Initial Comments:
Based on the findings of a complaint investigation completed on December 12, 2025, Chandler Hall Health Services, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C &;;; D, Conditions of Participation: Hospice Care.
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Plan of Correction:
418.100(b) STANDARD
GOVERNING BODY AND ADMINISTRATOR
Name - Component - 00
A governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operation of the hospice. The administrator must be a hospice employee and possess education and experience required by the hospice's governing body.
Observations:
Based on a review of the clinical records, and an interview with the administrator, the governing body and the administrator failed to develop and implement written policies and procedures governing the administration and management of patient -controlled analgesia (PCA) therapy in the home setting
Findings include:
Request for hospice policies pertaining to PCA pump on December 12, 2025, at approximately 3:30 P.M, revealed that the agency did not have the requested policies.
An interview was conducted with the agency administrator on December 21, 2023, at approximately 4 P.M. The administrator stated, " I do not see a CADD/PCA policy".
A review of clinical files conducted on October 1, 2025 from approximately 9:35 am to 3:30 pm and then on December 11, 2025 at approximately 2pm, revealed the following:
CR #1 Start of care August 13,2025, certification period- August 13, 2025, through November 10, 2025. Hospice order for Dilaudid CADD pump infusion via PCA via midline cath. Basal 0.2mg/hr. Bolus 0.05mg q 15min prn pain on September 12, 2025. Nurses notes document the patient receiving Dilaudid via CADD PCA pump via midline catheter, from September 12, 2025 to September 23, 2025. in the patient's residence.
An interview with the Administrator on December 12, 2025, at approximately 6:00 P.M. confirmed the above findings.
Plan of Correction:At the time of the investigation, Patient-Controlled-Analgesia use was placed on hold. No further use of CADD- PCA pumps has been nor will be initiated for hospice patients while a "PCA administration and management in the home setting" policy is developed, reviewed, and approved.
The Administrative Director will develop a regulatory compliant policy for PCA administration and management in the home setting. The policy will be reviewed and approved by the hospice medical director, hospice team and Chandler Hall Board of Directors prior to implementation.
Once approved, the Administrative Director will submit the policy to the Policy Coordinator to update the master policy directory. Policies will be reviewed annually and as needed by at least 1 Registered RN and the Administrative Director of Hospice.
418.100(g)(3) STANDARD
TRAINING
Name - Component - 00
(3) A hospice must assess the skills and competence of all individuals furnishing care, including volunteers furnishing services, and, as necessary, provide in-service training and education programs where required. The hospice must have written policies and procedures describing its method(s) of assessment of competency and maintain a written description of the in-service training provided during the previous 12 months.
Observations:
Based on employee file (EF's) review, and an interview with the administrator, the hospice failed to ensure and maintain documented, device specific competency for nursing staff administering or managing PCA therapy using the Continuous Ambulatory Delivery Device (CADD) for Patient Controlled Analgesia (PCA) for four (4) out of the five (5) EFs reviewed. (EF#2-5)
Findings include:
Request for hospice policies pertaining to PCA pump on December 12, 2025, at approximately 3:30 P.M, revealed that the agency did not have the requested policies.
An interview was conducted with the agency administrator on December 21, 2023, at approximately 4 P.M. The administrator stated, " I do not see a CADD/PCA policy".
Employee file review was conducted on October 1, 2025 from approximately 3:30pm to 4 pm, then again on December 12, from approximately 9am to 12pm, and at approximately 5pm revealed the following:
EF#4 Date of hire 6/28/22: Did not contain a "Competency for CADD Pump Cassette Change". No other documentation regarding competency specific to the CADD PCA on file. A skills check list dated 3/19/25 for PCA.
EF#3 DOH 4/22/19: Did not contain a "Competency for CADD Pump Cassette Change". No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/25/25 for PCA on file.
EF#4 DOH 2/17/21: Did not contain a "Competency for CADD Pump Cassette Change". No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/17/25 for PCA on file.
EF#5 DoH 1/22/20: Did not contain a "Competency for CADD Pump Cassette Change". No other documentation regarding competency specific to the CADD pump on file. A skills check list dated 3/13/25 for PCA on file.
An interview with the Administrator on December 12, 2025, at approximately 6:00 P.M. confirmed the above findings
Plan of Correction:At the time of the investigation, Patient-Controlled-Analgesia use was placed on hold. No further use of CADD- PCA pumps has been nor will be initiated for hospice patients until clinical staff has proven competency on file.
The CADD competency will be added to the required annual competency checklist for Registered Nurses to ensure anyone administering or managing medication in a PCA pump is competent to do so. The RN will be evaluated by another RN. All new hire RNs will be trained and checked off prior to managing a PCA in the home.
Administrative Director will coordinate with IV Solutions Pharmacist to train all Registered Nurses on CADD pump management and schedule an in-service.
The Operations Coordinator will audit 100% of RN employee files for competencies in Q1 and Q2 of 2026 and annually thereafter.
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