Every finding on record at Compassus Bsmh Richmond Hospice, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 23 (4%) clinical records reviewed and home visits observed, the agency did not ensure the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 01/05/2025 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (Personnel Record 4) on 02/10/2025, the hospice medication profile (printed on 02/10/2025) was compared to the ALF medication profile (printed on 02/10/2025). The ALF medication profile documented an order dated 10/24/2024 for Milk of Magnesia 1200/15, two (2) tablespoons (30 ml) every 12 hours as needed. The hospice medication profile documented an order dated 01/05/2025 for Milk of Magnesia 1200/15, two (2) tablespoons (30 ml) every 12 hours scheduled. During an interview on 02/10/2025, the Director of Clinical Services, who was present during the home visit, confirmed the finding with the "as needed versus scheduled" and advised the medication should have been updated to the scheduled dosage as of 01/05/2025.

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: hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by document review, interview, and observation. The Centers for Disease Control and Prevention (CDC) "Clinical Safety: Hand Hygiene for Healthcare Workers" (dated 02/27/2024) stated in part, "CDC provides the following recommendations for hand hygiene in healthcare settings. Immediately before touching a patient...Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices...Before moving from work on a soiled body site to a clean body site on the same patient...After touching a patient or patient's surroundings...After contact with blood, body fluids, or contaminated surfaces...Immediately after glove removal." In 1 of 6 (17%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated per the CDC recommendations. Home Visit 5: During the home visit with the Registered Nurse (RN) [Personnel Record 12] on 02/11/2025, the RN typed on her tablet and then switched to assessing the patient without changing gloves or sanitizing their hands. The RN did not perform hand hygiene immediately before touching the patient. The Director of Clinical Services (DCS), who was present during the home visit, confirmed the finding. During Home Visit 5 on 02/11/2025 with Personnel Record 12 (RN), she was observed to utilize her vital sign equipment (blood pressure cuff, stethoscope, pulse oximeter) to take the patient's vital signs and then place them back inside her nursing bag without sanitizing them. She was then observed to remove her tablet and place it directly on the patient's bedside table without utilizing a protective barrier. She began typing on her tablet and then switched back to assessing the patient, without changing gloves or sanitizing her hands. The hospice Director of Clinical Services was present on the visit and observed these infection control variations and spoke to the RN after the the visit. The Director later reported back during an interview with the Administrator in the office the RN stated "as soon as I did it I knew it wasn't right" when they were talking about putting the equipment back in the bag.

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the Hospice Aide. Clinical Record 8: The patient elected hospice care on 07/14/2023 with a diagnosis of malignant neoplasm of the female breast. The patient's level of care changed from routine to respite on 12/20/2024. Respite care was provided at the facility owned by the hospice. The HA care plan dated 12/20/2024 assigned the HA the relevant tasks: assist to toilet, bathing via shower, dressing, hair care, skincare, stand-by assist with ambulation, assist with side rails, fall precautions, vital signs to include blood pressure, pulse, respirations, temperature all to be completed every visit. The plan of care ordered HA services three times weekly. The patient returned to a routine level of care on 12/26/2024. No updates were made to the HA care plan. The skilled nursing (SN) visit note, and a physician order dated 01/22/2025 documented a Foley catheter was started on the patient. The HA care plan was not updated to include the Foley catheter care during personal care. The patient returned to respite on 01/28/2025, and the Foley catheter was removed on 02/02/2025. As of the clinical record review on 02/12/2025, the HA care plan dated 12/20/2024 has remained the same, with no updates since the patient's first respite stay. Clinical Record 21: The patient elected hospice care on 07/05/2024 with a diagnosis of malignant neoplasm of the female breast. The HA care plan dated 08/30/2024 assigned the HA the relevant tasks: bathing via bed bath, dressing, oral care, skin care, RN communication for any incomplete tasks, bleeding precautions, fall precautions, and infection control precautions. All tasks were to be completed every visit with a HA visit frequency of twice weekly. For the second benefit that started 10/03/2024, the recertification nursing assessment documented: "Coccyx Pressure Ulcer, Stage IV apply silver dressing and gauze; covered with foam; blister on right calf, covered with gauze; unstageable wound on left calf covered with gauze and right heel wound covered with foam. The HA care plan was not updated to notify the aide of the wounds or to provide the HA with instructions to notify the RN if the dressings became soiled, dislodged, or wet. The Administrator and Regional Director of Quality confirmed the finding during an interview and a joint clinical record review on 02/12/2025. The Administrator stated that the "aide care plan in Clinical Record 8 had not been updated to remove the inpatient unit tasks when the patient returned home from respite, and the tasks for the Foley care had not been added to the aide care plan during the time the patient had the Foley and the wound care instructions Clinical Record 21 had "also been overlooked on the aide care plan."

