Every finding on record at Compassionate Health Hospice, Inc

Based on observation, interview, and record review, the hospice failed to ensure one of three sampled patient (Patient 3's) medication profile was updated.  This failure had the potential for not providing consistent and quality care to the patient.Findings: --- Review of hospice's P&P titled  Medication Profile revised 5/2024, showed medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A drug regimen review will be performed at the time of initial and comprehensive assessment.  The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. During subsequent visits , the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians, understand the medication regimen. Review of Patient 3's clinical record was initiated on 2/23/26.  The clinical record showed the SOC was 4/10/25.  The patient was certified  for hospice services during the certification periods from 4/10/25 to 7/8/25, 7/9/25 to 9/6/25, 9/7/25 to 11/5/25, 11/6/25 to 1/4/26, and 1/5/26 to 3/5/26.On 2/25/26 at 0825 hours, a home visit was conducted with RN 1 to Patient 3's residence.  A concurrent medication profile review and interview was conducted with RN 1.Review of Patient 3's Current Treatment/Medication/DME List showed the following medications:-olopatadine hydrochloride ophthalmic solution (antihistamine) one drop on both eyes once daily,-Lasix (diuretic) 20 mg one tablet daily,-atrovent Inhaler (anticolinergic bronchodilator) 2 puffs, four times a day, -azithromycin (antibiotic) 250 mg two tablets now then 1 tablet everyday for four days, -Proventil HFA (bronchodilator) 2 puffs every six hours  as needed for shortness of breath ,wheezing, -Symbicort (corticosteroid) to inhale twice a day,-Tamiflu (antiviral) 75 mg one tablet twice a day,-Ambien (hypnotic) 5 mg one tablet every hour of sleep as needed -megestrol acetate (appetite stimulant) 40 mg one tablet once daily.However, Patient 3 did not have and did not currently use the above medicationsRN1 was informed of the above findings. RN 1 was asked how often should the patient's medications be checked by licensed hospice nurses.  RN 1 replied the patient's medications should always be checked every home visit.  RN 1 verified Patient 3's medication profile should have been updated.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient’s POCs no less frequently than every 15 calendar days for three of three sampled patients (Patients 1, 2, and 3).  This failure had the potential for not providing appropriate, consistent, and quality care to these patients. Findings: --- 1. Review of Patient 3's clinical record was initiated on 2/23/26.  The clinical record showed the SOC was 4/10/25.  The patient was certified for hospice services during the certification periods from 4/10/25 to 7/8/25, 7/9/25 to 9/6/25, 9/7/25 to 11/5/25, 11/6/25 to 1/4/26, and 1/5/26 to 3/5/26. Review of Patient 3's POC/IDG Review dated 4/10/25, showed the patient’s identified care plan problems included self care deficit, risk for harm/injury, bowel and bladder incontinence, risk for skin impairment, impaired mobility, activity intolerance, impaired verbal communication, and reduced food portion consumption.  The identified problems were opened on 4/10/25 with a target date of 7/8/25. However, review of the POC/IDG Review dated 4/15, 4/29, 5/13, 5/27, 6/10, 6/24, and 7/8/25, failed to show documented evidence the IDG had updated the care plans to provide appropriate care to the patient. Further review of the POC/IDG Review dated 7/22, 8/5, 8/19, 9/2, 9/5, 9/19, 10/3,10/17,10/30,11/13, 11/26, 12/11,12/26, 1/9, 1/23, 2/6, and 2/20/26, failed to show documented evidence a care plan was developed for the patient.  There was no documented evidence the IDG have reviewed the established care plans on 4/10/25, to determine whether the care plans continued to be current problems and addressed all the patient’s care needs. 2.  Review of Patient 1’s closed clinical record was initiated on 2/23/26.  The clinical record showed the SOC was 9/15/24. The patient was certified for hospice services during the certification periods from 9/15/24 to 12/13/24, 12/14/24 to 3/13/25, 3/14/25 - 5/12/25, 5/13/25 to 7/11/25, 7/12/25 to 9/9/25, 9/10/25 to 11/8/25 11/9/25 to 1/7/26 and 1/8/26 to 3/8/26.  Patient 1 was discharged on 1/31/26.   Review of Patient 1's POC/IDG Review dated 10/15/24, showed the patient’s identified care plan problem included deficit in self-care, altered cardiac status, risk for fall, knowledge deficit on oxygen use, high risk for skin breakdown, impaired mobility, altered musculoskeletal status and altered respiratory status.   The identified problems were opened on 9/15/24 with a target date of 10/6/24. However, review of the POC/IDG Review dated 10/29, 11/12, 11/26, 12/10, 12/24/24, showed the care plan problem were unresolved; however, there was no documented evidence the IDG had updated the care plans to provide appropriate care to the patient. 3.  Review of Patient 2's closed clinical record was initiated on 2/23/26.  The clinical record showed the SOC was 10/12/24.  The patient was certified for hospice services during the certification periods from 10/12/24 to 1/9/25, 1/10/25 to 4/9/25, 4/10/25 to 6/8/25, 6/9/25 to 8/7/25 and 8/8/25 to 10/6/25.  Patient 2 was discharged 8/13/25.  Review of Patient 1's POC/IDG Review dated 11/12/24, showed the patient’s identified care plan problem included knowledge deficit related to hospice services and support.  The identified problem was opened on 10/15/24 with a target date of 1/9/25. However, review of the POC/IDG Review dated 11/26, 12/10, and 12/24/24, failed to show documented evidence the IDG had updated the care plan to provide appropriate care to the patient. On 2/25/26 at 1120 hours, an interview and concurrent clinical record review was conducted with the Medical Records Volunteer, Medical Director Designee, and Administrator.  They were informed and verified the above findings.

