Every finding on record at Copper Communities Hospice LLC

Observed in Record Review. In 10 of 10 active patient records reviewed, most plan of care goals were not measurable. Here are some examples. Patient and caregiver will: feel needs are being met as the have defined; will be able to verbalize/demonstrate effective coping skills; will demonstrate effective care management and knows to call RN for questions and concerns. Patient will have information necessary for questions and concerns. Self-determined directives of care. In addition, completion target dates were consistently the last day of the current benefit period and were changed to the last day of each successive period. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization did not ensure that the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example, MAHC – 10 scores in the initial comprehensive assessments of records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7 indicated high risk for falls. Goals included a generic statement about safety but did not address reducing risk and preventing injury. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization use standing orders that were not consistent with assessed clinical needs. The following orders were written in every record, even if the absence of a clinical indication. May insert indwelling catheter for relief of urinary retention or incontinence. Irrigate and/or change catheter prn. May obtain chest x-ray or PPD as needed or required on admission. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Record Review. In 10 of 10 active patient records reviewed, the hospice interdisciplinary team did not consistently update the plan of care. For example, in the meeting notes of core team members there was little or no documentation of patient decline, progress towards desired outcomes, goals and plans for the following two weeks. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Leadership Session. The hospice governing body did not evaluate the QAPI program annually as required. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement activities for the prevention of infections and communicable diseases as required by policy. At the home visit for RRHV#3 an RN left her bag open while providing care. This RFI was reviewed with the CEO and Director of Education and Compliance. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement activities for the prevention of infections and communicable diseases as required by policy. At the home visit for RRHV#1 an RN removed Cavi Wipes from the tub prior to entering the patient's home, placed then in a plastic bag that zipped and brought them in her visit bag for use in the home. This RFI was reviewed with the CEO and Director of Education and Compliance. Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement activities for the prevention of infections and communicable diseases as required by policy. At the home visit for record RRHV#1 an RN turned the water faucet off without using a paper towel. At home visit for record RRHV#2 a home health aide did not consistently perform hand hygiene before donning and after doffing gloves. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in HR File Review. In 1 of 1 home health aide HR files reviewed, the organization could not provide documentation of clock hours of education towards the 12 required for the home health aide year to date in 2025 for personnel file HR#4 HHA. This RFI was reviewed with the CEO and Director of Education and Compliance.

Observed in Record Review. In 5 of 5 patient records reviewed, During the record review session session, the nurse surveyor noted that the POC was indicating PRN visits in the amount of 5 and 8 visits. In addition the goals were indicated for the 90 day period instead of the next IDT. The goals were also not measurable containing phrases such as: urine output will be appropriate, anxiety will be controlled, pain will be managed at a comfortable level, will maintain usual bowel patters. This was validated in a discussion with and observation by the Interim Administrator and the DCS.

Observed in Competency Session. In 4 of 4 contracts reviewed, During the contract review session, the nurse surveyor noted that the contracts for Therapy, DME, Pharmacy and SNF had not been reviewed annually for fulfilling the contract requirements. This was validated in a discussion with and observation by the Interim Administrator and the DCS.

Observed in Competency Session. In 5 of 9 HR files reviewed, During the competency session, the nurse surveyor noted that the licenses were not validated in the proper time frames. In LPN 1 hired on 9/14/2022 was not verified on hire but done on the date of survey; In LPN 2 the license expired on 4/1/2020 but not verified until 5/7/2020; in CNA 2 the license expired on 6/30/21 and verified on 7/1/21; in NP 1 the DOH was 10/5/2020 but the verification was not dated and the expiration on 4/1/2022 was not dated; in NP 2 the hire date was 11/25/2019 and not verified. The license expired on 4/1/2020 but not verified until 8/26/2022. This was validated in a discussion with and observation by the Interim Administrator and the DCS.