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the hospice election form for each patient/resident. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits observed of a patient residing in a skilled nursing facility (SNF), the agency did not ensure that the SNF received the patient's hospice election form. Home Visit 5/Clinical Record 5: The patient elected hospice care on 07/04/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 12] on 02/11/2025, the Clinical Director, who was present for the home visit, advised the SNF staff had not "allowed the hospice staff to keep a binder at the facility with the required paperwork, so she had brought one." During an interview, the SNF Director of Nursing (DON) advised that the SNF "was going paperless, and they had scanned all the hospice paperwork into the computer." A joint review with the hospice Clinical Director of the patient's documents scanned into the SNF computer revealed the facility's coordination of care documentation, the patient's plan of care, and the patient's advance directives. The hospice binder provided by the Clinical Director was reviewed, and patient documents were included, except for the hospice election form. A second joint review of the hospice documents in the SNF computer with the SNF DON and the hospice Clinical Director did not reveal the hospice election form. The patient who elected hospice care on 07/04/2024 received bi-weekly nursing visits, bi-weekly aide visits, monthly social worker (SW), spiritual counselor, and volunteer visits. The Registered Nurse (RN) or SW had attended the SNF care conferences but had not updated the binder or verified it contained the hospice election form. Home Visit 5 on 02/11/2025 with Personnel Record 12 (RN), accompanied by the Hospice Clinical Director, was conducted at the Skilled Nursing Facility (SNF). Upon arrival, the Clinical Director advised the SNF staff had not "allowed the hospice staff to keep a binder at the facility with the required paperwork so she had brought one." Once the patient care observation was completed, the Clinical Director and I met with the SNF Director of Nursing, Kim. Kim advised the SNF "was going paperless and they had scanned all the hospice paperwork into the computer." Kim allowed us to look at the computer. The hospice items in the computer were the facility coordination of care, the hospice plan of care and the advance directives. The hospice binder brought by the Clinical Director was reviewed and the remaining required elements were present except for the hospice election form. We reviewed the SNF computer chart again for the form, Kim checked with medical records and the Clinical Director checked her binder but the form was not present. This patient had been on hospice services since 07/04/2024. She had bi weekly nursing visits, bi weekly aide visits, monthly social worker, spiritual counselor and volunteer visits. The RN or SW has been attending her care conferences but had not updated the binder or verified it contained the correct elements.

Observed in Infection Control System Tracer. During the Infection Control System Tracer, the surveyor noted that the organization's evaluation of the 2021 Annual Quality Plan for Hospice indicated a goal for incidence rate for infection was not met (Goal: less than or equal to 1% Actual: 2.4%). A thorough breakdown of the infections/infection sites leading to the overall rate and to assist in evaluating and responding to rate of infection was unavailable. Data presented indicated a high percentage of infections for which site was unspecified and/or unavailable. For example, for Oct. - Dec. 2021, organization data indicated treatment of infection for which 294 sites of infection were unspecified (78%) and 81 instances for which the site was specified as one of the following: UTI, respiratory, skin/wound, conjunctivitis, yeast, or diarrhea (22%). This observation was discussed with the Director of Hospice and the Quality and Compliance Officer.

Observed in Building Tour. The organization did not ensure that patient care equipment was cleaned and disinfected on a regular basis. For example, during the building tour of the inpatient unit east wing 2 oxygen concentrators were bagged as clean and disinfected. The label to indicate the date of cleaning/disinfection for the two oxygen concentrators was 2018 in patient room #1. In patient room #2, one oxygen concentrator was bagged as clean and disinfected. There was no label to indicate the date of cleaning/disinfection for this one oxygen concentrator. This observation was reviewed with the Facilities Supervisor. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.

Observed in Building Tour. The surveyor observed that the piping for approved automatic sprinkler systems was supporting other items. For example, there was a yellow cord resting on the sprinkler pipe. This observation was reviewed with the Facilities Supervisor. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.