Every finding on record at Compassus Ohiohealth Columbus 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; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed the agency did not ensure that all of the patient's current medications were included in the patient's drug profile. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/22/2025. The initial nursing assessment dated 08/22/2025 documented "Patient utilizes oxygen continuously." The medication profile dated 08/22/2025 did not document oxygen. CLINICAL RECORD 26: The patient elected the hospice benefit on 08/29/2025. The initial nursing assessment dated 08/29/2025 documented "Patient utilizes oxygen at 2 liters continuously." The medication profile dated 08/29/2025 did not document oxygen. During joint record reviews and interviews on 11/19/2025 and 11/21/2025, the Area Executive of Clinical Operations confirmed the above findings, stating, "Oxygen is not on the medication profiles for these patients."

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed, the agency did not ensure that planned interventions based on problems identified in the initial and updated comprehensive assessments were included in the patient's individualized written plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/04/2025. The initial nursing assessment dated 11/04/2025 documented "Patient is always incontinent." The plan of care dated 11/04/2025 through 02/01/2026 did not include interventions related to skin integrity. CLINICAL RECORD 12: The patient elected the hospice benefit on 10/30/2025. The initial nursing assessment dated 10/30/2025 documented "Patient is always incontinent." The plan of care dated 10/30/2025 through 01/27/2026 did not include interventions related to skin integrity. During joint record reviews and interviews on 11/18/2025, 11/19/2025, and 11/20/2025, the Area Executive of Clinical Operations confirmed the above findings, stating, "There are no interventions for skin integrity on the plans of care".

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-C_12A "Supervision of Hospice Aides and LP/VN Colleagues" (dated 12/31/2024) read in part "The RN is responsible to perform a supervisory visit of the LPN/LVN at least every 30 days." In 3 of 27 (11%) clinical records reviewed of patients who received Licensed Practical Nurse (LPN) services, the agency did not ensure that a Registered Nurse (RN) performed a supervisory visit of the LPN at least every 30 days, as per agency policy. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/26/2025. The plan of care dated 09/22/2025 through 11/20/2025 ordered "Skilled Nurse (SN) 1x weekly." The LPN documented visits completed on 09/24/2025, 10/23/2025, and 11/12/2025. A clinical record review revealed no documented evidence of LPN supervisory visits. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/09/2025. The plan of care dated 08/09/2025 through 11/06/2025 ordered "SN 1x weekly." The LPN documented visits completed on 08/15/2025, 08/25/2025, 09/08/2025, 09/15/2025, 09/22/2025, and 09/29/2025. The first LPN supervisory visit was on 09/03/2025. The next LPN supervisory visit was on 10/30/2025, with 57 days outstanding. CLINICAL RECORD 17: The patient elected the hospice benefit on 10/15/2025. The plan of care dated 10/15/2025 through 01/12/2026 ordered "SN 1x weekly". The LPN documented visits completed on 10/16/2025, 11/14/2025, 11/17/2025, and 11/19/2025. A clinical record review revealed no documented evidence of LPN supervisory visits. During joint record reviews and interviews on 11/18/2025 and 11/20/2025, the Area Executive of Clinical Operations confirmed that Licensed Practical Nurse supervisory visits were not completed every 30 days per agency policy.

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 6 of 20 (30%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/28/2025 with a diagnosis of Huntington's Disease. The patient resided in a skilled nursing facility (SNF). The plan of care dated 10/28/2025 through 01/25/2026 ordered "Seizure precautions." A physician's order dated 10/31/2025 ordered "Hospice Aide 2 times per week." The Hospice Aide care plan dated 11/15/2025 did not include instructions to the Hospice Aide regarding seizure precautions. CLINICAL RECORD 7: The patient elected the hospice benefit on 04/17/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided at home. The plan of care dated 10/14/2025 through 12/12/2025 ordered "Oxygen 3 liters via nasal cannula continuously" and "Hospice Aide 2 times per week." The Hospice Aide care plan dated 11/17/2025 did not include instructions to the Hospice Aide regarding the oxygen. CLINICAL RECORD 13: The patient elected the hospice benefit on 09/09/2025 with a diagnosis of end-stage heart failure. The patient resided at home. A physician's order dated 09/10/2025 ordered wound care with a dressing to wounds on the patient's coccyx, left arm, and right arm. The plan of care dated 09/09/2025 through 12/07/2025 ordered "Hospice Aide 2 times per week." The Hospice Aide care plan dated 09/09/2025 assigned the HA the task of "Bed bath every visit." The Hospice Aide care plan was not updated to include wound dressing instructions, should the wound dressings on the patient's coccyx, right arm, and left arm become dislodged during the bed bath. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/09/2025 with a diagnosis of end-stage renal disease. The patient resided at home. The plan of care dated 08/09/2025 through 11/06/2025 included orders for a Foley catheter and "Hospice Aide 2 times per week." The Hospice Aide care plan dated 08/09/2025 did not include instructions for Foley catheter care. CLINICAL RECORD 26: The patient elected the hospice benefit on 08/29/2025 with a diagnosis of traumatic brain injury. The patient resided at home. The plan of care dated 08/29/2025 through 11/26/2025 ordered "Hospice Aide 3 times per week." The skilled nursing (SN) visit note dated 08/30/2025 documented that "RN placed 16 French (Fr) Foley catheter." The Hospice Aide care plan dated 08/29/2025 was not updated to include instructions for Foley catheter care. CLINICAL RECORD 27: The patient elected the hospice benefit on 07/23/2025 with a diagnosis of congestive heart failure (CHF). The patient resided in an assisted living facility (ALF). The plan of care dated 07/23/2025 through 10/20/2025 ordered "Hospice Aide 1 time per week." The SN visit note dated 08/11/2025 documented "Patient now has a Foley catheter." The Hospice Aide care plan dated 07/23/2025 was not updated to include instructions for Foley catheter care. During joint record reviews and interviews on 11/18/2025, 11/20/2025, and 11/21/2025, the Area Executive of Clinical Operations confirmed the above findings, stating, "Wound dressing instructions, Foley catheter care instructions, seizure precautions, and oxygen precautions were not included in the HA care plans."

