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

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed, the agency did not ensure that the comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record 5: The patient elected hospice care on 5/2/2022. The initial plan of care ordered a social worker evaluation to be done in five calendar days. There was no evidence that initial contact was made with the patient/family until 6/12/2022, 41 days after the start of care. This visit was rescheduled, the initial evaluation by the social worker was made on 6/21/2022, 50 days after the start of care. A review of the RN's initial assessment documented that no psychosocial needs were identified, but no initial psychosocial assessment was completed. During an interview with the Director of Operations on 9/21/22, it was confirmed that the social worker was required to make an initial assessment within five calendar days of admission, She stated that the visit continuously got rescheduled due to family requests. There was no documentation found to support this. During an interview with the Director of Operations on 9/21/22 it was confirmed that the social worker was required to make an initial assessment with 5 calendar days of admission, She stated that the visit continuously got rescheduled due to family requests. There was no documentation found to support this.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: Education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by a review of personnel records, documents, and interviews. According to agency policy, HR-001E Orientation-Professional Patient Care Employee states, "The hospice will provide an orientation program for all newly employed patient care staff. An orientation plan is developed for each employee and adapted according to the employee's needs." 2 of 11 (18%) personnel records reviewed by the agency did not ensure that employee orientation was documented. Personnel Record #6: Social Worker LSW, Date of Hire, 6/7/2021. There was no documented evidence that the employee completed any policy reviews, or required orientation about the employee's specific job duties. Personnel Record #8: RN, Date of Hire, 2/23/2022. There was no documented evidence that the employee had completed any policy review, or required orientation pertaining to the employee's job duties. An interview with the Office Manager and Director of Operations on 9/21/22 verified that each employee was required to complete a six- to nine-week orientation. According to agency policy HR-001E Orientation-Professional Patient Care Employee it states "The hospice will provide an orientation program for all newly employed patient care staff. An orientation plan is developed for each employee and adapted according to the employee's needs." In an interview with the office manager and Director of Operations on 9/21/22 it was verified that each employee was required to complete a 6 to 9 week orientation.

The hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of personnel records. 2 of 11 (18%) personnel records reviewed, the agency did not ensure that an initial clinical competency assessment was documented. Personnel Record #6: Social Worker LSW, Date of Hire, 6/7/2021. There was no documented evidence that the Social Worker had been assessed for an initial clinical competency evaluation. Personnel Record #8: RN, Date of Hire, 2/23/2022. There was no documented evidence that the RN had been assessed for an initial clinical competency evaluation.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by a review of clinical records and documents. Agency policy AA-o13A states, "prior to any discharge, a written order for the discharge must be obtained by the Medical Director." 1 of 1 (100%) clinical record review of a discharged patient, the agency did not ensure a physician's order for discharge. Clinical Record 11: There was no physician order for discharge given by Medical Director. During an interview with the Clinical Manager, she confirmed that the discharge process should include a doctor's order. The date of discharge for this patient was 4/28/22. In agency policy AA-o13A it states " prior to any discharge, a written order for the discharge must be obtained by the medical director."