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. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed in which a hospice aide was accepted, the hospice did not ensure the care plan included specific written patient care instructions for the hospice aide. Clinical Record 4: The patient elected hospice care on 03/07/2023, with PEG (percutaneous endoscopic gastrostomy) continuous tube feedings. The hospice aide care plan did not include documentation of instructions for the care of the skin around the PEG tube during the bed bath or that the patient had the PEG tube. Additionally, on 03/30/2023 the physician ordered dressing changes to the patient's wounds on the right trochanter and left ankle. The aide care plan was not updated to include written instructions for the hospice aide for the dressings during bathing. During an interview and a joint review of the clinical record, the Clinical Manager stated that the aide plan should have included the dressing change and PEG tube directions.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the clinical record contained complete physician orders. Clinical Record 4: The patient elected hospice care on 03/07/2023. On 03/30/2023 the physician ordered wound care, "clean with saline, pat dry, apply border dressing." The clinical notes included documentation of wounds on the patient's right trochanter and left ankle with dressings applied during each visit. The physician's order did not document the location and frequency of the wound care and dressing changes. During an interview, the Clinical Manager confirmed that the physician's order was missing the location and frequency of the wound care.

It is required that the hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. CONTINUING PRIOR REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. 2 of 3 (67%) clinical records reviewed where the patients resided in nursing facilities (NF), the hospice plans of care lacked an integrated care plan specifying which provider was responsible for performing which functions or treatments. Clinical Record 2: The patient residing in a NF elected hospice care on 5/3/2023. The hospice plan of care dated 5/3/2023 through 7/31/2023 documented concerns with the patient's anxiety, nutrition, skin, and refusal of medications. The clinical visit notes documented coordination with the NF staff after each visit. However, there was no evidence or documentation of an integrated care plan specifying which provider was responsible for performing which functions or treatments. Clinical Record 4: The patient residing in a NF elected hospice care on 3/7/2023 with wound care and percutaneous endoscopic gastrostomy (PEG) tube feedings. The clinical visit notes documented coordination with the NF staff after each visit. However, the plan of care dated 03/07/2023 through 05/06/2023 and updated plans of care lacked evidence or documentation of an integrated care plan specifying which provider was responsible for performing which functions or treatments. During an interview, the Clinical Manager stated that the plans should have included the specifics and would investigate why the documentation was absent.

It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 1 (100%) clinical record reviewed where the discharge reason was revocation, the agency did not obtain a written statement requesting revocation from hospice services by the patient or primary caregiver. Clinical Record 2: The patient, with the election of hospice benefits dated 11/24/2021, had a discharge date effective 6/28/2022 by the agency for revocation. The patient tested positive for COVID-19 at the long-term care facility, and the patient was sent to the hospital by the facility and notified the hospice nurse effective 6/28/2022. No documentation or evidence of a request for revocation from hospice services by the patient or primary caregiver. An interview with the Administrator on 1/12/2023 confirmed the revocation statement form was missing during the joint record review.

