Compass Behavioral Center of Houma, LLC

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44495 Based on observation and interview, the facility failed to ensure care in a safe setting. The deficient practice is evidenced by the presence of 9 sleigh beds with head and foot boards that present ligature risks in the facility. Findings: Tour of the facility on 05/13/2025 between 2:15 PM and 2:20 PM revealed 9 of 20 beds in the facility were molded plastic sleigh style beds. The beds were noted to be in the rooms designated for the patients at suicide risk, beds a, b and e, as well as beds c, d, f, g, h, and i. Review of the patient census at that time revealed no patients on suicide precautions. At the time of discovery, S2DON verified the possibility of a ligature risk with the head and foot boards.”

“QAPI GOVERNING BODY, STANDARD TAG CFR(s): 482.21 ... The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement) ... The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Standard is not met as evidenced by: 44495 Based on record review and interview the governing body failed to ensure all provided services had established policies and procedures for safe provision of care and were included the Quality Assessment and Performance Improvement (QAPI) program . The deficient practice is evidenced by failure to establish policies for the transport of discharged patients and failure to include the transportation services in the QAPI plan. Findings: Review of the provided policy, HR-317 titled “Transportation,” revealed in part, “Purpose: To clearly define the requirements and expectations of those employees for who transportation is an essential job function.” Further review of the policy failed to reveal any guidelines related to transporting patients such as the documentation in a transport log or where stops could be made and the documentation of those stops. Review of the QAPI measures for the year 2025 failed to reveal measures for the provision of transportation service. In interview on 05/12/2025 at 10:19 AM, S1Adm verified transportation services was not included in the QAPI plan. In interview on 05/12/2025 at 11:45 AM, S2DON explained the process of getting patients home after being released from the hospital. If the patient did not have family to pick the patient up and the patient had Medicaid, the discharge planner would arrange for transport with the Medicaid provider. If the patient was self pay and did not have family to pick them up, the transportation would be provided by the facility, by employees of the hospital or by the drivers of the outpatient clinic. S2DON also verified the policy on transportation referenced above did not contain any instructions to the drivers about keep a log of those transported or where stops could be made for gas and restrooms. In interview on 05/12/2025 at 2:15 PM, S4SO verified that her job occasionally included the transporting of patients to their home after discharge. S4SO verified she was not aware of policies restricting where she could stop along the way and verified she was never instructed to wait outside the residence until the patient went inside when returning the patients to their place of residence.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 44495 Based on record review and interview, the facility failed to ensure the discharge plan was updated as needed. The deficient practice is evidenced by failure of the discharge planning staff to document changes made during the discharge planning process in 1 (#1) of 3 (#1-#3) reviewed records. Findings: Review of the medical record for Patient #1 revealed the patient was involuntarily admitted on 04/30/2025. At the time of admission, the patient was the resident of a group home, but refused release of information to the home. Further review of the record revealed the patient was discharge back to the same group home on 05/08/2025, but there was no documentation in the medical record of contact with the home to verify that they would accept Patient #1 back. In interview on 05/12/2025 at 1:42PM, S2DON verified there was no documentation the group home was contacted during Patient #1’s admission. In interview on 05/12/2025 at 1:44 PM, S3DP verified she did not document any updates to the discharge plan, but verified she had worked on his discharge planning throughout his stay. S3DP verified the Patient #1 had informed her after admission that he had been accepted to another home in Baton Rouge. S3DP verified that she called the facility and the representatives of the facility had no knowledge of him. Patient #1 then agreed to return to his original group home. S3DP further explained that Patient #1 was discharged on 05/07/2025, but the weather was too bad to travel the distance to his group home, so the discharge was delayed a day. S3DP verified the group home was notified by phone of the delay of discharge and the home was also notified by phone on 05/08/2025 that he would be leaving the facility. S3DP verified she did not document in the medical record of Patient #1 her efforts related to discharge planning and verified the plan was never updated after the initial plan was established.