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 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 2 of 20 (10%) clinical records reviewed for patients who received Hospice Aide services, the agency did not ensure that Hospice Aide (HA) supervisory visits were completed at least every 14 days. CLINICAL RECORD 14: The patient elected the hospice benefit on 08/09/2025. The plan of care dated 08/09/2025 through 11/06/2025 ordered "Hospice Aide 2 times per week starting week of 08/10/2025." The first Hospice Aide visit was dated 08/15/2025. The first Hospice Aide supervisory visit was dated 09/24/2025, with 40 days outstanding. CLINICAL RECORD 23: The patient elected the hospice benefit on 03/26/2025. A physician's order dated 06/06/2025 ordered "Hospice Aide 2 times per week starting week of 06/08/2025." The first Hospice Aide visit was dated 06/10/2025. Hospice Aide supervisory visits were conducted on 06/20/2025 (10 days), 07/02/2025 (12 days), and 07/18/2025 (with 16 days outstanding). During joint record reviews and an interview on 11/20/2025, the Area Executive of Clinical Operations confirmed that Hospice Aide supervisory visits were completed less frequently than every 14 days.

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed, the agency did not ensure that all physician orders were included in the patient's clinical record. CLINICAL RECORD 26: The patient elected the hospice benefit on 08/29/2025. The nursing visit note dated 08/30/2025 documented "RN placed 16Fr Foley catheter." A clinical record review revealed no documentation of a physician's order for the Foley catheter. CLINICAL RECORD 27: The patient elected the hospice benefit on 07/23/2025. The nursing visit note dated 08/11/2025 read in part "Patient now has a Foley catheter." A clinical record review revealed no documentation of a physician's order for the Foley catheter. During joint record reviews and an interview on 11/21/2025, the Area Executive of Clinical Operations confirmed the above finding, stating, "There is not an order in the charts for a Foley catheter".

Based on record review and interview, the agency failed to ensure the drug profile included all of the patient's prescription and over-the-counter drugs. This affected one (Patient #3) of 18 medical records reviewed.  The agency census was 182. Findings include: --- Review of the medical record for the Patient #3 revealed an admission date of 10/21/24.  The admission paperwork contained documentation the patient was on Keppra 1000 milligrams by mouth twice a day.  The electronic medical record (EMR) in Homecare Homebase lacked mention of the Keppra.  The patient had a respite stay at Kobacher House from 01/08/25 through 01/11/25.  The Keppra was listed on the After Visit Summary from Kobacher House.  The Client Medication Report in Homecare Homebase lacked documentation of the Keppra after admission and after the respite stay. During an interview on 03/24/25 at 10:15 AM, Staff B stated that the Keppra was in the old EMR but did not get crossed to the new EMR which was HomeCare Homebase.  During the investigation into this incident, Patient #3's spouse stated she continued to give him his Keppra until he could not swallow so he did not miss a dose.  When he couldn't swallow, his spouse stopped all medications.

Based on record review and interview, the agency failed to ensure care and services are provided in accordance with the plan of care.  This affected one (Patient #3) of 18 medical records reviewed.  The agency census was 182. Findings include: --- Review of the medical record for the Patient #3 revealed an admission date of 10/21/24.  On 01/17/25 the nurse noted patient decline and not taking scheduled medications consistently.  The nursing frequency was increased to daily visits to monitor the decline.  The medical record lacked documentation of nursing visits on 01/18/25 and 01/19/25.   During an interview on 03/24/25 at 10:15 AM, Staff B stated that the two daily visits were scheduled but not assigned in the system so they were not completed.

Based on medical record review, of the complaint log, staff interview and policy review, the agency failed to follow procedures for drug disposal. This affected two (#5 and #6) of three patients reviewed for drug disposal. The agency census was 339. --- 1. Review of the complaint log from 03/01/23 through 06/20/23 revealed on 04/13/23 it was documented the nurse had Patient #6 sign a revocation from hospice. The nurse documented she was unable to count or dispose of medications as Patient #6s husband was being aggressive. A referral was made to another hospice. 2. Medical record review revealed Patient #5 died at home on 06/19/23. The nurse documented medication counts and disposal, however the record was silent for any witness. Review of the agency policy titled "Hospice Disposal of Medication in the Home," dated 07/21/21, revealed it was agency policy dispossl of medications containing controlled substances must happen when a medication is no longer needed by the patient and at the time of death. The disposal must occur in one of the three methods below: Performed by a hospice employee and witnessed by the patient or patient's family member; Performed by the patient or patient's family member and witnessed by a hospice employee; Performed by a hospice employee and witnessed by another hospice employee. Interview on 06/22/23 at 10:25 AM, Staff O confirmed there was no documented evidence of a witness for disposal of Patient #5's medications at the time of her death and there was no documented evidence of accountability of Patient #6's medication after she revoked the hospice benefit.