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, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by a review of clinical records, interviews, and observations. In 1 of 3 (33%) observations where the medications in the patient's home were reconciled against the provided medication profile, the agency did not include a scheduled prescribed medication. Home Visit 1: During the home visit with the Medical Social Worker on 1/11/2023, permission was provided by the daughter to reconcile medications against the medication profile (Client Medication Report) printed and provided by the agency. As a result, the patient's eye medication was not listed on the Client Medication Report or the Hospice Recertification Plan of Care Update dated 12/7/2022 for the current benefit period, 12/22/2022 through 2/19/2023. The daughter stated the patient had been using the medication daily, which was started before admission to hospice. An interview with the Administrator on 1/11/2023 after the home visit confirmed the eye medication was missing from the profile and instructed the clinical manager to follow up with the daughter to update the medication profile's accuracy.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. All physician employees, and those under contract, must function under the supervision of the hospice medical director. This standard was not met as evidenced by a review of documents and interviews. Interviews with the agency's physicians revealed the Medical Director was not supervising the other physicians. Contract 1: Hospice Medical Director Agreement between physician and agency with the effective date of April 4th, 2022, stated in part under subtitle Exhibit A-Medical Director Services (page 13 of 23) … (11) "Oversee and supervise other employed and/or contracted Hospice Physicians and designate a Hospice Physician to serve as Acting Medical Director during any time that Director will not be available to perform his duties under this Agreement." An interview with the Medical Director on 1/11/2023 stated no involvement or oversight over the alternate delivery site (ADS) or other contracted physicians. An interview with the Associate Medical Director on 1/13/2023 confirmed real oversight of the ADS location; however no collaboration or supervision by the Medical Director.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 2 of 2 (100%) clinical records reviewed where the agency provided bereavement services to the bereaved, the agency did not include frequencies consistently for documented bereavement services in the bereavement plan of care. Clinical Record 1: The patient, with the election of hospice benefit dated 6/2/2022, died on 8/1/2022. The Bereavement Care Plan Report for the identified low-risk bereaved dated 6/6/2022 and modified 10/14/2022 did not include frequencies for the following documented services of initial sympathy care/letter, standard bereavement form letters, information/referral to community resources, and cards/newsletters. Clinical Record 4 The patient, with the election of hospice benefit dated 6/7/2022, died on 9/11/2022. The Bereavement Care Plan Report for the identified moderate risk bereaved dated 6/24/2022 and modified 9/12/2022 did not include frequencies for the following documented services of initial sympathy care/letter, standard bereavement form letters, and cards/newsletters. Interview with the Bereavement Coordinator on 1/12/2023 reviewed the development of the bereaved care plan based on the bereavement risk assessment. The Bereavement Coordinator reviewed an internal form titled Bereavement Program with documented tasks and timeframes. The initial sympathy card was to be mailed within seven days of the patient's death, and mailings are to be completed 30 days after the patient's death, then at three (3) months, six (6) months, nine (9) months, and thirteen (13) months after the date of death of a patient. Mailings were also scheduled for holidays, birthdays, and anniversaries. The Bereavement Coordinator confirmed the services did not include the frequencies consistently in the documented bereavement care plans during the joint record review for Record 1 and Record 4.

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, interviews, and observations. In 1 of 1 (100%) Home visits where the hospice aide was observed, the agency did not ensure specific written patient care instructions to the hospice aide on the care plan. Home Visit 3: During the home visit with the hospice aide on 1/12/2023, it was observed that the patient was sitting in a wheelchair. The hospice aide reviewed the care provided to the patient, including a chair bath on a bedside commode in the patient's room. An interview with the daughter stated the patient had not ambulated since May 2022 after a hip fracture and suffering a second fall in June 2022. The patient's current functional status was a transfer from a wheelchair to a bed or bedside commode with moderate assistance, sometimes by two people per the daughter and the hospice aide. The patient was unable to stand up from the chair without assistance. The Aide Care Plan Report updated 1/6/2023, printed and provided by the agency, had assigned interventions of "stand-by assistance with ambulation" and bed bath with details "chair bath in the patient bedroom per daughter's request." An interview on 1/12/2023 with the Administrator stated the type of bath of chair bath was not available in the electronic medical record (EMR). "Stand-by assistance with ambulation" at every visit was documented for the patient's functional status; however, during the home visit, the patient was a 1–2-person moderate assist with standing, pivoting, and transfers. The patient has not ambulated since the summer of 2022 after suffering from a significant fall, per the daughter. Later, the agency contacted the EMR, and the aide care plan was updated with the accurate interventions on 1/13/2023.

