Every finding on record at Comfort Care Hospice, LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received specific written patient care instructions to meet the patient's needs. CLINICAL RECORD 2: This patient elected the hospice benefit on 12/12/2025 with a terminal diagnosis of senile degeneration of the brain. The RN initial comprehensive assessment dated 12/12/2025 documented the patient was diagnosed with dysphagia. On review of the HA care plan dated 12/12/2025, it was noted that there was no direction to the HA for dysphagia precautions. During an interview and a joint record review on 12/22/2025, the Clinical Manager confirmed the finding and stated, "I reviewed the record, and I missed that one."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse (RN) as the changes related to the plan of care and any quality assessment and improvement activities. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/29/2025 with a terminal diagnosis of malignant neoplasm of the colon. The hospice plan of care dated 10/29/2025 ordered HA visits to start 11/02/2025 at visit frequency of two times a week for 12 weeks. The HA care plan assigned the HA to make the patient's bed at each visit. The HA visit notes for 11/25/2025, 12/11/2025, and 12/18/2025 were reviewed and revealed the patient declined the bed to be made at each visit. The clinical record was reviewed and evidenced no documentation that the RN of the declinations. The HA was interviewed on 12/23/2025 and stated that she did not know that she was to notify the RN if the HA care plan was not followed. During the joint record review and interview on 12/23/2025, the Executive Director confirmed that the clinical record did not include documentation that the RN was notified that the patient had declined the bed to be made.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Executive Director and Volunteer Coordinator on 12/24/2025 revealed that the volunteer utilization was 1.87% for the period 01/01/2024 through 12/31/2024, and 1.34% for the calendar year of 2025, 01/01/2025-11/01/2025 which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During an interview on 12/24/2025, the Executive Director stated that the Volunteer Coordinator was hired 08/04/2025 and was rebuilding the volunteer program. The agency had also implemented a performance improvement plan (PIP) to re-build the volunteer program. A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Executive Director and Volunteer Coordinator on 12/24/2025 revealed that the volunteer utilization was 1.87% for the period 01/01/2024 through 12/31/2024, and 1.34% for the calendar year of 2025, 01/01/2025-11/01/2025 which did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies was documented in the clinical record. CLINICAL RECORD 5: This patient elected the hospice benefit on 10/29/2025 with a terminal diagnosis of malignant neoplasm of the colon. The initial comprehensive assessment dated 10/29/2025 documented the patient had the following equipment: wheelchair, mechanical lift, power wheelchair, shower chair, and rollator. Review of the clinical record revealed no documentation that the patient or caregiver was educated on the instruction of proper handling, storage, and safe utilization of the medical equipment. CLINICAL RECORD 6: This patient elected the hospice benefit on 08/09/2025 with a terminal diagnosis of hypertensive heart disease with heart failure. The patient was ordered an air mattress and oxygen per nasal cannula 2-3 liters as needed for shortness of breath on 08/12/2025. The equipment was delivered on 08/14/2025. Review of the clinical record revealed no documentation that the patient or caregiver was educated on the instruction of proper handling, storage, and safe utilization of the medical equipment. During the joint clinical record review and interview on 11/23/2025, the Executive Director and Clinical Manager stated that the education of the DME was usually documented in the RN narrative, but the documentation was not found in these two clinical records.

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. This standard was not met as evidenced by a review of clinical records, observation on home visits, and interview. 5 of 11 (45%) records reviewed revealed that the agency did not ensure that the drug profiles included all drugs prescribed, specifically oxygen. Clinical Record 1: The patient elected the hospice benefit on 12/31/22 with a diagnosis of Alzheimer's Disease. The respiratory section of the comprehensive assessment, completed by the admitting nurse on 12/31/22, documented that the patient was on oxygen. The drug profile, current as of 2/15/23, did not include oxygen. Clinical Record 2: The patient elected the hospice benefit on 3/11/22 with a diagnosis of Hemiplegia following Cerebral Infarct. The respiratory section of the comprehensive nursing assessment, completed by the admitting RN on 3/11/22, documented that the patient was on oxygen. The drug profile, current as of 2/15/23, did not include oxygen. Clinical Record 3: The patient elected the hospice benefit on 5/10/22 with a diagnosis of Heart Failure. The respiratory section of the comprehensive assessment, completed by the admitting RN on 5/10/22, documented that the patient was on oxygen. The drug profile, current as of 2/15/23, did not include oxygen. Clinical Record 6: The patient elected the hospice benefit on 11/5/22 with a diagnosis of Hypertensive Heart Failure with Heart Failure. The patient was observed (Home Visit #2) to be wearing oxygen via nasal cannula. The respiratory assessment of the comprehensive assessment, completed by the admitting RN on 11/5/22, documented that the patient was using oxygen. The drug profile, current as of 2/15/23, did not include oxygen. Clinical Record 10: The patient elected the hospice benefit on 9/2/21 with a diagnosis of Interstitial Lung Disease and expired on 9/20/22. The respiratory section of the comprehensive assessment, completed by the admitting RN, documented that the patient was using oxygen. The drug profile was not updated during the patient's hospice episode to include oxygen. In an interview with the Executive Director on 2/15/23, she said that oxygen had not been entered on the drug profiles of these patients and that it should have been.