Observed in Record Review. In 1 of 1 patient records reviewed, with wound pictures, the organization failed to protect privacy of health information. During record review for HOSRRNHV#6, the Hospice Nurse Surveyor observed the wound pictures along with patient names were being texted to the owner/ Admin designee. She stated that she has a medical doctorate so it must be okay. The family sent the original photo but the owner/ Admin designee continued to text PHI regarding the wound. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to assess its patients. During record review for HOSRRNHV#1 and HOSRRNHV#4, the Hospice Nurse Surveyor observed the patient's comprehensive assessments were not completed. For example in HOSRRNHV#1, the patient was admitted 13 days prior to survey but the psychosocial assessment was not completed as of survey day. For HOSRRNHV#4, the patient was in their second benefit period but the spiritual care assessment had never been completed. There was no documentation of attempts to reach the patient to schedule the assessments. And there was no evidence that the assessments were completed by nursing. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to follow their policy on wound documentation. During record review for HOSRRNHV#6, the patient developed a Stage II pressure Ulcer and it had not been measured in 2 1/2 weeks. The organizational policy was wound measurements weekly. This was discussed and reviewed with the Hospice Owner/ Admin Designee.

Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to document assessments as required. During record review for HOSRRNHV#1, the Hospice Nurse Surveyor observed the patient was admitted 16 days prior to survey but there was no documentation of a bereavement assessment. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization failed to document a comprehensive assessment no less than every 15 days. During record review for HOSRRNHV#4 and HOSRRNHV#6, the patients had no RN comprehensive assessment as required at least every 15 days. For example in HOSRRNHV#4, the patient had a gap of 19 days and in HOSRRNHV#6, the patient had a gap of 17 days. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRNHV#1, HOSRRNHV#5, and HOSRRNHV#6, the Hospice Nurse Surveyor observed the plan of care was not complete. For example in HOSRRNHV#1, the patient has no documented nursing goals but narrative nursing notes state the patient is struggling with oral intake and SOB with minimal exertion. In HOSRRNHV#5, the patient was struggling with increased weakness and decreased oral intake in recent narrative nursing notes but these were not addressed on the plan of care. There were no goals and interventions related to nursing on the plan of care. In HOSRRNHV#6, the patient had a wound develop 17 days prior to survey but it was not addressed on the plan of care. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRNHV#1. For example in HOSRRNHV#1, the order for nursing frequency was incomplete. It read _____ per 2 weeks. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, where recertification was needed, the organization failed to plan the patient's care. During record review for HOSRRNHV#4 and HOSRRNHV#6, the Hospice Nurse Surveyor observed both patient were entering their next benefit period the day of survey but there were no documented updates to the comprehensive assessments and progress towards goals. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 3 of 6 patient records reviewed, the organization failed to provide care, treatment, or services for each patient. During record review for HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, and HOSRRNHV#6, the frequency orders were not followed. For example in HOSRRNHV#2 and HOSRRNHV#3, , the patients did not have nursing visits the week of 11/17. They were ordered once weekly. For HOSRRNHV#4, the patient had no visit the week of 11/9. SN visits were ordered weekly. