Every finding on record at California Comfort Care LLC

Upon patient record review, 7 of 8 (Patients #1, #2, #3, #4, #5, #6, #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The patient had Morphine, Ativan, Ondansetron, Albuterol, and Oxygen. These medications were not included on the medication profile. Patients #2, #3, #4, #5, #6, #7: The record reflected these patients had oxygen. Oxygen was not included on the medication profile.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #6: The Initial Bereavement Risk Assessment was completed on 4/26/23. This assessment was completed after patient died (4/11/23) and not within 5 days of hospice start of care.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 8 (Patients #3, #4, #5, #6) did not have evidence the plan of care (POC) must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: The MSW visit frequency indicated PRN and recertification. The SC frequency was listed as 1X then PRN. These frequencies did not identify number of PRN's for the MSW or SC on the POC. Patient #4: The MSW and SC visit frequency indicated 1X then PRN. These frequencies did not identify number of PRN's for the MSW or SC on the POC. Patient #5: The SC frequency indicated 1X then PRN. This frequency did not identify number of PRN's on the POC. Patient #6: The MSW and SC visit frequency indicated 1X then PRN. These frequencies did not identify number of PRN's for the MSW or SC on the POC.

Upon patient record review, 1 of 8 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: This patient had Morphine, Ativan, Ondansetron and Albuterol Solution at the Board and Care. These medications were not included on the plan of care.

Upon patient record review, 4 of 8 (Patients #1, #2, #3, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patients #1, #2, #3, #5: The record reflected that these patients had an albuterol inhalation solution orders on the plan of care. The DME Nebulizer machine was not included on their individualized plan of care.

Upon patient record review, 2 of 8 (Patient #1,#8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1: IDG met on Friday 6/28/24 and Friday 7/26/24. There was no evidence the IDG met on Friday 7/12/24 to review the plan of care. Patient #8: IDG met on Friday 6/28/24 and Friday 7/26/24. There was no evidence the IDG met on Friday 7/12/24 to review the plan of care.

Upon patient record review, 1 of 8 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care (POC). Patient #6: The POC listed MSW visit frequency of 1 X per week. The MSW had visited 1X monthly, not weekly.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence of involvement of the governing body (GB) and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program in GB meeting minutes regarding Annual Summary of QAPI in binders. There are annual PIP's only.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Medical social services Personnel #8: The Social Worker is paid as contracted 1099 employee. Agency/MSW confirmed this personnel is not on payroll for withholdings to be directly deducted and paid to the government.

Upon patient record review, 4 of 8 (Patients #2, #3, #4, #8) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients #2, #3, #4, #8: The bereavement care plan did not contain assigned interventions, tasks and frequencies to meet the needs of the bereaved. There was evidence of letters sent, but no individualized care plan approved/meeting by IDG after patient passing.

Upon patient record review, 2 of 8 (Patient #1, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The Aide has been visiting 2X's per week from 4/29/24. This frequency is not indicated on POC or listed as a supplemental order. Patient #5: The Aide had been visiting 2X's per week. This frequency is not indicated on POC or listed as a supplemental order.

Upon patient record review 2 of 8 (Patients #3, #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: The POC listed aide visit frequency of 2 X's per week (6/12/24). For Benefit Week there was only 1 visit on 6/13/24. Patient #4: The POC listed aide visit frequency of 2 X's per week (6/12/24). For Benefit Week there was only 1 visit on 6/13/24.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency was not providing core services as evidenced by the social worker was a contracted 1099 employee and not on the agency payroll for withholdings. In addition, the agency did not have involvement of the governing body in the QAPI program as there was no evidence of approval of the frequency and detail of data collection and annual summary of QAPI.

Upon contract review, 1 of 4 (alternate medical director contract) did not have evidence of a contract to fulfill the role of alternate medical director. The agency was unable to locate the alternate medical director contract.

Upon patient record review, 4 of 8 (Patients #1, #4, #5, #7) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patents #1 and #5: The election statement did not include BFCC-QIO contact information or hospice agency name on the form. Patent #4: The election statement did not include effective date for hospice services to start. Patient #7: The election statement indicated effective date of 12/6/22. The hospice services began on 12/7/22.

Upon patient record review, 2 of 8 (Patients #5, #6) did not have evidence that the discharge summary includes all required information. Patients #5, #6: Did not have evidence that the discharge summary included patients plan of care as required.

Upon personnel record review, 1 of 12 (Personnel # 9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #9: The Criminal Background check for the Aide had a misspelled name with an extra letter "c" added; this does not match employee name.