Every finding on record at Compassionate Care Hospice of Northern New Jersey, LLC

Upon patient record review, 10 of 19 (Patient #2,#3,#4,#6,#8,#9,#10,#11,#12,#14) 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 includes an entry on 4/17/24 for Medrol dose pack to be given per instructions. There is no evidence that the medication profile includes instructions for administering the medication. Patient 3,9,11 and 12:The medication profile includes an entry for Oxygen 2-4 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the medication profile includes titration instructions for the oxygen range. Patient 6:The medication profile includes an entry on 5/23/24 of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. Patient 4 and 14:The medication profile includes an entry on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. Patient 8:The medication profile includes an entry on admission of oxygen 8 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. Patient 10:The medication profile includes entries on 6/11/24 of Tylenol 325 2 tabs q 4 hours as needed for fever >101 and on 7/11/24 of Acetaminophen 325 2 tabs q 4 hours as needed for fever>101. There is evidence that these are duplicate therapies.

Upon patient record review, 4 of 19 (Patient #2,#5,#6,#14) 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 medical record includes documentation that the patient is on a pureed diet with a risk for aspiration and that oxygen at 2 liters per minute via nasal cannula can be used as needed for shortness of breath. There is no evidence that the plan of care includes goals and interventions for altered diet and aspiration prevention or problems, goals and interventions for oxygen use and safety. COS Patient 5:The plan of care includes problem statements of altered comfort and oxygen use. There is no evidence of goals and interventions for the problem statements. The medical record includes documentation that the patient has a peritoneal dialysis catheter located in the left abdomen and an implanted port located in the upper right chest. There is no evidence that the plan of care includes problems, goals and interventions to manage the peritoneal dialysis catheter or the implanted port. Patient 6:The medical record contains documentation of a primary diagnosis of protein calorie malnutrition, oxygen in use at 2 liters per minute as needed of shortness of breath and that the patient is at a high risk for falls. There is no evidence that the plan of care includes problems, goals and interventions for altered nutrition, the management and use of oxygen or safety/falls. Patient 14:The medical record includes documentation that the patient is a risk for skin breakdown, is currently on anticoagulation therapy and is at risk for falls. The plan of care includes problem statements for altered skin integrity, potential for bleeding or hemorrhage and safety/falls. There is no evidence of active goals and interventions for the problem statements.

Upon patient record review, 9 of 19 (Patient Patient #2,#3,#4,#6,#8,#9,#11,#12,#14) 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 plan of care includes an order on 4/17/24 for Medrol dose pack to be given per instructions. There is no evidence that the order includes instructions for administering the medication. Patient 3,9,11 and 12:The plan of care includes an order for Oxygen 2-4 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the order includes titration instructions for the oxygen range. Patient 6:The plan of care includes an order on 5/23/24 of oxygen 2 liters per minute as needed for shortness of breath and an entry on 6/21/24 of Medi honey with dose noted as per instructions and instructions written as apply to wound 2 times weekly until healed. There is no evidence that order includes route of administration for oxygen or the dose/amount of Medi honey for wound care. Patient 4 and 14:The plan of care includes an order on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the order includes route of administration for oxygen. Patient 8:The plan of care includes an order on admission of oxygen 8 liters per minute as needed for shortness of breath. There is no evidence that the order includes route of administration for oxygen.

Upon patient record review, 3 of 19 (Patient #1,#10,#11) 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 medical record contains nursing documentation that patient uses rolling walker for ambulation. There is no evidence that the plan of care includes a rolling walker as equipment needs for the patient. Patient 10:The medical record contains nursing documentation that patient uses a wheelchair for mobility. There is no evidence that the plan of care includes a wheelchair as equipment needs for the patient. Patient 11:The medical record contains documentation that the patient's equipment needs include a hospital bed bed, rails, oxygen concentrator, O2 supplies, wound care supplies and incontinence supplies. There is no evidence that the plan of care includes these items as equipment needs for the patient.

Upon patient record review, 4 of 19 (Patient #4,#7,#9,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4:The medical record contains documentation that the patient is at risk for aspiration. The aide plan of care includes the task of assist with meals. There is no evidence that the aide plan of care includes aspiration precautions. Patient 7:The aide plan of care includes the task of bed bath. There is no evidence that the plan of care also includes the task of undressing and dressing. Patient 9:The medical record contains documentation that the patient plan of care includes the use of coumadin for anticoagulation therapy and is a high risk for falls. There is no evidence that the aide plan of care includes bleeding precautions. Patient 10:The aide plan of care dated 5/2/24 through 7/9/24 includes the assigned task of sponge bath. There is no evidence that the plan of care includes a frequency for provision of the service.

Upon patient record review 1 of 19 (Patient #2) 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 2:The aide plan of care included the task of shampoo hair weekly. The visit frequency is three times weekly. The aide visit documentation noted the task as completed on 5/17/24, 5/20/24, 5/22/24, 5/24/24, 5/29/24, 5/31/24, 6/3/24, 6/5/24, 6/7/24, 6/10/24, every visit for three weeks.

Upon personnel record review, 5 of 15 (Personnel #1,#3,#4,#10,#11) 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 Files 1, 3, 4, 10 and 11:There is no evidence that an initial skills competency assessment was conducted by a skilled professional initially during orientation.