Every finding on record at Comfort Care Hospice, LLC

It is required that a hospice aide provide services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. CLINICAL RECORD 9: The patient elected hospice care on 12/28/2023 with a primary diagnosis of chronic obstructive pulmonary disease (COPD) unspecified. The HA care plan dated 12/09/2024 assigned the HA the relevant tasks: apply barrier cream, apply deodorant, assist patient with dressing, assist to toilet, bathing - seated shower using chair/bench, brush teeth, clean nails, comb or brush hair, do not remove O2 (oxygen) during bath, perineal care, shampoo, stand-by assistance with ambulation, contact clinical mgr for guidance if patient/household member reports s/s of respiratory symptoms, date of last BM notify SN (skilled nurse) if greater than 3 days, was there anything that required RN notification? If yes, document what was reported and to whom." The HA visit note dated 08/20/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Not required this visit bedbath...Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." The HA visit notes dated 08/25/2025 and 09/03/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Bedbath...Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." The HA visit note dated 08/27/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Not required this visit...Shampoo; Completed: N; Note: Not required this visit... Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." A bed bath was not an assigned task included in the HA care plan. Shampoo was an assigned task. During a joint clinical record review and interview on 09/19/2025, the Executive Director/Registered Nurse confirmed that the Hospice Aide did not provide services included in the plan of care.

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 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure the Hospice Aide (HA) notified the Registered Nurse of the changes in the patient’s needs. CLINICAL RECORD 8: The patient elected hospice care on 09/06/2024 with a primary diagnosis of alcoholic cirrhosis of the liver without ascites. The HA care plan dated 08/14/2025 assigned the HA the relevant tasks: apply barrier cream, apply deodorant, apply lotion to all extremities, bathing - bed bath, clean mouth using oral swabs, clean nails weekly, comb or brush hair, dress patient, perineal care, shampoo, change linens, contact clinical mgr (manager) for guidance if patient/household member reports s/s of respiratory symptoms, date of last BM (bowel movement) notify RN (Registered Nurse) if no BM in 3 days, was there anything that required RN notification? If yes, document what was reported and to whom." The HA visit notes dated 09/02/2025, 09/04/2025, 09/09/2025, 09/11/2025, and 09/18/2025 documented, "Shampoo; Completed: N [no]; Note: Not required this visit... Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." A clinical record review revealed no evidence that the RN was notified of the changes to the HA care plan. CLINICAL RECORD 9: The patient elected hospice care on 12/28/2023 with a primary diagnosis of chronic obstructive pulmonary disease (COPD) unspecified. The HA care plan dated 12/09/2024 assigned the HA the relevant tasks: apply barrier cream, apply deodorant, assist patient with dressing, assist to toilet, bathing - seated shower using chair/bench, brush teeth, clean nails, comb or brush hair, do not remove O2 (oxygen) during bath, perineal care, shampoo, stand-by assistance with ambulation, contact clinical mgr for guidance if patient/household member reports s/s of respiratory symptoms, date of last BM notify SN (skilled nurse) if greater than 3 days, was there anything that required RN notification? If yes, document what was reported and to whom." The HA visit note dated 08/20/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Not required this visit bedbath...Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." The HA visit notes dated 08/25/2025 and 09/03/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Bedbath...Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." A bed bath was not an assigned task included in the HA care plan. The HA visit note dated 08/27/2025 documented, "Bathing - seated shower using chair/bench; Completed: N; Note: Not required this visit...Shampoo; Completed: N; Note: Not required this visit... Was there anything that required RN notification? If yes, document what was reported and to whom; Completed: N; Note: Not required this visit." A clinical record review revealed no evidence that the RN was notified of the changes to the HA care plan. During a joint clinical record review and interview on 09/19/2025, the Executive Director/Registered Nurse confirmed that the Hospice Aide did not document notification of the RN regarding changes in the HA care plan.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical records reviewed for a patient who revoked the hospice benefit, the agency did not ensure that the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 16: The patient elected hospice care on 12/30/2024with a primary diagnosis of chronic obstructive pulmonary disease (COPD). A clinical record review revealed a discharge summary dated 07/14/2025. There was no evidence that the discharge summary was forwarded to the patient's attending physician. During a joint record review and interview on 09/19/2025, the Executive Director/Registered Nurse confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.

It is required that each patient’s individualized written plan of care reflects patient and family goals identify planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedures. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 6 of 13 (46%) clinical records reviewed, the plans of care were missing measurable goals and outcomes with time frames for projected achievement of goals. The agency policy #17.03 dated 12/01/2021 "HOSPICE IDG CARE PLANNING" read in part, "measurable outcomes anticipated from implementing and coordinating the plan of care." Clinical Record 1: The plan of care identified "Altered home safety" as a problem on 04/05/2022 with the goal "caregiver/family will demonstrate proper safety measures related to fall prevention." Clinical Record 2: The plan of care identified "Altered genitourinary status" as a problem on 09/13/2022 with the goal "caregiver/family will verbalize/demonstrate measures to protect skin integrity." Clinical Record 12: The plan of care identified "Altered skin integrity" as a problem on 09/24/2022 with the goal "Patient/ caregiver will demonstrate proper wound care." Clinical Record 4: The plan of care identified the "need for skilled teaching regarding pain." as a problem on 10/19/2022 with the goal " Patient/caregiver will verbalize and demonstrate understanding of pain management measures." Clinical Record 3: The plan of care identified "Alteration in skin integrity." as a problem on 10/04/2022 with the goal "Patient will demonstrate proper wound care." Clinical Record 13: The plan of care identified "Altered endocrine system." as a problem on 09/29/2022 with the goal "Blood glucose level is obtained and any applicable action taken." The Clinical Managers were interviewed on 11/30/2022 and stated that the goals for the problems identified were not specific and measurable.