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 a review of clinical records and interviews. In 3 of 11 (27%) clinical records reviewed where hospice aide services were accepted, the agency did not ensure a process of reporting to the Registered Nurse by the Hospice Aide of assigned interventions not completed. Clinical Record 1: The patient, with the election of hospice benefit dated 6/2/2022, had a primary diagnosis of heart failure and received hospice aide services twice weekly. The Aide Care Plan Report dated 6/2/2022 documented assigned interventions to be completed at every visit, including bed bath, shampoo, skin care, oral care, applying barrier cream, and the date of the last bowel movement. Aide hospice visit dated 6/7/2022 documented shampoo as not completed due to "not required this visit," and oral care was not completed due to "patient preference." Aide hospice visit dated 6/9/2022 documented shampoo not completed due to "patient refused" and oral care not completed due to "not required this visit." Aide hospice visit dated 6/21/2022 documented shampoo as not completed due to "not required this visit." No documentation or evidence of the RN being notified of interventions not conducted by the aide for the visits on 6/2/2022, 6/7/2022, 6/9/2022, or 6/21/2022. Clinical Record 7: The patient, with the election of hospice benefit dated 12/13/2022, had a primary diagnosis of lung cancer and received hospice aide services while living in a long-term facility. The Aide Care Plan Report dated 12/13/2022 documented assigned interventions' frequencies to be completed at every visit, including turn and position in bed, bed bath, hair care, skincare, catheter care, perineal care, dressing, applying deodorant and applying barrier cream. Aide hospice visit note dated 12/21/2022 documented assigned inventions not completed, including turn and position in bed due to the "patient refused," bed bath was "already completed," hair care not conducted due to "not required this visit," perineal care due to "patient refused," shaving not conducted due to "not required this visit," and dressing and apply deodorant were already completed. No documentation or evidence of the RN being notified of interventions not conducted by the aide Clinical Record 8: The patient, with the election of hospice benefit dated 10/15/2022, had a primary diagnosis of hypertensive heart failure and received hospice aide services five days per week. The Aide Care Plan Report dated 10/17/2022 documented assigned interventions' frequencies to be completed at every visit, including shower bath, skincare, and dressing. Aide visit noted dated 11/9/2022 with an in-home time of 11:28 AM until 12:02 PM documented all interventions as not completed due to assigned tasks being completed or not required this visit, resulting in a missed visit. There was no documentation or report by the aide to the RN of interventions not being completed. An interview with the Administrator confirmed the RN was not notified of interventions not completed by the hospice aide in Record 1, Record 7, or Record 8 during a joint record review.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 3 (33%) clinical records reviewed where the patient was receiving treatments, the agency did not have proper physician orders or no physician orders for treatments provided to the patient. Clinical Record 7: The patient, with the election of hospice benefit dated 12/13/2022, had a primary lung cancer diagnosis and was admitted with a Foley catheter. The Hospice Certification and Plan of Care dated 12/13/2022 for benefit period 12/13/2022 through 1/24/2023 documented, "Hospice nurse to insert/maintain indwelling catheter 18 FR/10CC balloon, may irrigate with 30 ML of normal saline PRN. Change every month for obstruction, occlusion, and or dislodgement as needed." The Coordination Note dated 1/5/2023 documented that the indwelling catheter was discontinued "yesterday" after completing bladder training. No documentation of a physician order for discontinuation of the indwelling catheter; however, a physician order dated 1/3/2023 documented the bladder training. Coordination Note dated 12/29/2022 recorded, "patient arm has fresh new dressing and treatment nurse states bleeding has stopped today." However, no physician orders for wound care were documented in the record. An interview with the Administrator on 1/12/2023 confirmed the indwelling catheter physician order was not written accurately because the agency's procedure was to change every month, not just as needed. The Administrator confirmed the physician order was missing for discontinuing the indwelling catheter during the joint record review.