Every finding on record at Comfort Care Coastal Hospice, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) records reviewed, there was no documented evidence the medication profile was updated with an added medication. Clinical Record 2: The patient elected hospice care on 5/10/2022. Per the Plan of Care dated 11/6/2022 - 01/04/2022, the hospice aide visit frequency was ordered five times a week. The Skilled Nurse updated the aide care plan on 12/2/2022 with specific instructions for the "aide to apply barrier cream to sacrum every visit". The barrier cream was not added to the medication profile. During joint review of the records with the Director of Nurses and the Executive Director on 12/14/22, it was stated, "The barrier cream was not listed on the medication profile".

It is required that each patient’s individualized written plan of care (includes): a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) patients receiving Skilled Nursing services and Medical Social Worker services, there was no documented detailed statement for the PRN (pro re nata; as needed) visits ordered. Clinical Record 1: The patient elected hospice care on 01/20/2022. The plan of care dated 11/16/22-1/14/23, ordered the Skilled Nursing visit frequency as ”1xw1, 2xw8, 3 prn” and the Medical Social Worker visit frequency as “1M1, 2M1, 1M1, 2 prn”. There were no reasons documented for the PRN visits ordered. During joint record review with the Director of Nurses and Executive Director (ED) on 11/16/2022, the ED stated, “There are no reasons documented for the PRN visits. We are supposed to have a reason for the PRN visits".

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by a review of clinical records, interviews and observation on home visits. 1 of 1 (100%) observation home visits for a patient residing in a SNF, revealed that all required documents were not present in the facility's record. Home Visit 1: On 12/15/2022 during the observed visit with Skilled Nurse (Staff 3), it was noted that there is one notebook provided by the hospice agency which has all the agency's patient's information included. There was no documented evidence of the most recent Plan of Care, dated 11/16/2022- 01//4/2023, in the notebook. The Skilled Nurse stated, “Everything else is here, even the most recent physician order dated 11/29/2022, but the Plan of Care is not here”.