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on observations, policy and procedure review, and interview, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice was evidenced by the hospital front entrance exterior doors and front lobby conference room door not locked at all times to maintain security. Findings: Observation upon arrival to the hospital on 12/09/2024 at 7:52 AM revealed the front entrance exterior doors were not locked. The surveyor entered through the doors and into the lobby of the hospital. There was no hospital staff in the lobby or receptionist area. The surveyor observed a closed conference room door in the lobby area and knocked on the door three separate times with no response. The conference room door was not locked and the surveyor entered the room and called out to staff again. The surveyor was then greeted by S3Registered Nurse. Further observation revealed that after entering the hospital conference room, an individual could gain access to administration, staff offices, and other areas of the hospital. Review of the hospital policy titled Security Management Plan, effective 07/02/2012 revealed, in part: Policy: The hospital will maintain a security program to protect employees, patients, & visitors. Procedure: 2. Front entrance exterior doors will remain locked at all times to maintain security. In an interview on 12/10/2024 at 8:09 AM, S1Administrator confirmed front entrance exterior doors and lobby conference room door should be locked at all times to maintain security. S1Administrator confirmed that by not locking the lobby conference room door an individual could gain access to administration, staff offices, and other areas of the hospital.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 14442 Based on record review and interview, the hospital failed to establish an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to ensure written discharge instructions were clear and concise for 2 (#1, #2) of 3 sampled patients. Findings: Review of hospital policy PC-301: Discharge Planning, Effective: July 10, 2012, with no revised date documented revealed, in part: Procedure: The case manager, along with other members of the treatment team, will discuss and document discharge plans with the patient and family prior to discharge. The purpose of the contact is to: 1. Finalize living arrangements and aftercare plans. 3. Review patient’s medication regimen. Review of Patient #1’s Multi-Disciplinary Note dated 07/31/2024 revealed, in part: Patient discharged to hotel. Medications to be called in to pharmacy. Review of Patient #1’s Discharge Orders/Instructions/Transition Record dated 07/31/2024 revealed, in part: Discharge Diagnosis: Major Depression recurrent severe with psychosis. Discharge Patient To: Grandparents home. Discharge Medications: Mobic 7.5 mg. Abilify 2 mg. Continue the above medications until you are instructed by your physician to stop. (No) Antipsychotic medications prescribed at discharge. The following home medications were changed or discontinued during your hospital stay and should be discarded: Abilify, Mobic. Additional Patient Instructions: Continue to take meds as prescribed. In an interview on 09/09/2024 at 1:33 p.m., S2DON confirmed Patient #1 discharged to a hotel. S2DON confirmed Patient #1’s discharged instructions were incorrect and should have stated patient discharged to hotel and not grandparents’ home. S2DON confirmed Abilify was an antipsychotic medication. S2DON confirmed Patient #1’s discharge instruction were incorrect and should have stated patient had 1 antipsychotic medication prescribed at discharge. S2DON confirmed Patient #1’s discharge instructions pertaining to medications were not clear and concise. S2DON confirmed Patient #1’s discharge medication instructions indicated to both continue and discontinue taking the same medications. Review of Patient #2’s Discharge Orders/Instructions/Transition Record dated 08/28/2024 revealed, in part: Discharge Medications: Anafranil 50 mg. Zyprexa 7.5 mg. Vistaril 25. Continue the above medications until you are instructed by your physician to stop. The following home medications were changed or discontinued during your hospital stay and should be discarded: Anafranil, Zyprex, and Vistaril. Additional Patient Instructions: Continue to take medications as prescribed. In an interview on 09/09/2024 at 1:54 p.m., S2DON confirmed Patient #2’s discharge instructions pertaining to medications were not clear and concise. S2DON confirmed Patient #2’s discharge medication instructions indicated to both continue and discontinue taking the same medications.