Compass Home Health and Rehab LLC

The agency failed to ensure the discharge planning was conducted in accordance with agency policy/procedure for two (2) of two (2) patients discharged from the agency or skilled nursing (SN) services without goals having been met.

The agency failed to ensure TB screening was completed in accordance with agency policy/procedure, CDC and PA DOH recommendations or requirements for two (2) of two (2) agency staff whose date of hire was after October 5, 2022. (Employees #2 and #7) Findings include: On August 8, 2025 at…

The agency failed to ensure the name of the collaborating or supervising physician was included on the plan of care (treatment) for five (5) of five (5) patients for whom orders for home health services were provided by a nurse practitioner or physician assistant.

The agency failed to ensure verbal orders included on the plan of care were countersigned by the primary care provider (PCP) within 30 days of the verbal order date for three (3) of six (6) patients for whom home health services were provided for a minimum of 30 days during the current…

The president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure physician orders for certification and recertification were reviewed/countersigned by the attending physician within 30 days of the start of care date for three (3)…

The agency failed to submit a report of six (6) of six (6) reportable incidents to the PA DOH ERS website prior to August 9, 2022. Findings include: On August 12, 2022 at approximately 4:10 PM, review of agency policy 4-017, titled "Incident Reporting", revealed the following under "Procedure": 6.…

The agency failed to ensure the start of care or recertification comprehensive assessments were approved by the assessing clinician following completion of OASIS data review for six (6) of twelve (12) active patients who were admitted or recertified for care.

The president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure a RN or qualified practitioner responsible for furnishing or supervising care generated/obtained verbal orders to initiate home health services for two (2) of two…

The president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure the updated visit schedule/frequency was provided in writing to three (3) of three (3) patients whose admission folder was available for review during the onsite…

The president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the agency failed to ensure updated treatment orders were provided in writing to three (3) of three (3) patients whose admission folder was available for review during the onsite home visit.

The agency failed to ensure wound measurements were obtained or intravenous site assessment was completed for two (2) of seven (7) active patients for whom wound or intravenous care was provided by skilled nursing (SN).

The president/clinical manager/occupational therapist (PRES/CM/OT) and the clinical supervisor/RN (CS/RN). the administrator failed to ensure personnel files included documentation of completion of PICC (peripherally inserted central catheter) skills demonstration for one (1) of two (2) registered…

The agency failed to ensure the "Emergency Management Plan" included a complete "Hazard Vulnerability Analysis".

The agency failed to ensure the "Emergency Management Plan" included the names and contact information of agency staff.

The agency failed to ensure the contact information for the Centers of Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and/or the Quality Improvement Organization were included on patient rights notification forms provided to six (6) of six (6) patients…

The agency failed to ensure information/instructions regarding how to access axillary aids (accessible web sites, assistive aids identified in the American's with Disabilities Act) and language services were included on patient rights notification forms provided to six (6) of six (6) patients whose…

The agency failed to submit one (1) of two (2) reports of alleged abuse to the PA-DOH ERS website.

The agency failed to ensure that physician orders for certification and recertification were countersigned by the attending physician within 30 days of the start of care or recertification date for eight (8) of eleven (11) patients who maintained status as an active patient within 30 days of the…

The agency failed to ensure written notification regarding the name and contact information for the clinical manager was provided to six (6) of six (6) patients whose start of care date was after January 13, 2018 and whose admission folder/booklet was available for review during the home visit.

The agency failed to ensure three (3) of five (5) registered nurses (RN) assessed/measured the arm circumference of patients for whom physician orders for peripherally inserted central catheter (PICC) orders were included on the "Plan of Care-Preview".