Every finding on record at Comfort Care

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with any tribal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the Emergency Plan communication plan includes a primary and alternate contact information for tribal emergency preparedness staff.

Upon patient record review, 3 of 14 (Patient #1,2 & 8) did not have evidence in the patient record that an updated review was completed of all prescription and non-prescription medications Patient #1 was documented on nursing visit dated 5-01-23 as taking Tessalon Pearls for cough which was not included in the medication profile. Patient #2 as observed during the home visit, the medication Humalog Kwik Pen Injection, which was ordered with a sliding scale that was not included in the medication profile. The patient's Lantus Insulin Injection was changed to 14 units 6 months ago, as confirmed by both the patient and the daughter caregiver, but was still listed in the medication profile as 15 units. Patient #8 was on active antibiotic medication Cephalexin oral which was not updated or included in the medication profile.

Upon patient record review, 1 of 14 (Patient #1) 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.

Upon patient record review, 2 of 14 (Patient #1 and 9) did not have evidence the plan of care included all of the patient's medications dose, route, frequency necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 was on active medication Humalog Insulin Injection TID that had a sliding scale which was not included in the plan of care. The comprehensive assessment indicated that the patient had a catheter which did not include the specific treatment orders in the plan of care. Patient #9 the comprehensive assessment indicated that the patient had an open abdominal wound which did not include the specific treatment orders in the plan of care.

Upon patient record review, 6 of 14 (Patient #1,5,6,8,9 & 10) did not have evidence the plan of care included all equipment's and supply needs necessary for the palliation and management of the terminal illness and related conditions. Patient #1 was identified in the comprehensive assessment to have air mattress, hospital bed, walker, wheelchair, suction machine that were not included in the plan of care Patient #5 was identified in the comprehensive assessment to have a walker, overbed table that were not included in the plan of care Patient #6 was identified in the comprehensive assessment to have a walker that were not included in the plan of care Patient #8 was identified in the comprehensive assessment to have a hospital bed, walker, recliner chair, e tank that were not included in the plan of care Patient #9 was identified in the comprehensive assessment to have a bedpan, commode, nebulizer, and e tank, foley catheter and wound care supplies that were not included in the plan of care Patient #10 was identified in the comprehensive assessment to have a wheelchair and shower chair that were not included in the plan of care.

Upon client record review, 2 of 14 (Patient #1 and 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 Developed a Stage 2 coccyx area pressure ulcer after the comprehensive assessment and initial plan of care on 4-03-23, that was identified on 4-16-23, was not reviewed in the IDG meeting/update on 4-28-23 and not revised in the updated plan of care to include a new wound care order. Wound care provided by nurse without orders. Patient #9 Nursing visit on 3-08-23 documented patient was assessed to have had an abnormal pulse at 45 which was not coordinated or called to the physician, the plan of care included an order to call physician for an abnormal vital signs result of less than 60. Nurse instructed patient to hold the Metoprolol medication which was ordered as daily in the plan of care without a call or any documented coordination done.

Upon personnel record review, 1 of 14 (Personnel #4) did not have evidence in the personnel file that a competency assessment was performed by the aide with a patient which must have included; ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient.

Upon observation, there was no evidence that documented the cost savings achieved by agency through the use of volunteers. The Documentation must have included the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence these hospice personnel have received orientation on the hospice philosophy.

Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence that these hospice personnel have received orientation on their specific job requirements.

Upon personnel record review, 3 of 14 (Personnel #8, 9 &10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for these personnel and volunteer during orientation.

Upon observation, there was no evidence the hospice designated a physician to serve as Medical Director. This was corrected on Day 3 of survey with an appointment of personnel #10 as the Medical Director.

Upon contract review, 1 of 4 (Alok Saxena) did not have evidence of a contract to fulfill the role of medical director. There was not an evidence in the contract identifying the role of a Medical Director, contract identified the role as Alt MD. This was corrected on Day3 of survey, agency appointed one of the 2 associate medical directors as the Medical Director.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence in the election statement of the effective date of election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement in accordance with 418.24

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that all entries were clear, complete, and appropriately authenticated. SN visit 5-13-23 documented that patient was still being provided care in the facility, when patient was discharged from the facility on 5-11-23 and was back to home during the 5-13-23 visit.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the hospice forwarded a summary to the admitting facility and a copy of the patient record, if requested, to a facility when patient was transferred on 11-22-22.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that when the patient revoked the election of hospice care and was discharged from hospice on 1-13-23, the hospice forwarded the discharge summary and a copy of the patient records(if requested) to the patient's attending physician in accordance with §418.26

Upon observation, there was no evidence the organizational chart did match the hospice's information submitted to CMS and/or State licensing agencies management personnel. The current DPCS was not listed for the position she is holding as DPCS and the Alt DPCS was not listed for the position he is holding as Alt DPCS.