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Tracer Activities. Leaders did not act on or comply with reports or recommendations from external authorized agencies.During tracer activities, the Hospice Nurse Surveyor observed there were repeat findings from previous survey activity including wound assessments, and comprehensive assessments. This was discussed and reviewed with the Owner/ Admin Designee. Observed in Tracer Activities. The organization governing board failed to document appointment of an administrator when the previous administrator resigned. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, requiring recertification, the organization failed to assess its patients. During record review for HOSRRNHV#4 and HOSRRNHV#6, the Hospice Nurse Surveyor observed both patients were entering their next benefit period on the day of survey but there was no documentation that the medical director reviewed their clinical information and signed the CTI prior to recertification. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Tracer Activities. The organization failed to comply with law and regulation. During tracer activities, the Hospice Nurse Surveyor observed the administrator was not updated CMS application and that the previous administrator prior to the last administrator is listed as the administrator on the 855A. Per conversation with the organizational staff, the person listed was administrator some time ago. This was discussed and reviewed with the Owner/ Admin Designee.

Observed in Record Review. In 2 of 2 patient records reviewed, of patients with wounds the surveyor observed that the wound not measured weekly as required by organization policy. The surveyor observed 5 weeks between measurements on 2 records. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 6 of 10 patient records reviewed, The surveyor observed that the RN had not visited the hospice patient every 15 days to conduct an assessment. This was observed on 6 hospice records with missing visits in excess of 5 weeks on 2/5 records reviewed. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 4 of 10 patient records reviewed, The hospice surveyor observed in review of record associated with HV#1 that the POC had not been followed related to SN visits as evidenced by the RN admission had been completed with POC ordering weekly nursing visits and the record showed over 3.5 weeks before the patient was visited again . On a second and third record review the surveyor observed that care plan had visits from nursing ordered weekly the visits had not occurred weekly , but with 2 week intervals between visits. The issue was discussed and confirmed with organization leader.

Observed in Record Review. In 4 of 5 patient records reviewed, with home health aides the surveyor observed that the aide supervision had not occurred every 14 days and on 2/5 records the surveyor observed 6 weeks between documented supervision visits by RN. This issue was discussed and confirmed with organization leadership.

Observed in Leadership Session. The surveyor observed that their had been no documented evidence that the hospice had any recruitment activities, while the organization stated that they had tried to recruit there was no documentation to support their statements for the years of 2022, 2023 2024 . This issue was discussed and confirmed with organization leadership.

Observed in Document Review. The organization had not at the time of survey had a formalized volunteer program that provided 5% of the total patient care hours of all paid hospice employees and contracted staff. The organization was able to provide surveyor with evidence from 2021 and previous, but nothing was documented for 2022, 2023, 2024. The organization had begun to regroup program and collect some data in September of 2025This issue was discussed and confirmed with organization leadership.

