Every finding on record at Compassus Op of Ohio, LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. Agency policy and procedure #HOS-C_19A, stated in part, "A Bereavement Risk assessment is completed upon admission by the Social Worker as part of their initial assessment. A Spiritual Counselor or RN Case Manager may be asked to complete the assessment if the Social Worker is not able to complete the assessment timely." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment of the needs of the patient's family and other individuals. Clinical Record 4: The patient elected hospice care on 04/17/2025. A clinical record review, including a review of the Registered Nurse (RN), Chaplain (SC), and Social Worker's (SW) initial assessments dated between 04/17/2025 and the review date on 05/06/2025, revealed no evidence that an initial bereavement assessment was completed. The Hospice Area Executive confirmed the findings during a joint review of clinical records and an interview on 05/07/2025. No further information was provided before the exit conference.

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, document review, and interview. Agency policy # HOS-C_09A "Individualized Plan of Care" (dated 01/01/2024) stated in part, " The content of the plan includes at minimum: An assessment of the patient and family's needs and goals...An identification of the services to be provided, including management of symptoms...i. Treatments, drugs, biologicals, and other interventions..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 11/03/2023 with a diagnosis of cerebral vascular disease (CVA). The initial assessment, dated 11/03/2023, and the updated assessment, dated 11/04/2023, documented that the patient had dysphagia. The plan of care did not identify planned interventions or goals related to dysphagia. The findings were confirmed with the Hospice Area Executive of Clinical Operations during a joint review of clinical records on 05/07/2025.

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. This standard was not met as evidenced by document review, interview, and observation. Agency policy and procedure #IPC.11_A2. "Hand Hygiene- Hand Washing" stated in part, " Once patient care has started, do not reach into the bag without performing hand hygiene." In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed when indicated according to the agency's policy. Home Visit 2: The patient elected hospice care on 11/23/2023. During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 05/06/2025, the RN touched their tablet, then reached into their equipment bag to obtain their equipment to complete their assessment. The RN did not sanitize their hands after touching their tablet before reaching into their equipment bag per the agency's policy. This finding was confirmed by the Hospice Area Executive of Clinical Operations during the joint home visit with the RN on 05/06/2025.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years (more frequent training occurs if there is a significant update of EP policies and procedures); a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and, documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review, document review and interview. 3 of 11 (27%) records reviewed revealed that emergency preparedness training was not completed in accordance with the agency's policy. Policy #A01-Emergency Operations-Revised-9/27/2019-states in part: "Policy Provisions-3. Plan Training-a. All colleagues, including contract colleagues and volunteers, will receive initial and annual training regarding the EOP" Record #87744 (Chaplain/Bereavement Coordinator, date of hire 1/31/2011: There was no documented evidence of annual Emergency Preparedness training in the record. Record #80062 (Dietician, date of hire 2/14/2014): There was no documented evidence of annual Emergency Preparedness training in the record. Record #95076 (Volunteer Coordinator, date of hire 7/1/2016): There was no documented evidence of annual Emergency Preparedness training in the record. The Hospice Area Executive of Clinical Operations was interviewed on 6/28/2022. She stated that the sign-in sheets for the Emergency Preparedness training were completed, however, the agency was not able to produce a copy of the completed sign-in sheets thus compliance with policy could not be validated.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: for all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; demonstration of staff knowledge of emergency procedures; a periodic review and rehearsal of the hospice’s EP plan with hospice employees (including non-employee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others; and documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by personnel record review, document review and interview. 5 of 11 (45%) records reviewed revealed that emergency preparedness training was not completed at hire. Policy #A01-Emergency Operations-Revised-9/27/2019-states in part: "Policy Provisions-3. Plan Training-a. All colleagues, including contract colleagues and volunteers, will receive initial and annual training regarding the EOP" Record #58550 (hospice physician, date of hire 2/1/2021): There was no documented evidence of Emergency Preparedness training at hire present in the record. Record #79887 (hospice medical director, date of hire 7/1/2021): There was no documented evidence of Emergency Preparedness training at hire present in the record. Record #49042 (RN case manager, date of hire 2/15/2021): There was no documented evidence of Emergency Preparedness training at hire present in the record. Record #43834 (Social Work, date of hire 8/12/2021): There was no documented evidence of Emergency Preparedness training at hire present in the record. Record #90195 (Hospice Aide, date of hire 9/1/2021): There was no documented evidence of Emergency Preparedness training at hire present in the record. The Hospice Area Executive of Clinical Operations was interviewed on 6/28/2022. She stated that the sign-in sheets for the Emergency Preparedness training were completed, however, the agency was not able to produce a copy of the completed sign-in sheets, thus compliance could not be validated.

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. The medication review process includes the identification of the following: the effectiveness of drug therapy; actual or potential drug interactions. 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. 3 of 13 (23%) clinical records reviewed revealed that drug profiles were incomplete or not updated. Record #97880: the patient elected the hospice benefit on 1/14/2022. The initial assessment by the RN Case Manager (RNCM) documented that the patient was on Oxygen at 2 liters per minute (lpm) on a PRN (as needed) basis. Oxygen was not listed on the medication profile. Record #76564: the patient elected the hospice benefit on 6/2/2021. A coordination note entered on 7/29/2021 stated that Oxygen at 2 lpm was being ordered for the patient. A visit note dated 8/19/2021 stated that the patient was "now using O2 (Oxygen) @2lpm/NC (nasal cannula) PRN." Oxygen was not listed on the medication profile. Record #72958: the patient elected the hospice benefit on 4/6/2021. The initial RN assessment, completed on 4/16/2021, as well as the recertification RN assessment, completed on 5/18/2022, documented that the patient was using Oxygen on a PRN basis. Oxygen was not listed on the medication profile. The Hospice Area Executive of Clinical Operations was interviewed on 6/28/2022 and agreed that Oxygen was not present on the medication profiles. She stated that she had already instituted a Performance Improvement Plan to address the concern. She had no additional information to provide.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness; education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by personnel record review and interview. 1 of 11 (9%) records reviewed revealed that there was no documentation of a completed orientation. Record #93064 (Nurse Practitioner with a date of hire on 3/1/2017: the agency was not able to produce documented evidence of a completed orientation in the personnel record. The Hospice Area Executive of Clinical Operations was interviewed on 6/28/2022 and agreed that the orientation documentation was missing for this employee. She had no additional information to provide.