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40. I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 3 (100%) clinical records reviewed where the patients were discharged and transferred to Medicare/Medicaid-certified facilities, the agency did not forward a copy of the patient's discharge summary for continuity of care. Clinical Record 5: The patient, with the election of hospice benefit dated 5/14/2022, was discharged from the agency effective 10/28/2022. The agency discharged the patient for requesting to be transferred to another hospice agency, and a transfer form was signed on 10/28/2022 by the caregiver. No evidence or documentation of the discharge summary dated 10/28/2022 was forwarded to the receiving hospice. Clinical Record 3: The patient, with the election of hospice benefit dated 5/18/2022, was discharged from the agency effective 7/27/2022. The agency discharged the patient for requesting to be sent to a non-contracted facility, a local hospital, to seek treatment for active symptoms of shortness of breath. The patient was admitted to the hospital with NSTEMI, CHF, and COPD exacerbation diagnoses. No evidence or documentation of the discharge summary dated 7/27/2022 being forwarded to the local admitting hospital. Clinical Record 2: The patient, with the election of hospice benefit dated 11/24/2021, was discharged from the agency effective 6/28/2022 for revocation. The patient tested positive for COVID-19 after the long-term facility tested the patient and sent the patient to a local hospital. No evidence or documentation of the discharge summary dated 6/28/2022 was sent to the hospital where the patient was admitted. An interview with the Administrator confirmed the discharge summaries for Record 2, Record 3, and Record 5 were not sent to the receiving facilities during the joint record review.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 3 of 4 (75%) clinical records reviewed where the patients resided in nursing facilities (NF), the hospice plans of care lacked an integrated care plan specifying which provider was responsible for performing which functions or treatments. The Agency policy number 17.13, titled Hospice Care for Facility Residents dated 12/1/2021, stated in part under the subtitle Process/Procedure... (4) "A written Hospice plan of care will be established and maintained in consultation with SNF/NF or ICF/MR representatives. All Hospice care provided will be in accordance with this Hospice plan of care. The Hospice plan of care will identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Hospice plan of care. The Hospice plan of care reflects the participation of Hospice, the SNF/NF or ICF/MR, and the patient and family to the extent possible. Any changes in the Hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/MR representatives, and must be approved by Hospice before implementation"... Clinical Record 1: The patient with an election of hospice benefit dated 6/2/2022 received hospice services as a resident at a local nursing facility. The Hospice Certification and Plan of Care dated 6/2/2022 for the benefit period 6/2/2022 through 8/30/2022 lacked documentation of an integrated care plan with the nursing facility. Clinical Record 4: The patient with an election of hospice benefit dated 6/7/2022 received hospice services as a resident at a local nursing facility. The Hospice Certification and Plan of Care dated 6/7/2022 for the benefit period 6/7/2022 through 9/4/2022 lacked documentation of an integrated care plan with the nursing facility. Clinical Record 7: The patient with an election of hospice benefit dated 12/13/2022 received hospice services as a resident at a local nursing facility. The Hospice Certification and Plan of Care dated 12/13/2022 for the benefit period 12/13/2022 to 1/24/2023 documented the hospice nurse's intervention to coordinate the care plan with facility staff. However, there was no evidence or documentation of an integrated care plan with the nursing facility. An interview with the Administrator on 1/13/2023 confirmed the agency's plans of care for Record 1, Record 4, and Record 7 lacked integration with the patient's nursing facilities during the joint record review.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of contracts and interviews. In 1 of 1 (100%) Facility contracts reviewed for providing the level of care of general inpatient (GIP), the agency did not include the criminal background check clause in the contract. Contract 2: The GIP contract titled Service Agreement between Hospice and Hospital, with an effective date of November 8, 2017, was missing the criminal background clause. The Vice President of Operations was contacted on 1/12/2023 about the criminal background clause and confirmed the clause was missing. The agency tried to send the hospital an addendum statement to the contract with the added clause before the exit conference to obtain a signature.