Observed in Record Review. Leadership failed to mange the implementation of 418.54 Condition of Participation: Initial & Comprehensive Assessment of the Patient Initial Assessment, Completion and Update of Comprehensive Assessment as evidenced by greater than 5 weeks on multiple records since RN assessment of patient. This issue was discussed and confirmed with leadership.

Observed in Record Review. In 7 of 10 patient records reviewed, The surveyor observed missing nursing notes that had been entered as done into the EMR system and either had nothing recorded on the note except time / date of visit or had been filled out in part , but not signed off and entered into completion into electronic medical record. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, of patients discharged alive the surveyor observed that the organization had not completed a discharge summary for patients. The issue was discussed and confirmed with organization leadership.

Observed in Patient Home. In 3 of 3 home visits conducted, - Information was not found in admission packet, patient handbook or documents provided to patient and family

Observed in HR File Review. In 2 of 6 HR files reviewed, the surveyor observed that they had not documented primary source verification on 1 LPN and 1 RN upon renewal of license . This issue was discussed and confirmed with organization leadership.

Observed in Record Review. The organization did not ensure the interdisciplinary group discussed/revised the patient’s plan of care at required intervals. For example, the surveyor noted in clinical records for HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, RR #4, RR #5, RR #6, and RR #7, there were greater than 15-day intervals of the interdisciplinary group coordination documented. Standards require the interdisciplinary group, in collaboration with the attending physician, review and revise the patient’s plan of care at least every fifteen calendar days. These findings were reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Patient Home. The staff failed to complete hand hygiene at required times outlined in the organization’s policy. For example, on HV #3/RR #3, the surveyor observed the RN changing gloves multiple times while conducting patient care, without completing hand hygiene in between. The organization’s policy requires standard precautions to be used, including hand hygiene after glove removal. These findings were reviewed, discussed, and confirmed with the Director of Patient Care Services.

Observed in Record Review. In 2 of 2 patient records reviewed, The organization failed to ensure post-death bereavement risk assessments were completed as required by the organization’s policy. For example, the surveyor noted on BR #1 and BR #2, there were no post death documentation, indicating the family/caregiver’s level of bereavement risk. The organization’s Bereavement Program policy requires a post-death bereavement risk assessment be completed, determine the bereaved risk level. These findings were reviewed, discussed and verified with the Director of Patient Care Services.

Observed in HR File Review. The organization failed to ensure their staff was competent to carry out role responsibilities as required by the organization’s policy. For example, the surveyor noted on PR #1, the CHHA’s record did not contain a skill’s competency checklist for the past year. The organization’s policy “Competency Program” requires a skills checklist, which reflects essential skills, will be utilized to demonstrate personnel’s competence in patient care on hire and annually. These findings were reviewed, discussed and verified with the Director of Patient Care Services.

Observed in Record Review. The organization did not ensure the registered nurse complete the hospice aide’s plan for patient care as required. For example, the surveyor noted on HV #1/RR #1 and RR #8, the aide’s care plan did not contain the frequency for aide visits. Standards require a registered nurse, as a member of the interdisciplinary group, prepare written care instructions for the hospice aide. These findings were reviewed, discussed, and verified with the Director of Patient Care Services.

Observed in Record Review. In 3 of 8 patient records reviewed, The organization did not ensure the registered nurse complete hospice aide supervisory visits as required. For example, the surveyor noted in the records of HV #1/RR #1, HV #3/RR #3 and RR #6, there were multiple occurrences where documentation of aide supervisory visits being completed at least every 14 were not present. Standards require the registered nurse supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. These findings were reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. The organization did not ensure the certification of terminal illness (CTI) was included in the patient’s record. For example, the surveyor noted on HV #1/RR #1, a CTI statement was not present in the patient’s electronic or hard clinical record. Standards require a written certification statement of terminal illness be filed in the patient’s record. These findings were reviewed, discussed, and confirmed with the Director of Patient Care Services.