Every finding on record at Compassus Bsmh Hampton Roads Hospice, LLC

It is required that The hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview, and observation. Agency policy and procedure #IPC.11_A2 "Infection Control: Bag Technique and Standard Precautions" (reviewed 01/01/2025) stated in part, "Remove all needed supplies from the bag utilizing at least 2 barriers for each visit, one barrier for clean items and one barrier for dirty, for placement of reusable items once they have been used i a visit. Wipe down supplies and equipment to be returned to the bag with an organization-approved disinfectant wipe. Allow to air dry prior to placing in bag." In 1 of 4 (25%) home visits observed, the agency did not ensure safe handling of soiled items and equipment per the agency's policy. Home Visit 3: The patient elected hospice care on 02/19/2025 with a diagnosis of malignant neoplasm of the rectum. During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 03/05/2025, the RN placed one barrier on the patient's bedside table, retrieved the blood pressure cuff, thermometer, and stethoscope from the nursing bag, and placed the equipment on it. The RN used the equipment to assess the patient's vital signs and then placed the used equipment on the same barrier. The RN cleansed their hands and cleaned the equipment with a disinfectant wipe. The RN placed the clean equipment on the same barrier to dry and then placed the equipment into the nursing bag. The RN did not use two barriers (clean and dirty) per the agency's policy. During an interview, the Area Executive of Clinical Operations (ACO), who was present for the home visit, confirmed that two barriers were not used and stated in part, "I saw that she placed the clean equipment on the dirty barrier."

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C15 "Nursing Services" (reviewed 12/24/2024) stated in part, "Supervision of LPN's/LVNs and paraprofessionals in the delivery of assigned tasks: i. LPNs/LVNs will receive an evaluation of services delivered at least every 1 month." In 1 of 17 (6%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) visits, the agency did not ensure that a Registered Nurse (RN) provided supervision of LPN services per agency policy. Clinical Record 14: The patient elected hospice care on 10/12/2024 with a diagnosis of Alzheimer's Disease. The hospice plan of care dated 10/12/2024 through 01/09/202 ordered skilled nursing (SN) services twice (2) weekly beginning 10/12/2024. The LPN completed nursing visits on 10/24/2024, 11/07/2024, and 12/05/2024. An LPN supervisory visit was completed on 12/19/2024. A clinical record review revealed no evidence that LPN supervisory visits were completed in October and November per agency policy. In a joint record review and interview on 03/05/2025, the Area Executive of Clinical Operations confirmed that LPN supervisory visits were not completed per agency policy, not less than monthly.

It is required that hospice aides are supervised by a registered nurse who makes 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 (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS-C15 "Nursing Services" (reviewed 12/24/2024) stated in part, "Hospice Aides will receive an evaluation of care provided at least every 14 days." In 1 of 12 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that a Registered Nurse (RN) 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 HA. Clinical Record 4: The patient elected hospice care on 01/09/2025 with a diagnosis of chronic lymphocytic leukemia. The hospice plan of care dated 01/09/2025 through 04/08/2025 ordered HA services three (3) times weekly beginning 01/12/2025. The HA visits were provided beginning 01/12/2025 as ordered. The HA supervisory visits were provided on 01/24/2025 and 02/11/2025, with 18 days outstanding. In a joint record review and interview on 03/05/2025, the Area Executive of Clinical Operations confirmed that, per agency policy, HA supervisory visits were not completed every 14 days.

Observed in Patient Home. In 4 of 4 home visits conducted, the hospice organization had not informed and/or provided the patient with a written description of any state law concerning advance directives. In review of the Hospice Patient Handbook for HOS RRHV #1 that is provided to patients and families although there is information regarding the organization's policies on advance directives there is no evidence that a written description of Virginia state laws were provided. This also occurred in review of the Hospice Patient Handbook for HOS RRHV #2, HOS RRHV #3 and HOS RRHV #4. This was validated with the Hospice Director of Clinical Services.