Based on review of medical records (MR), agency policy and procedure and staff interviews, it was determined the hospice failed to complete a comprehensive patient assessment within 5 days of admission. This deficient practice affected 1 of 10 MR reviewed and did affect MR # 9 and had the potential to affect all patients served by the hospice. Findings include: Agency Policy: Social Work Services Policy Number: H505 Revised: February 1, 2022 Policy Comfort Care Hospice ... will offer psychosocial care to all admitted patients and their families/caregivers. Procedure 3. The Social Worker will: a. Perform an initial admission assessment within five (5) days of a patient's admission to Comfort Care Hospice. 1. MR # 9 was admitted to the agency on 2/11/22 with diagnoses including Malignant Neoplasm of Pancreatic Duct and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Review of the Hospice Plan of Care (POC) dated 2/11/22 to 5/11/22 revealed, "MSW (Medical Social Worker): MSW Frequency: 1V x 1M (1 visit times 1 month) starting month of 02/11/2022..." Review of the MR revealed MSW Comprehensive Assessment-Psychosocial documented on 2/22/22, which was 11 days after admission to the agency. The MSW failed to perform the initial comprehensive patient assessment within 5 days of admission as directed per the agency policy. An interview was conducted on 3/10/22 at 11:12 AM with Employee Identifier (EI) # 1, Agency Administrator, who verified the MSW failed to complete a comprehensive patient assessment within 5 days of admission per agency policy.

Based on observations, review of medical records (MR), agency policy and procedure and interviews with staff, it was determined the hospice staff failed to ensure all patient medication (med) lists were current and accurate. This affected 2 of 3 home visits (HV) conducted including HV # 3 and HV # 2. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication/ DME (Durable Medical Equipment) Review Policy Number: H701 Revised: April 1, 2020 Policy All medications and DME will be reviewed with the patient and/or family every fifteen (15) days and as necessary. Procedure 1. Review all medications and DME with the patient and/or family every fifteen (15) days and as necessary. ...3. List all medications on the Hospice Medication Profile. 4. List any new and/or changes with medications on the Hospice Medication Profile upon occurrence. 1. HV # 3 was recertified to hospice from 1/22/22 to 3/22/22 with diagnoses including Parkinson's Disease, and Unspecified Combines Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Review of the Hospice Plan of Care (POC) Order dated 1/22/22 to 3/22/22 revealed the SN (Skilled Nurse) frequency of 2v x 8w, 1v x 1w (2 visits times 8 weeks, 1 visit times 1 week). A HV was conducted on 3/8/22 at 3:08 PM to observe care provided by Employee Identifier (EI) # 5, MSW (Medical Social Worker). Prior to the HV, the surveyor was provided a med list printed on 3/8/22 at 8:47 AM. The med list was compared to the medications observed in the home, and the following discrepancies were observed: 1. Hydrocodone-Acetaminophen 5 mg (milligrams) - 325 mg oral tablet 1 tab (tablet) q (every) 4-6 h (hours) prn (as needed). The caregiver verbalized the medication was not in the home and that the patient had not taken the medication in over a year. The caregiver stated, "I can't remember an exact date or month". 2. Mucinex 400 mg 2 tabs oral bid (two times a day) prn. The caregiver verbalized the medication was not in the home. The caregiver further verbalized that he/she doesn't remember the patient ever taking this medication. An interview was conducted on 3/10/22 at 11:14 AM with EI # 1, Agency Administrator, who confirmed staff failed to update the med list per agency policy. 2. HV # 2 was admitted 8/28/19 and recertified for 2/13/22 to 4/13/22 with diagnoses including Malignant Neoplasm of Prostate, Malignant Neoplasm of Bone and Malignant Neoplasm of Unspecified Lung. Review of the Recertification POC Order dated 2/13/22 revealed the SN was to visit 2 times per week, the MSW and Chaplain to visit 1 time per month and the Hospice Aide was to visit 2 times per week. A HV was conducted 3/8/22 at 1:10 PM to observe care provided by EI # 4, Hospice Aide, and review medications. The medications in the home were compared to the med list provided by the agency on 3/8/22, and verified by the patient's spouse. The following discrepancies were identified: a. Dakins Quarter Strength 0.125% daily for wound care was on the med list in the home. The spouse stated that had not been in the home and in use since "last year sometime." b. A prescription bottle labeled HM Laxative 5 mg po q day was in the home dated 1/4/22 and not listed on the med list. c. Tylenol 325 mg 1-2 tabs every 4 hours as needed was on the med list and the Tylenol in the home was 500 mg. The spouse stated, "the patient has always taken 500 mg for headache." d. Guaifensin ER (extended release) 1200 mg one bid (twice a day) dated 2/25/22 was in the home and not on the med list. Review of the physician orders in the MR revealed no order for Guaifesin ER. An interview conducted 3/10/22 at 12:06 PM with EI # 1 confirmed the med list was not current and accurate. EI # 1 provided an Intrdisciplinary Group meeting note dated 2/25/22 with documentation "start Mucinex (brand name for Guaifensin) 600 mg po bid. EI # 1 confirmed the strength listed was not 1200 mg ER as observed in the home by the surveyor.

