Every finding on record at Compassionate Healthcare Solutions Inc

Upon patient record review 13 of 15 (Patient #1.#2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #1.#2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15: There was no evidence of a spiritual needs assessment performed by nurse, social work, or spiritual care.

Upon patient record review, 6 of 15 (Patient #5,#6, #7, #12, #13, #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 #5: The medication profile dated 1/11/2023 includes Triamcinolone cream 1% 1x day to affected area. There was no evidence of an area to apply. Patient #6: The medication profile dated 10/13/2023 included MS 30mg/5ml SL Q 3-4 hours PRN pain, and Dilaudid 5mg i cap PO Q 4-6 hours for severe pain, there was no evidence of parameters for dispensing. Patient #7: The medication profile did not include O2 (ordered 2/18/2023). Agency found old profile from H&P, no other documents exist. There was no documented medication profile for this pt. Patient #12: The medication profile did not include O2 (ordered 7/5/2023). Patient #13: The medication profile did not include O2 (ordered 10/7/2023). Patient #15: SN noted dated 9/23/2023 included O2 at 2L/M, during continuous care visit. The medication profile did not include O2.

Upon patient record review, 9 of 15 (Patient #1.#2, #3, #4, #5, #6, #7, #10, #12) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, #2, #3, #4, #5, #6, #7, #10, #12: There was no evidence of a bereavement assessment on the comprehensive assessment.

Upon patient record review, 2 of 15 (Patient #7, #14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #7: Comprehensive assessments dated 1/20/2023 and 2/22/2023, no evidence of occurring no less frequently than every 15 days. Patient #14: Comprehensive assessments dated 8/8/2023 and 8/30/2023, no evidence of occurring no less frequently than every 15 days.

Upon patient record review, 8 of 15 (Patient #1, #2, #3, #4, #5, #6, #10, #12) 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, #2: SOC SN assessment identified high risk for falls, no evidence on the POC of a problem/interventions/goals for fall risk. Corrected on site. Patient #3: Taking Eliquis to prevent clotting, there was no evidence on the POC of a problem/interventions/goals for bleeding precautions. Patient #4:SOC SN identified Norton pressure score risk "9" very high, patient has documented dysphagia. No evidence on the POC of a problem/interventions/goals for skin integrity or dysphagia. Patient #5: SOC SN assessment identified high risk for falls, no evidence on the POC of a problem/interventions/goals for fall risk. Patient #6: SOC SN assessment identified high risk for falls, Norton pressure score risk "15" medium. No evidence on the POC of a problem/interventions/goals for skin integrity or falls. Patient #10: SOC SN assessment identified high risk for falls, no evidence on the POC of a problem/interventions/goals for fall risk. Patient #12: SOC SN assessment identified high risk for falls, Norton pressure score risk "9" very high, pt has order for O2. No evidence on the POC of a problem/interventions/goals for skin integrity, falls or Oxygen.

Upon patient record review, 3 of 15 (Patient #6, #10, #11) 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 #6: Spiritual care and MSW on SOC ordered "as needed", no evidence of detailed statement of scope and frequency. Patient #10: Spiritual care on SOC ordered "PRN", no evidence of detailed statement of scope and frequency. Patient #11: Spiritual care on SOC ordered "as needed", no evidence of detailed statement of scope and frequency.

Upon patient record review, 5 of 15 (Patient #6, #7, #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 medications and treatments. Patient #6: Order dated 10/13/2023 included MS 30mg/5ml SL Q 3-4 hours PRN pain, and Dilaudid 5mg i cap PO Q 4-6 hours for severe pain, there was no evidence of parameters for dispensing. Patient #7: Order dated 2/18/2023 included O2 @2L/M for SOB and Sat <90%. There was no evidence of a route. Patient #11: Physician visited pt. 6/19/2023, notes included medications: Flomax, Lotrel, ASA, Finasteride. There were no documented orders for medications for this pt. Patient #12: Order dated 7/5/2023 included O2 2L/M for SOB. There was no evidence of a route/order not signed. Patient #15: SN noted dated 9/23/2023 included O2 at 2L/M, during continuous care visit. There was no evidence of an order for O2.

Upon client record review, 1 of 15 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7: SOC 4/18/2022, added O2 orders 2/18/2023, there was no evidence Oxygen was added to the POC.

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 #1: RN placed items used for vitals back into nursing bag without cleaning them. In and out of clean bag without cleansing hands.

Upon patient record review, 1 of 15 (Patient #10) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #10: There was no evidence of an after death bereavement assessment/plan of care/offer of bereavement services.

Upon patient record review, 1 of 15 (Patient #15) 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 #15: Identified at SOC as high fall risk, no evidence of fall risk on aide assignment.

Upon patient record review 1 of 15 (Patient #14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel #6: Was functioning as a volunteer (unpaid) VC, no evidence of a designated hospice employee. Corrected on site.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. One current volunteer, 17 years old, for administrative work only. There was no evidence of the ability to provide a direct care volunteer. VC taking on this role, Corrected on site.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 There was no evidence of volunteer cost savings since 2020 with previous agency. Agency purchased by current owner July 2023.

Upon patient client record review, 1 of 17 (Patient #1) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1: Requested list of uncovered items, no evidence this was provide

Upon client record review, 1 of 15 (Patient #6) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #6: There was no evidence of the hospice forwarding a summary of the patient record when transferred.

Upon client record review, 3 of 15 (Patient #3, #4, #5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patients #3, #4, #5: There was no evidence that a discharge summary was sent to the attending physician.

Upon client record review, 3 of 15 (Patient #3, #4, #5) did not have evidence that the discharge summary includes all required information. Patient #3, #4, #5: There was no evidence the discharge summary included current Plan of care, physician orders or a complete summary of patients stay.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. Agency purchased in July 2023, had not been providing since purchase. Patients on service today have now received- corrected on site.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. Patients #1, #2: There was no evidence the policies and procedures for managing controlled drugs was provided. Corrected on site. Patients #6, #11, #15: There was no evidence the policies and procedures for managing controlled drugs was provided.

Upon client record review, 5 of 15 (Patient #1, #2, #6, #11, #15 ) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients #1, #2: There was no evidence the policies and procedures for managing controlled drugs was provided. Corrected on site. Patients #6, #11, #15: There was no evidence the policies and procedures for managing controlled drugs was provided.