DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
391649 A. BUILDING __________
B. WING ______________ 		04/19/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMPASSUS - GREATER PHILADELPHIA 500 HAWK RIDGE ROAD, SUITE 6, HAMBURG, PA, 19526
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0591      
40929 Based on review of agency policies, clinical record (CR), and staff interviews, the hospice nurse failed to ensure the nursing needs of the patient were met by providing adequate on-call nursing services for one (1) of one (1) clinical records reviewed (CR# 1). Findings included: A review of agency policy on 4/19/22 at approximately 12:30 PM which revealed the following: " Procedure: On call services " stated, " the Compassus on call nurse is expected to respond as quickly as possible to requests for after-hours support, including visits when indicated ... " " Job Description: Hospice On-call Registered Nurse " stated, " Completes routine and emergency assessments on each patient as indicated by departmental policy ...prevents unwarranted hospitalizations by meeting patient and family needs in the home and being proactive and reactive during crisis situations ...Case management of routine and emergency patient care, educated patient/caregiver regarding care of patient, disease process, dying process, symptom control and wound care ... " A review of one (1) CR was reviewed on 4/19/22 at approximately 10:30AM which revealed: CR #1: Start of Care (SOC): 4/24/2021. Certification period: 4/24/21-7/22/21. Date of Death: 6/20/2021. Hospice Certification and Plan of Care contained the following orders: Skilled Nurse once weekly for 1 week then twice weekly for 13 weeks, social worker once monthly for 1 month, and Chaplain once monthly for 1 month. Reviewed emails from on-call nurse to supervisor about events/calls on 6/20/21 which stated, " Received call from (patient ' s wife) stating that patient had went into a " coma " , she stated, he had been in and out of a " coma " for a few days, reviewed s/s (signs/symptoms) of end of life she verbalized understanding, patient resting comfortable no distress, spoke to her at length and f/u (follow-up) call placed, no further concerns. " In reviewing phone logs from that night supervisor stated call above was received at 11:49 PM on 6/19/21, she also stated there was no log in system about a return follow-up call. Next log in on call nurse ' s email stated, " Received call from (patient ' s wife) that patient had passed, this writer pronounced patient, TOD (time of death) 3:20 AM, support offered, low bereavement risk. " Supervisor stated that this phone call was logged in the phone system as 2:08 AM. Skilled nurse visit from 6/20/21 stated, " Family contacted this nurse to inform that they believe patient has passed ...This nurse received patient in bed. Unable to obtain vital signs, they were absent...This nurse pronounced patient at 3:20 AM on 6/20/2021 ...Wife (wife ' s name) present and are grieving appropriately. Reviewed bereavement services with family. Appear to be low bereavement risk ... " Interview with Director of Clinical Services on 4/19/22 at approximatley 1:30 PM confirmed above findings. Director of Clinical services stated the on-call nurse should have gone out to the patient's house to provide support and/or a nursing evaluation.