Based on reveiw of medical records (MR) and interviews it was determined the agency failed to ensure an initial bereavement risk assessment was completed for each patient/family. This affected 2 of 13 records reviewed including MR # 2, MR # 4 and had the potential to affect all patients/families served by the hospice. Findings include: 1. MR # 2 was admitted 2/4/22 with diagnosis of Alzheimer's Disease. Review of the initial assessmemts completed by the nurse on 2/4/22, social worker on 2/7/22, and chaplain on 2/4/22 revealed no documentation of an initial bereavement risk assessment. An interview conducted 3/10/22 at 12:02 PM with Employee Identifier (EI) # 1, Agency Administrator, confirmed there was no documentation the initial bereavement risk assessment was completed. 2. MR # 4 was admitted to the agency on 12/7/21 with diagnosis including Secondary Carcinoid Tumors of Liver and Carcinoid Syndrome. Review of the Plan of Care orders dated 12/7/21 revealed Skilled Nurse (SN) frequency of 2 times per week and MSW (Medical Social Worker) and Spiritual was declined. Review of the initial assessment completed by the SN on 12/7/21 revealed no documentation of an initial bereavement risk assessment. An interview conducted 3/10/22 at 11:30 AM with EI # 1 confirmed there was no documentation the initial bereavement risk assessment was completed.

Based on the review of medical records (MR), agency's policy and procedure and staff interview, it was determined the agency failed to ensure all members of the Interdisciplinary group (IDG) for the hospice team were present at each meeting. This affected 4 of 10 active records reviewed including MR # 9, MR # 6, MR # 7, MR # 8. This had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Interdisciplinary Team (IDT) Policy Number: H403 Revised: April 1, 2020 Policy The IDT supervises the care and services provided by Comfort Care Hospice. The core IDT is composed of: ... Medical Director/Associate Hospice Physician ... Registered Nurse (RN) ... Social Worker ... Spiritual Coordinator/Counselor... Procedure ...2. The IDT will supervise and evaluate the performance of Hospice caregivers based on reports provided by the Patient Care Coordinator. ...5. In regard to direct patient care, the IDT has the responsibility of: ...c. Reviewing and updating each Care Plan every 15 days at a formal meeting. 1. MR # 9 was admitted to the agency on 2/11/22 with diagnoses including Malignant Neoplasm of Pancreatic Duct and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Review of the Hospice Plan of Care (POC) dated 2/11/22 to 5/11/22 revealed, "MSW (Medical Social Worker): MSW Frequency: 1V x 1M (1 visit times 1 month) starting month of 02/11/2022..." Review of the IDT meeting dated 2/25/22 revealed no documentation and no signature the MSW attended the IDT meeting as part of the IDT team per agency policy. An interview was conducted on 3/10/22 at 11:12 AM with Employee Identifier (EI) # 1, Agency Administrator, who verified the MSW was not present at the 2/25/22 IDT meeting. EI # 1 verified the agency failed to ensure all IDT members were present at the 2/25/22 IDT meeting as directed per agency policy. 2. MR # 6 was admitted to the agency 2/8/22 with diagnoses including Chronic Obstructive Pulmonary Disease With Acute Exacerbation, Hypertensive Chronic Kidney Disease and Type 2 Diabetes. Review of the IDT meetings dated 2/11/22 and 2/25/22 revealed no documentation and no signature the MSW attended the IDT meeting as part of the IDT team per agency policy. An interview conducted 3/10/22 at 12:11 PM with EI # 1 confirmed there was no MSW present or involved in the IDT meetings on 2/11/22 and 2/25/22. 