instruction daily as directed, isosorbide ER 30mg tab daily per instruction daily as directed. The NP documented "...patient is receiving wound care per facility protocol and under antibiotic treatment with doxycycline 100mg BID x 7 days" however, there was no evidence this was included in plan of care or orders for either were documented in hospice agency chart. Patient #4: The medication profile listed ipratropium 0.5mg-albuterol 3mg (2.5mg base)per instruction Q12 hours however, there was no evidence of a route and quantity/dose. corrected on site Patient #5: The medication profile listed maxitrol eye drops without evidence of directions for specific eye(s), miralax powder without evidence of mixing directions, oxygen at 3lpm continous without evidence of a route, and Z-pack 250mg daily per instructions as directed. corrected on site Patient #6: The medication profile listed percocet 5-325mg 1 tab every 6 hours PRN pain and acetaminophen suppository every 4 hours PRN fever without evidence of maximum dosing. corrected on site Patient #15: The medication profile included acetaminophen 325mg every 4 hours PRN pain and acetaminophen 650mg every 4 hours fever without the maximum allowable dosing.

Upon patient record review, 13 of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15) 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 #1: The nurse documented on admission patient has a low air loss mattress however, there was no evidence of this included on the plan of care. corrected on site Patient #2: The nurse documented on admission patient has a oxygen and walker and medication profile includes albuterol inhalation requiring a nebulizer however, there was no evidence these were included on the plan of care. corrected on site Patient #3: The nurse practitioner documented patient has a hospital bed and on home visit #1 patient observed using a wheelchair however, there was no evidence these were included on the plan of care. corrected on site Patient #4: The nurse documented on admission patient has oxygen, hospital bed, wheelchair, and overbed table however, there was no evidence these were included on the plan of care. corrected on site Patient #5: The nurse documented on admission patient has oxygen, hospital bed, overbed table and medication profile includes ipratroprium and albuterol inhalation requiring a nebulizer however, there was no evidence these were included on the plan of care. corrected on site Patient #6: The plan of care included multiple pieces of equipment that agency confirmed patient was not using, such as oxygen concentrator, liquid oxygen, home fill oxygen, bipap, cpap, geri chair, broda chair, enteral pump, electric scooter, hoyer, etc. corrected on site Patient #7: Upon home visit #2 patient observed sleeping in hospital bed however, there was no evidence of this included on the plan of care. corrected on site Patient #8: The nurse documented bipap and walker however, these were not included on the plan of care. corrected on site Patient #9: The nurse documented hospital bed and overbed table however, these were not included on the plan of care. corrected on site Patient #10: The nurse documented wheelchair and cushion however, these were not included on the plan of care. corrected on site Patient #11: The nurse documented on admission patient has oxygen, hospital bed, overbed table and medication profile includes ipratroprium and albuterol inhalation requiring a nebulizer however, there was no evidence these were included on the plan of care. corrected on site Patient #12: The nurse documented on admission patient has oxygen, hospital bed, overbed table and medication profile includes ipratroprium and albuterol inhalation requiring a nebulizer however, there was no evidence these were included on the plan of care. corrected on site Patient #15: The nurse documented on admission patient has oxygen, hospital bed, wheelchair, and wheelchair however, there was no evidence these were included on the plan of care.

Upon patient record review, 5 of 19 (Patient #2, #4, #8, #11, #13) 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 #2: The patient signed DNR on 05/11/2023 also signed by physician after admission on 04/29/2023 however, there was no evidence the plan of care was updated to include this advanced directive. corrected on site Patient #4: The patient had documented wound that developed after admission on 04/24/2022 however, there was no evidence the plan of care was updated to include problems/interventions/goals. corrected on site Patient #8: The nurse noted patient began using PRN oxygen in July and continue with breathing problems in 08/04 note along with worsening anorexia however, there were not problems/interventions/goals related to respiratory or nutrition added to plan of care. The plan of care continued with social work and spiritual care problems/interventions/goals however, both disciplines had been declined from patient/family after admission. corrected on site Patient #11: The patient had signed DNR on admission dated 07/03/2023 also signed by physician a however, there was no evidence the plan of care was updated to include this advanced directive. corrected on site Patient #13: The patient had a documented upper respiratory infection on 07/19 however, the plan of care was never updated to include problems/interventions/goals for respiratory or infections.