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48051 Based on observations and interviews, the facility failed to ensure each patient’s right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure the patient’s physical environment was free of safety risks and did not afford opportunities for self-injury or harm to others Findings: Observation during the facility tour on 11/27/2023 from 10:28 a.m. to 11:30 a.m. revealed the following safety risk: a. Unsecured toilet seats in 9(Rooms A-I) of 10(Room A-J) patient restrooms which could create a potential ligature risk. b. A hand rail that was partially detached from the wall in Room D restroom, with 6 anchor screws, not securely fastened in place. The screws could potentially be unscrewed by hand. This created a potential fall risk, ligature risk, and contraband risk. In an interview on 11/27/2023 at 11:30 a.m. S2DON confirmed the above mentioned findings.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure a medical history and physical was documented within 24 hours after admission for 3 (#1-#3) of 3 (#1-#3) sampled patient medical records reviewed. Findings: A facility policy review of PC-104: Assessments of Patients revealed in part, the purpose is to define the scope and time frames for patient assessments for each discipline involved in an individual patient’s treatment. This plan outlines the elements of the assessments, which must be performed and documented in the patient’s medical record. The specified time frame for history and physical completion is within 24 hours of admission. A medical record review for Patient #1-#3 revealed the following: Patient #1 was admitted on 10/22/2023 at 7:50 a.m. The history and physical was signed on 10/24/2023 at 10:41 a.m. This history and physical was documented 50.8 hours after admissions. Patient #2 was admitted on 10/19/2023 at 10:10 p.m. The history and physical was signed on 10/21/2023 at 8:56 a.m. This history and physical was documented 34.7 hours after admissions. Patient #3 was admitted on 11/21/2023 at 9:10 p.m. The history and physical was signed on 11/23/2023 at 1:51 p.m. This history and physical was documented 40.7 hours after admissions. In an interview on 11/28/2023 at 11:30 a.m. S2DON confirmed the medical history and physicals of Patients #1 - #3 were not documented within 24 hours of admissions.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 48051 Based on record review and interview, the facility failed to ensure all practitioner’s orders were contained in patients’ medical records. This deficient practice was evidenced by failing to ensure there was an order for capillary blood glucose testing. Findings: A medical record review of Patient #3 revealed a secondary diagnosis of Diabetes Mellitus Type II. Admission lab work reveal a Hemoglobin A1C of 8.4% (reference range is 4.8 - 5.6 %) which is indicative of Diabetes. The patient’s home medication list included Jardiance 25 mg daily. A review of the physician orders revealed no order for the monitoring of the patient’s blood glucose. There was a reference to Diabetes on the medical history and physical. A review of the facilities log of current diabetic patients revealed Patient #3 as one of the patients receiving a daily capillary blood glucose check from 11/22/2023 to the present day, 11/28/2023. In an interview on 11/28/2023 at 11:00 a.m. S2DON confirmed there was no physician order on Patient #3’s medical record for the performance of a capillary blood glucose level check.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 48051 Based on observation, record review, and interview the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were not available for patient use as evidenced by having an open multi-dose vial without an opened date written on it and an open multi-dose vial with an expired open date. Findings: A review of facility policy PHARM-024 Expiration of Medications, Last Revised: 06/03/2021 revealed in part, the facility uses policies and procedures to prevent administering medications beyond their date of expiration. Further, the policy states, “All multi-patient use medications shall be considered expired 30 days after opening. All such medications shall be labeled with “date opened” upon opening.” An observation on 11/27/2023 at 10:30 a.m. of the medication room’s sample medication refrigerator revealed 1 open vial of Tuberculin Purified Protein Derivative 5TU/0.1ml vial with no open date on the box or vial and 1 open vial of Tuberculin Purified Protein Derivative 5TU/0.1ml vial with an open date of 07/26/2023 written on the box it was stored. In an interview on 11/27/2023 at 10:38 S2DON confirmed the facility policy required multi-dose medications to be discarded after 30 days of being open and all multi-dose medications need to be dated upon opening. S2DON further confirmed the findings of the above mentioned open multi-dose medication vials.”