Every finding on record at Comfort Care Hospice Inc

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: The record indicated oxygen was ordered at the time of admission. There was no evidence of oxygen safety written on the care plan. COS.

Upon patient record review, 1 of 5 (Patient #3) 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. Patient #3: The record indicated a mechanical lift was ordered by the physician. There was no evidence as to who would use the equipment and who would provide maintenance on the equipment. The DPCS confirmed that the patient owned this equipment, and should have been included as equipment used by the patient. COS.

Upon patient record review, 1 of 5 record reviewed (Patient #3) 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 #3: The record indicated a Mechanical Lift was ordered by the physician. There was no evidence on the hospice aide care plan giving any instructions for this mechanical lift. COS.

Condition of Participation: Emergency Preparedness

Upon observation, there was no evidence the hospice has developed and maintained an emergency preparedness plan that must be reviewed, and updated at least every two years. No evidence of an emergency preparedness plan, the agency had contact information for the local, state tribal, federal entities and a hazardous risk assessment, however no agency specific plan and agency specific communication plan.

Upon observation, there was no evidence the Emergency Preparedness plan: • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans

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

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan included a primary and alternate means for communicating with hospice's employees.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. The agency educated staff on the NHPCO emergency preparedness guidelines, and not the agency emergency preparedness plan or communication plan.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. The agency had tabletop exercises completed on 8/10/22, 8/10/23 and 8/9/24. No evidence of a full scale community based exercise for the past 3 years. No evidence that the agency activated their emergency plan within the last 3 years.

Upon patient record review 3 of 14 (Patient #3, 6, 12) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 3, 6, 12 no evidence of an initial psychosocial assessment.

Upon patient record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 9, 10) 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, 2, 3, 4, 5, 9, 10 nursing documentation that the patient has Oxygen, no evidence of Oxygen on the medication profile. Patient 1 Triamcinolone Acetonide topical bid ordered and does not include where to apply on the medication profile. Patient 2 nursing visit 7/29/24 documented Macrodantin for UTI, no evidence of this on the medication profile. Patient 3 nursing visit 8/20/24 documented the use of Tramadol, no evidence of this on the medication profile. Patient 4 Lidocaine 4% topical ordered and does not include the location to apply on the medication profile. Patient 9 nursing visit 7/31/24 documented Tramadol changed from prn to bid, no evidence Tramadol on the medication profile. Patient 10 Tylenol 325 mg 2 tab via GT Q4h pain/fever and Oxycodone 5/325mg 1-2 tab via GT 4x day both ordered, no evidence of a max dose for the Tylenol of 4000mg daily.

Upon patient record review, 5 of 14 (Patient #1,3,5,6,12) 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 1,3,5,6,12 no evidence of an initial bereavement risk assessment.

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

Upon patient record review, 2 of 14 (Patient #6, 9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6 initial nursing assessment on 8/20/24 includes assessment of the breast wound, no evidence of wound assessment after this visit. Patient 9 nursing visit 8/15/24 documents excoriation to both knees and wound care provided, no evidence of wound assessment or follow up.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1, 3, 10 on Aspirin, no evidence of bleeding precautions. Patient 2 on Aspirin, no evidence of bleeding precautions. Currently taking Divalproex for seizures, no evidence of seizure precautions. Spiritual care is seeing the patient monthly, no evidence of a care plan to address identified spiritual care problems. Patient 4 on Eliquis, no evidence of bleeding precautions. Patient 5 currently taking Gabapentin for seizures, no evidence of seizure precautions or a neurological care plan. Patient 6 nursing visits document edema to right arm and hand, high fall risk and utilization of a walker. No evidence of a care plan to address identified problems. Patient 7 nursing documented high risk for aspiration, no evidence of aspiration precautions. Patient 8, 10 spiritual care is seeing the patient, no care plan to address identified spiritual care problems. Patient 9 currently taking Valproic for seizures, no evidence of seizure precautions or a neurological care plan. Spiritual care is seeing the patient, no care plan to address identified spiritual care problems. In addition, patient has morphine started at admission, no evidence of a care plan to address pain.

Upon patient record review, 5 of 14 (Patient #2,5,8,9,10) did not have evidence the plan of care 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 2,5 SC/SW ordered as 1x and PRN, no evidence of a routine frequency or quantity for the PRN. Patient 8 SC/SW ordered 1PRN, no evidence of a routine frequency. Patient 9, RN ordered _ w and 3 PRN, no evidence of a routine frequency. Patient 10 SW ordered 1 PRN, no evidence of a routine frequency.

Upon patient record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 9, 10) 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, 2, 3, 4, 5, 9, 10 nursing documentation that the patient has Oxygen, no evidence of an order for Oxygen. Patient 1 Triamcinolone Acetonide topical bid ordered and does not include where to apply. Patient 2 nursing visit 7/29/24 documented Macrodantin for UTI, no evidence of an order. Patient 3 nursing visit 8/20/24 documented the use of Tramadol, no evidence of an order. Patient 4 Lidocaine 4% topical ordered and does not include the location to apply. Patient 9 nursing visit 7/31/24 documented Tramadol changed from prn to bid, no evidence of an order for Tramadol. Patient 10 Tylenol 325 mg 2 tab via GT Q4h pain/fever and Oxycodone 5/325mg 1-2 tab via GT 4x day both ordered, no evidence of a max dose for the Tylenol of 4000mg daily..

