Every finding on record at Compassus Bsmh Youngstown Hospice, LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. 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 4 of 17 (24%) clinical records reviewed from the community program in which a Hospice Aide was accepted, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. CLINICAL RECORD 1: The patient elected hospice care on 01/14/2026 with a diagnosis of prostate cancer. The HA care plan was documented on 01/16/2026 and updated on 01/31/2026, assigning the HA the tasks of bed bath and perineal care on every visit. On 01/30/2026, the physician ordered wound care for a new wound on the patient's coccyx that required cleaning and a foam border dressing to be changed every 3 days. The HA care plan did not identify the patient's wound and did not provide the HA with instructions for what to do if the dressing became soiled, wet, or dislodged. CLINICAL RECORD 4: The patient elected hospice care on 11/26/2025 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The HA care plan was documented on 11/26/2025, assigning the HA the tasks of bed bath, shampoo, and perineal care on every visit. The patient had wound dressings that began on 12/12/2025 on the left and right breasts. The right breast wound was healed as of 01/15/2026. The left breast care wound continues as of the clinical record review on 02/03/2026. The HA care plan did not provide the HA with instructions for what to do if the wound dressing became soiled, wet, or dislodged. CLINICAL RECORD 10: The patient elected hospice care on 01/29/2026 with a diagnosis of pancreatic cancer. On 01/29/2026, the physician ordered a Foley catheter. The HA care plan was documented 02/02/2026, assigning the HA the tasks of bed bath and perineal care every visit. The HA care plan did not provide the HA with instructions for Foley catheter care or emptying the drainage bag. CLINICAL RECORD 12: The patient elected hospice care on 01/14/2026 with a diagnosis of esophageal cancer. The initial comprehensive nursing assessment, dated 01/14/2026, documented that the patient had a Foley catheter. The HA care plan was documented on 01/14/2026 and updated on 01/15/2026, assigning the HA the tasks of bed bath, oral care, shampoo, and perineal care on every visit. The HA care plan did not provide the HA with instructions for Foley catheter care or emptying the drainage bag. During an interview and a joint record review on 02/04/2026, the Director of Clinical Services stated that the details of tasks on the aide care plan were missing.

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; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of community hospice patients receiving Hospice Aide services for greater than 14 days, the agency did not ensure that the Hospice Aide was supervised by a Registered Nurse (RN) at least every 14 days. CLINICAL RECORD 7: The patient elected hospice care on 09/12/2025 with diagnoses of Parkinson's disease and chronic obstructive pulmonary disease (COPD). The plan of care ordered HA services 2 times a week. The first HA visit was dated 09/13/2025. HA supervisory visits were documented on 09/18/2025 and 10/09/2025, with 20 days outstanding. During an interview and a joint record review on 02/05/2026, the Director of Clinical Services stated that the 14-day supervision was not documented.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed for the community program, the agency did not ensure that the patient's clinical record included treatment orders to meet the patient's needs. CLINICAL RECORD 10: The patient elected hospice care on 01/29/2026 with a diagnosis of pancreatic cancer. The initial comprehensive assessment dated 01/29/2026 documented that the Foley catheter was in place, draining bloody urine. A clinical record review revealed no orders to change or irrigate the catheter as of 02/03/2026. During an interview and a joint record review on 02/05/2026, the Director of Clinical Services stated that the order was not documented in the record.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code (LSC) fire drills at varied times on all shifts. This standard was not met as evidenced by document review, interview, and observation. Agency Policy and Procedure #C_28A.7 "Fire Drills and Sprinkler Checks - Hospice Inpatient Unit" (last revised on 05/31/2024) states, in part, that "The Hospice inpatient unit (IPU) manager (or designee) is responsible to ensure that planning, implementation, and conduct a Fire Drill for all shifts." This procedure also referenced "Quarterly fire drill documentation" in the "Equipment" section. The agency did not ensure that the inpatient unit (IPU) conducted and documented quarterly fire drills for each shift. During the IPU tour on 02/04/2026, a review of the 2025 fire drill log referenced fire drills held on the following dates and shifts: 01/30/2025 (day shift), 02/27/2025 (afternoon shift), 03/14/2025 (night shift), 05/27/2025 (day shift), 09/04/2025 (afternoon shift), and 12/15/2025 (night shift). A review of the fire drill logs for the agency's inpatient unit (IPU) revealed that the agency did not ensure that fire drills were held quarterly for each shift. Additionally, this references K712 "Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift...." During an interview on 02/04/2026, the Director of Clinical Services (DCS) for the IPU stated that no additional fire drills had been held beyond those included in the 2025 fire drill log. The DCS confirmed that the IPU operates on a three-shift-a-day schedule. A review of the fire drill logs for the agency's inpatient unit (IPU) revealed that the agency failed to ensure that fire drills were held quarterly for each shift at the IPU. This also references K-Tag K712 (11742) which states that fire drills are to be held at expected and unexpected times under varying conditions, at least quarterly on each shift.