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by document review, interview and observation on home visits. In 1 of 3 (33%) observed home visits, the agency did not ensure that staff adhered to the agency's bag technique policy. The agency's Bag Technique Policy 4.19.10 [reviewed 3/23/22] states in relevant parts: "Procedure: 1) Place the bag on a barrier in a clean area. 3. Wash your hands with soap and water.... alcohol-based hand cleanser can be used. 4. Remove any items necessary for patient care. Close the bag before performing care. 6. Perform Hand Hygiene if you need to re-enter the bag for additional supplies during patient care. When the visit is completed, reusable equipment is cleaned using alcohol and/or soap and water as appropriate, hand hygiene is performed and only clean equipment and supplies are returned to the bag. 7. Perform Hand Hygiene, then repack and close the visit bag." Home Visit 1 (Clinical Record #1): The observed home visit was conducted on 2/14/23. During the visit, the RN (Staff 6) placed the nursing bag appropriately on a barrier. The RN used alcohol-based hand sanitizer and donned a pair of gloves prior to entering the bag to remove the thermometer, pulse oximeter and tape measure. She assessed the patient using this equipment and returned the equipment to the barrier. She then cleaned this equipment and returned it to the barrier. She re-entered the nursing bag to obtain the blood pressure cuff and stethoscope without removing gloves or performing hand hygiene. She assessed the patient, cleaned the blood pressure cuff and stethoscope, and returned the blood pressure cuff and stethoscope to the nursing bag without removing gloves or performing hand hygiene. She then returned the thermometer, pulse oximeter, and tape measure to the nursing bag without removing gloves or performing hand hygiene. She then removed her gloves, performed hand hygiene, and removed the barrier from underneath the nursing bag to discard it during which time she left the nursing bag on the table which was an unsanitized and unprotected surface. In an interview conducted on 2/15/23 with the Executive Director, it was said that the agency policy was not followed, and she stated, "Hands should be sanitized before going into the clean side of the bag."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. 6 of 9 (67%) records with accepted hospice aide services revealed a lack of clear and specific written instruction for the aide assignment related to fall risk prevention or safety instruction thus leaving the aide to make decisions outside of the aide scope of practice. Clinical Record 1: The patient elected the hospice benefit on 12/21/22 with a diagnosis of Alzheimer's Disease. The admitting RN completed a MACH-10 fall risk assessment as part of the Comprehensive Nursing Assessment on 12/21/22; the patient scored a 9 out of 10 (with a score greater than 4 the patient is considered to be at risk for falling). There were no instructions in the HA [hospice aide] plan of care regarding fall risk, prevention or safety. Clinical Record 2: The patient elected the hospice benefit on 3/11/22 with a diagnosis of Hemiplegia following Cerebral Infarct. The admitting RN completed a fall risk assessment as part of the Comprehensive Nursing Assessment on 3/11/22; the patient scored a 25 (with a score greater than 15 the patient is considered to be at risk for falling). There were no instructions in the HA plan of care regarding fall risk, prevention or safety. Clinical Record 5: The patient elected the hospice benefit on 12/15/22 with a diagnosis of Breast Cancer. The admitting RN completed a MACH-10 fall risk assessment as part of the Comprehensive Nursing Assessment on 12/15/22; the patient scored a 9 out of 10 (with a score greater than 4 the patient is considered to be at risk for falling). There were no instructions in the HA plan of care regarding fall risk, prevention or safety. Clinical Record 6: The patient elected the hospice benefit on 11/05/22 with a diagnosis of Hypertensive Heart Failure with Heart Failure. The admitting RN completed a MACH-10 fall risk assessment as part of the Comprehensive Nursing Assessment on 11/05/22; the patient scored a 7 out of 10 (with a score greater than 4 the patient is considered to be at risk for falling). There were no instructions in the HA plan of care regarding fall risk, prevention or safety. Clinical Record 7: The patient elected the hospice benefit on 5/6/22 with a diagnosis of Alzheimer's Disease. The admitting RN completed a fall risk assessment as part of the Comprehensive Nursing Assessment on 5/6/22; the patient scored a 20 (with a score greater than 15 the patient is considered to be at risk for falling). There were no instructions in the HA plan of care regarding fall risk, prevention or safety. Clinical Record 8: The patient elected the hospice benefit on 10/18/22 with a diagnosis of Kidney Disease. The admitting RN completed a MACH-10 fall risk assessment as part of the Comprehensive Nursing Assessment on 10/18/22; the patient scored a 7 out of 10 (with a score greater than 4 the patient is considered to be at risk for falling). There were no instructions in the HA plan of care regarding fall risk, prevention or safety. In an interview conducted on 2/15/23 with the Executive Director, she said that the HA plans of care should have contained instructions for the HA regarding fall risk and safety for these patients.