Upon client record review, 11 of 19 (Patient #1, #2, #3, #4, #7, #8, #9, #10, #12, #13, #14) 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 nurse frequency 05/04/2023 was 1W10, 2W3 however, the week of 07/09 there was no evidence of a visit. In addition, the NP frequency was 1M 2 PRN however, there was no evidence of a routine in June or July however, there was a PRN visit on 07/10. corrected on site Patient #2: The nurse frequency 06/25/2023 was 4W1, 1W4, 3 PRN however, the week of 06/25 there was only evidence of one visit on 06/27. In addition, the spiritual frequency 05/01 was 1M1, 1x monthly 2 PRN however, there was evidence of a visit performed on 06/01 and 06/30. The social work frequency 05/01 was 2M1 for initial and follow up then 2M1 monthly visit, 2 PRN and 5 telephone calls however, there was no evidence in June of visits or telephone calls and July there was no evidence of telephone calls. corrected on site Patient #3: The nurse frequency 07/12/2023 was 3W1, 1W9, 2W2, 1W1, 3 PRN and on 07/16 was 2W1, 1W3, 2W1, 1W4, 3W1, 2W1, 1W1 however, the week of 07/12 there was only evidence of two visits on 07/12 and 07/13 and week of 07/16 evidence of one visit on 07/20, week of 08/13 two visits on 08/17 and 08/18. The social work frequency 07/12 was 1M1 for initial, 2 PRN, 5 telephone calls however, there was evidence of visits performed 07/13, 07/27, 08/03, and 08/09. corrected on site Patient #4: The nurse documented "wound care done as physician orders" on 07/22, 07/27, 08/01, and 08/08 and there was no further evidence of details of wound care performed. In addition, on 07/12 documented "tolerated well" when referencing wound care however, there was no evidence of details of care. The nurse frequency ordered 06/18/2023 was 5W1, 1W3, 2W1, 1W2, 2W1, 1W1 however the week of 6/18 there was evidence of only one visit 06/20, week of 07/30 only 2 visits on 08/01 and 08/02, and the week 08/16 one visit 08/08. The spiritual frequency 06/01 was 7M1 psychosocial team VF daily alternate CH/SW, 2 PRN however, there was no evidence of visits in June. visit frequency corrected on site Patient #7: The nurse frequency 07/23 was 7W1, 3W1, 1W3, 2W2, 1W2, increase nurse VF to daily and 3 PRN however, the week of 07/23 there were visits each day except 07/27 and 07/29. The spiritual and social work frequency 07/21 was 6M1, 4M1 and 6M1, 2M1 respectively with language "psychosocial team VF daily alternate CH/SW" however, there was only evidence of visit from SW on 07/24 and SC 07/23 and 07/25. corrected on site Patient #8: The spiritual frequency 06/21/2023 was 1M1, 1 PRN and social work 06/21 was 1M1, 1M2, 1 PRN however, there were no visits for either the month of June and none for the social worker in July. corrected on site Patient #9: The social work frequency 06/01/2023 was 6M1, 4M2 a month visit with 2 PRN and 5 phone call PRN however, for June there was only evidence of visits on 06/01 and 06/14. corrected on site Patient #10: The nurse frequency 06/07/2023 was 1W1, 2W12 SN twice a week for patient assessment 3PRN however, the week of 06/04 and 07/02 there was evidence of one visit on 06/09 and 07/07. The social work frequency 06/07 was3M2, 2M1 three times a month phone visits however, there were visits on 06/08, 06/30, and 07/12. corrected on site Patient #12: The nurse frequency 06/21/2023 was 1W1, 2W12, 3 PRN however, the week of 07/02 there was one routine on 07/07 and one PRN on 07/05. Corrected on site Patient #13: The nurse frequency 06/15/2023 was 3W1, 2W12, 1W1, 3 PRN however, the week of 07/02 there was one visit 07/07, the week of 07/16 there was one routine 07/18 and two PRN 07/19, 07/22. Corrected on site Patient #14: The social work frequency 05/04/2023 was 1M1, 1M2, 2 PRN however, there were two visits in June on 06/09 and 06/28 and no visits in July. Corrected on site

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient visit #4: Upon observing the aide perform bath, the aide removed gloves during care, disposed of old gloves, and replaced with new gloves without washing hands per agency policy #PCP-001, under GUIDELINES bullet #4. Perform hand hygiene as follows: After removing gloves.

Upon patient record review 3 of 19 (Patient #1, #5, #11) 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 frequency 07/02 was 11W1, 14W6, 6W1 however, the patient was receiving one visit daily but Monday-Friday the agency was sending two aides. corrected on site Patient #5: The aide frequency 07/21/2023 was 4W1, 14W8 however, the patient was only receiving one visit daily however, the agency was sending two aides. corrected on site Patient #11: The aide frequency 07/23/2023 was 1W1, 4W1, 3W8, 2W1 however, the week of 07/23 there was no evidence of any visits. In addition, the plan of care directed to shampoo hair weekly however, aide documented shampooing on 08/02, 08/03, 08/04, 08/07, 08/09, 08/11. corrected on site

Upon patient client record review, 3 of 19 (Patient #9, #10, #12) did not have evidence that each patient record contains Advance Directives. Patient #9: The DNR initiated and signed by patient 03/06/2023 had no evidence of signature from physician as of date of survey. corrected on site Patient #10: The DNR initiated and signed by patient 03/09/2023 had no evidence of signature from physician as of date of survey. corrected on site Patient #12: The DNR initiated and signed by patient 06/21/2023 had no evidence of signature from physician as of date of survey. corrected on site

Upon patient client record review, 5 of 19 (Patient #3, #8, #9, #10, #11) 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 #3: The plan of care included problems/interventions/goals for medication management which included filling mediplanner and for medication administration by hospice nurse however, patient resides in a facility and facility is managing medication as well as administering. corrected on site Patient #8: The nurse documented "she had episodes of fatifa and sudoration in moderate exertion 91, ...", agency was unclear of meaning. In addition, the nurse documented on admission patient using bipap however, there was no evidence of an order or listed on plan of care. Agency investigated and reported this was an error and patient is not using a bipap. corrected on site Patient #9: The plan of care reflected problems/interventions/goals for discharge planning since 03/03/2023 however, the agency reported this was an error. corrected on site Patient #10: The plan of care reflected problems/interventions/goals for discharge planning since 03/09/2023 however, the agency reported this was an error. corrected on site Patient #11: The plan of care reflected medication administration by hospice nurse however, agency confirmed this was in error. corrected on site.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #14: The agency could not obtain employee files from contracted agency.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #13: The agency could not obtain employee files from contracted agency.

Upon personnel record review, 2 of 14 (Personnel #13, #14) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.