Observed in Record Review. In 1 of 10 patient records reviewed, there were no specific orders for the amount or for the frequency of drainage from a pleurx drain. This patient had abdominal ascites. The order was obtained by the organization during this survey for the missing order which covered a two- week time frame. This was confirmed by hospice leadership and quality management.

Observed in Individual Tracer. In 7 of 23 patient records reviewed, The hospice nurse surveyor noted (HOSVRR#1) that the comprehensive assessment was incomplete and did not include an evaluation of the severity of symptoms or the factors that alleviate or exacerbate physical symptoms of agitation, nausea, and dyspnea. Also, the electronic medical record document was blank for assessment of risk factors and the amount of oxygen the patient was currently using. Also, the patient was insulin dependent diabetic with wounds to his lower extremities; however, there was no assessment of the diabetes. In (HOSVRR#3), the surveyor noted that the assessment indicated that the patient has nausea, ascites and jaundice; however, there was no assessment of the severity of the symptoms. There was no evidence in the record for (ARR#8) of an assessment of the severity of the patients fungal rash under the breast or the foot fracture and brace use; in (ARR#9), (ARR#12 and (ARR#22) there was no documentation of the severity of agitation. In (ARR#20) there was no assessment of the severity of the patient's nausea, identified on admission with ordered antiemetic medication. This was confirmed with the clinical manager.

Observed in Individual Tracer. In 6 of 23 patient records reviewed, The hospice nurse surveyor noted (HOSVRR#1) that there were no measurable outcomes for managing the patients wound, edema or symptoms of hypo/hyperglycemia. In (HOSVRR#2) there were no measurable outcomes for managing dysphagia and risk for aspiration. Also, there were no measurable outcomes for ARR#12 for managing agitation and combativeness, ARR#13 did not have any measurable outcomes, ARR#14 did not include goals or measures for managing dyspnea and constipation, and ARR#20 did not include any goals or measurable outcomes for managing nausea, an indwelling Foley catheter or a wound. This was confirmed with the clinical manager.

Observed in Individual Tracer. In 11 of 23 patient records reviewed, The hospice nurse surveyor noted (HOSVRR#1) that the plan of care did not include all interventions to manage symptoms of edema and hypo/hyperglycemia for this insulin dependent patient. IN (HOSVRR#2), there were no interventions to manage dysphagia, syncope or pain, on the plan of care. Also,(HOSVRR#2), there were no interventions to manage the patient's dysphagia. In (HOSVRR#5), the patient has orders for daily nursing visits and the nurse explained that they were using the Pleurex drain to remove fluid daily. The orders were unclear and read Pleurex drain as needed and did not provide information about the amount of fluid to be removed or the maximum volume to be removed on a daily basis. In (HOSVRR#6) the patient was receiving oxygen continuously; however, the only order of file was for oxygen 2-5 lpm as needed and was not individualized to the patient's needs. The patient's caregiver indicated that she had decided to put the patient on 5 lpm the evening before, and there was no indication that she understood the dosing requirements for using the oxygen. There were no interventions that included educating the caregiver on the use of oxygen. In ARR#7, the notes indicated that the patient was on O2 3 lpm continuously; however, there were no orders or plan of care for continuous oxygen. Also, the plan of care indicated that the patient had a PEG and a midline wound; however, there was no evidence in the assessments or notes of a midline wound or PEG. In ARR#9, there were no interventions for wound care, in ARR#11, there were no interventions for dyspnea. In ARR#14, the assessment indicated that the patient has a wound, a Foley catheter, a port, symptoms of constipation; however, there were no interventions on the plan of care to manage the individual needs of the patient. In ARR#15, there were no interventions to manage the volume of fluid removed via Pleurex catheter as needed. In, ARR#18 the patient was on Oxygen 5 lpm continuously and there was smoking in the home; however, the care plan did not reflect the patients need for continuous oxygen or the safety needs related to oxygen and smoking. In ARR#21, the patient was assessed to have a blood pressure of 65/43; however, there were no interventions to address the hypotension. This was confirmed with the clinical manager. is was confirmed with the clinical manager.

Observed in Individual Tracer. In 27 of 27 patient records reviewed, The hospice nurse surveyor noted that the medication orders for IPURR#2 included Zofran oral medication dosing, that was instituted as a standing order.. The patient was also prescribed and receiving Zofran IV. The orders did not clarify whether she was to continue the IV dosing or if she could be transitioned to oral dosing. The standing order was not discontinued. The surveyor noted that all the IPU records (4) and the active routine care patients records reviewed (23) included standing medication orders and were not ordered to the individual needs of the patient. This was confirmed with the clinical director and medical director. Observed in Record Review. In 4 of 4 patient records reviewed, The hospice nurse surveyor noted (IPURR#1) that the standing medication orders were unclear. The surveyor observed the nurse administer Morphine and Ativan, with a saline flush after each medication via two different subcutaneous ports. In review of the medication administration record it was noted that the saline flush order was unclear and read sodium chloride flush 0.9% injection 10 ml IV prn for line care and included a prn use indication Foley catheter to continuous drainage if needed for urinary retention in the medication line. Also, the route did not include a subcutaneous option. The surveyor noted that the same order was populated to the 4 of 4 RR IPU the standing order populated in the EPIC EMR medication administration record, and did not include another option for subcutaneous use. In discussion with the clinical manager it was determined that it was an incorrect entry and should not have been documented as such, and that the EMR process was faulty and was created in error several months prior.