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,7) 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. Patient 1 has Albuterol Nebs ordered, no evidence for the order of the nebulizer DME. Patient 2, 3 has documentation of the use of oxygen in the initial nursing visit, no evidence of an order for oxygen DME. Patient 4 has documentation that an e-tank was delivered, no evidence of an order for an e-tank DME. Patient 5 has documentation in the initial nursing visit of a use of a walker, no evidence of an order for walker DME. Patient 7 Nursing visit 7/30/24 documents use of an air mattress and OBT, no evidence of an order for air mattress and OBT DME.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2 nursing visit on 7/29/24 documents antibiotic for UTI, no evidence of an update to the POC to include infection.

Upon client record review, 8 of 14 (Patient #2,3,4,5,6,8,9,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2 has spiritual care visit completed 7/2/24 and 8/3/24. SW visit completed on 7/26/24, no evidence of an order for these visits. Patient 3 has nursing visit frequency ordered as 2x/week, nursing visit completed on 8/20/24 and no evidence of a 2nd visit that week. Patient 4 SW visits completed on 5/30/24, 6/28/24, 7/26/24. SC visits completed on 5/30/24, 6/24/24 and 7/11/24. No evidence of an order for these visits. Nursing visit 7/25/24 documents wound care to the left toe, no evidence of an order for wound care. Patient 5 SC visits 6/23/24, 7/21/24 and SW visit completed on 7/21/24, no evidence of an order for these visits. Nursing visit on 8/14/24 documented straight Cath, no evidence of an order. Patient 6 SC visit completed 8/20/24, no evidence of an order. Wound care ordered 3 x/week. Nursing visit on 8/18/24, no evidence wound care was provided. Wound care was provided on 8/20/24 and 8/22/24 nursing visits. Patient 8 SC visit on 7/28/24, SW visit 7/29/24, no evidence of orders for these visits. Patient 9 RN visit 8/15/24 documented wound care provided to knees with no evidence of a wound care order. Nursing visit completed on 7/16/24, 7/23/24, 7/31/24, 8/7/24, 8/14/24 no evidence of an order for these visits. Patient 10 SC frequency ordered as 1x/month, no evidence of SC visits in May or June.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. No evidence of a frequency to track, monitor and demonstrate improvement in services and outcomes.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. The agency is performing patient charts audits, no evidence within the QAPI plan of what metrics will be tracked, audited or how they will be utilized within the QAPI plan.

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 the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. No evidence that the QAPI plan included defined metrics or how the plan will be implemented for 2024 or 2023, and no evaluation of the program.

Upon patient record review, 2 of 14 (Patient #13,14) 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 Patient 13 bereavement POC 1 month letter due to be sent in February, 1 month letter was sent on 3/14/24. Patient 14 bereavement POC 6 month letter due to be sent in April, 6 month letter was sent on 6/11/24.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 aide care plan includes change patient linens with no evidence of a frequency. Patient 2 aide care plan did not include seizure or bleeding precautions as identified in the nursing assessment. Patient 3 aide care plan includes change patient linens and turn and reposition, no evidence of frequency. Patient 4 aide care plan includes turn and reposition and change linen with no evidence of a frequency. No evidence of bleeding precautions as identified in nursing assessment. Patient 5 aide care plan includes change linen 2x/week and PRN. Aide care plan includes record BM with no evidence of frequency. Patient 6 aide care plan includes linen 2x/week and PRN. Patient 7 aide care plan has turn and reposition, no evidence of frequency. Patient 8,10 aide care plan has change linen 2-3x/week and PRN. Patient 9 aide care plan has change linen, no evidence of frequency. No evidence of seizure precautions as identified in nursing assessment.

Upon patient record review 2 of 14 (Patient #8,10) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 8 aide visit frequency ordered 5x/week, visits completed on 8/13/24, 8/14/24, 8/15/24 and 8/16/24, no evidence of a 5th visit this week. Patient 10 aide care plan includes shampoo 3x/week. Aide frequency is 5x/week. Shampoo completed 5x/week for weeks of 8/12 and 8/19.

Upon patient record review 1 of 14 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2 has aide supervisory visits completed on 7/22/24 and 8/6/24, 15 days lapsed between supervisory visits.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include 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 observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. 2023 percentage for volunteers is 0%.

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 did not have evidence of a QAPI program approved by the governing body that included an evaluation, current PIP's and how tracking of data would be performed. There was no evidence of an Emergency Preparedness Plan or communication plan to include community or actual events. There was no evidence of a volunteer cost savings report documented along with 0% documented for the total number of patient service hours provided by volunteers.

Upon patient client record review, 1 of 14 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 3 EOB effective date was blank.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Advance Directives. Patient 4 has documentation on initial consents of a Living Will, no evidence of a copy with agency.

Upon client record review, 1 of 14 (Patient #12) did not have evidence that the discharge summary includes all required information. Patient 12 discharge summary did not include all the required information: •A summary of the patient's stay, including treatments, symptoms and pain management •The patient's current plan of care •The patient's latest physician orders •Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility

Upon SNF/NF contract review, 1 of 3 (Eljen SNF/GIP/Resp) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon personnel record review, 1 of 13 (Personnel #11) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records.