Observed in Record Review. In 1 of 14 patient records reviewed, the comprehensive assessment was not updated by the RN at least every 15 days as required by regulation and organizational policy. In review of the medical record for HOS RRHV #2 there were 24 days between the initial comprehensive assessment by the RN at the time of admission to the hospice program and the next RN visit to complete the update to the comprehensive assessment. This was validated by the Hospice Director of Clinical Services.

Observed in Patient Home. In 2 of 2 home visits conducted, nursing staff, the organization failed to assesses potential medication-related problems. In review of the hospice medication list for HOS RRHV #3 and in observation of the LPN reconcile the medications in the home it was noted that there were four medications that had been discontinued or stopped more than a month ago but continued to remain on the hospice medication list including; Aspirin, Atorvastatin, Hydroxyzine and Multivitamin. Additionally, there were two medications in the home but not included on the hospice medication list including; Lorazepam and Morphine Sulfate. Additionally, in review of the hospice medication list for HOS RRHV #4 and in observation of the RN reconcile the medications in the home it was noted that the medication Hyoscyamine was listed on the medication list but the son who was the primary caregiver reported that they had never received that medication. In review of the medical record the Hospice Director of Clinical Services stated that the medication had not been ordered.

Observed in Record Review. In 1 of 1 patient records reviewed, of patients who reside in skilled nursing facilities (SNF), the hospice organization did not provide the SNF with all required documents and information. For example, in review of the hospice chart in the skilled nursing facility for HOS RRHV #2 there was no evidence that the hospice had provided the SNF with the Plan of Care at the time of admission to the hospice program more than 4 months ago. The SNF reported that all hospice documents are scanned into the SNF electronic medical record and that the original documents are kept in the hospice chart. The hospice chart for HOS RRHV #2 had one plan of care in the chart from the most recent interdisciplinary team meeting however there was no evidence of any other plan of cares. This was validated by the Hospice Director of Clinical Services.

Observed in Tracer Activities. During system tracer activities, the Hospice Nurse Surveyor observed the organization did not provide emergency preparedness training for it's volunteer's, which included their roles and responsibilities in the emergency operations plan for the agency. This was discussed with the Home Care and Hospice Administrative Director.

Observed in Record Review. In 12 of 13 patient records reviewed, the Hospice Nurse Surveyor observed the Interdisciplinary group did not update the comprehensive assessment in collaboration with the attending physician as frequently as the patient's condition required, or no less than every 15 days. For example: in HV#2, the first IDG meeting was held on 11/17/21 but the only discipline noting collaboration for IDG was the SW. This was also noted in RR#1, RR#2, and RR#5. This was verified with the Hospice Leadership.

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Nurse Surveyor observed the care plans did not contain time frames for achieving the listed goals. For example: In HV#1, the RN listed Hospice Orientation as the problem associated with several interventions and goals attached but did not contain timeframes for achieving the goals. This was discussed with Hospice Leadership who identified it as a recent process improvement project.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. In HV#2, the Home Health Aide(HHA) failed to follow the organization's hand hygiene policy when she did not wash hands after performing tasks that involved risk of exposure to body fluids. The HHA did peri care and buttocks care, then immediately placed soiled wash cloth onto the bedside table, wiped the table down with it and then proceeded to provide lotion to the back/ legs/ feet without washing hands per organizational policy. This was verified immediately following the visit with the Hospice Scribe and then discussed with the Home Care and Hospice Administrative Director. Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Nurse Surveyor noted that the organization was unable to demonstrate the infection prevention and control activities it had planned; for example, in HV#1, the nurse did not sanitize hands or computer between providing care and documenting on her laptop per organizational policy. This was verified with the scribe and discussed with the Hospice Leadership.

Observed in HR File Review. In 5 of 5 HR files reviewed, the organization did not assess or document, at least once every three years, staff were competent to perform their responsibilities. During the HR/ Competency tracer, it was noted that Hospice did not have documentation of joint visit's for the last 3 years for all RN/ Chaplain/SW and at least annually for HHA staff. This was reviewed and discussed with the Hospice Director and Home Health/ Hospice Administrator.