Observed in Individual Tracer. The hospice nurse surveyor noted (HOSVRR#1) that the nurse failed to clean the scissors used to remove a soiled dressing, before using them to cut the alginate dressing being applied directly to the wound. Also, the nurse failed to clean the inside blades of the scissors after use, and before returning them to her bag. Also, in (HOSVRR#3), the surveyor observed the chaplain place the soiled paper towels, used to clean his hand, back into his bag, instead of into the patient trash as instructed in the Bag Technique policy. This was confirmed with the clinical manager. Observed in Individual Tracer. In 2 of 6 home visits conducted, The hospice nurse surveyor noted (HOSVRR#1) that the nurse failed to change gloves when providing wound care. The surveyor noted that the nurse removed the dressing from the right lower extremity, examined the wound and measured the wound bed using a sterile applicator. The nurse then proceeded to partially remove the dressing from the right lower extremity, wearing the same gloves. Also, the nurse proceeded to measure the wound depth, using the contaminated applicator, used to measure the first wound, and then replaced the original dressing to the wound. The organization approved procedure required that a sterile device be used to perform wound measurements; however, the device was contaminated after use on the first wound. Also, gloves were not changed between dressing removal, accessing the second wound, measuring the wounds and then reinforcing the original dressing on the second wound. This was confirmed with the nurse manager.

Observed in Tracer Activities. The hospice nurse surveyor noted during tracer activities that the organization had not defined policies and procedures for managing the certificate of terminal illness process. The surveyor noted that nine patient records did not include the physician narrative for thirty days or longer and that two skilled nursing facility records, observed on site, did not include the completed certification statement. The surveyor noted in (HOSV#3), that the certification statement was not complete and there was no evidence that the section titled Certifying Physician Summary was completed since the patient was admitted in November. Also, the certification narrative summary was not completed in (ARR#8), (ARR#11, #13, #14, #15,#16 and #18). This was confirmed with the clinical manager and has been corrected on site. Observed in Tracer Activities. The hospice nurse surveyor noted that the organization did not have a defined process or policy for implementing standing orders. The surveyor noted on tracer activities that the orders for care were implemented by the nurses choice and not based on clear instruction or parameters. For example, oxygen 2-5 lpm prn as needed, Insert #14-22 Foley catheter for urinary incontinence or retention, Change every 30-60 days and prn. Irrigate with 30-50 ml sterile 0.9% Sodium Chloride prn for catheter obstruction and Naso-pharyngeal suction prn Yankauer or by suction catheter was ordered on all patients and did not include clear instructions for implementation that were based on the patient's individualized needs. In discussion with the leadership team and the medical director, it was confirmed that there were no policies that directed the use of standing orders, or a policy for review and approval. This was confirmed with the administrator.

Observed in Record Review. In 1 of 4 closed records reviewed, The hospice nurse surveyor noted (CRR#27) that discharge summary only indicated the patient revoked and went to a hospital to seek aggressive treatment for shoulder pain. There was no summary of the care, treatment and services provided to the receiving organization. This was confirmed with the clinical manager.

Observed in Individual Tracer. In 1 of 2 facility patient visits, The hospice nurse surveyor noted (HOSVRR#3) that the hospice failed to provide the facility with a copy of the patient’s most recent plan of care and there was no information about who was responsible for the components of the patient care and treatments. The surveyor noted that there was no evidence in the facility record or the hospice facility chart that the documents were provided since the patient was admitted to hospice in October. The only documents in the chart were visit note updates. The surveyor noted that there was no plan of care in the facility file. This was confirmed with the nurse manager.

Observed in Individual Tracer. In 1 of 4 home visits with oxygen, The hospice nurse surveyor noted (HOSVRR#6) that an M oxygen tank did not have a rack or cradle and was stored upright in the home. This was confirmed with the nurse manager.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. 1 of 3 (33%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that the hospice aide provided services included in the plan of care. Clinical Record 4: The patient elected hospice care on 01/07/23. The hospice aide care plan, effective from 01/07/23 to current, ordered two visits per week and included the assigned task: "shampoo every week." During the weeks of 03/26/23 and 04/02/23, the hospice aide documented that the shampoo task was "completed" on 3/31/23 and 3/27/23, and 04/03/23 and 04/07/23, two times weekly. During an interview and a joint record review, the Clinical Manager confirmed that the aide documented the shampoo was being completed with each visit rather than weekly as ordered.