3. MR # 7 was admitted 2/9/22 with diagnoses including Malignant Neoplasm of Cardia and Secondary Malignant Neoplasm of the Liver. Review of the IDT meetings dated 2/11/22 and 2/25/22 revealed no documentation and no signature the MSW attended the IDT meeting as part of the IDT team per agency policy. An interview conducted 3/10/22 at 11:54 AM with EI # 1 confirmed there was no MSW present or involved in the IDT meetings on 2/11/22 and 2/25/22. 4. MR # 8 was recertified for hospice from 2/1/22 to 5/1/22 with diagnosis including COVID-19 and Pneumonia Due to Coronavirus Disease 2019. Review of the IDT meetings dated 2/11/22 and 2/25/22 revealed no documentation and no signature the MSW attended the IDT meeting as part of the IDT team per agency policy. An interview conducted on 3/10/22 at 11:30 AM with EI # 1 confirmed there was no MSW present or involved in the IDT meetings on 2/11/22 and 2/25/22.

Based on review of medical records (MR), policies and procedures, and interviews, it was determined the agency failed to ensure staff followed the plan of care for the following: a) Staff monitored blood sugars and assessed for signs/symptoms of hypo/hyperglycemia as directed per the physician's orders. b) Staff ensured the caregiver performed a returned demonstration of wound care as directed per the physician's orders. This affected 2 of 10 active records reviewed and did affect MR # 3, Home Visit (HV) # 1 and had the potential to affect all patients served by the hospice. Findings include: Agency Policy: Plan of Care Policy Number: H402 Revised: June 30, 2021 Policy: An individualized Plan of Care will be established for each Hospice patient prior to the provision of care... Procedure: ...6. The Plan of Care is initiated upon the verbal order and initial certification of the terminal illness... 7. The content of the Plan of Care will include measurable outcomes anticipated from implementing and coordinating the Plan of Care. Agency Policy: Nursing Services Policy Number: H503 Revised: February 1, 2022 Policy ...Skilled nursing services include... the provision of emotional support the patient and the family, and the instruction of caregivers in providing care to the patient. Procedure 3. RN (Registered Nurse) Case Manager Responsibilities a. The PCC (Patient Care Coordinator) will assign an RN Case Manager to the patient/family to provide nursing care and to coordinate care with the Interdisciplinary Team (IDT) as well as outside agencies/vendors. ...d. Assess the patient/family for the need of care or services from other IDT members as well as outside individuals/organizations. Coordination of these services will be based upon physician orders for services ... 5. Nursing Staff: a. Provide nursing care per physician orders ... 1. MR # 3 was recertified to the agency from 2/1/22 to 4/1/22 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Type 2 Diabetes Mellitus Without Complications. Review of the Recertification Plan of Care Order dated 2/1/22 to 4/1/22 revealed, "SN (Skilled Nurse): 2V x 9W (2 visits times 9 weeks) starting week of 2/1/22 ... Monitor blood sugars: Weekly... Assess for signs/symptoms of hypo/hyperglycemia". Review of the IDT Meeting dated 2/4/22 revealed, "Wound # (Number) 1 Location Right inner ankle Stage 2 clean with NS (Normal Saline), dry with gauze, apply triad cream to wound bed, cover with comfort foam dressing... Change dressing every M, W, F (Monday, Wednesday, Friday) and prn (as needed)... Caregiver may perform wound care when return demonstration received. Wound # 2 Location right lateral maleous Stage 1 clean with NS... Change dressing every M, W, F and prn... Caregiver may perform wound care when return demonstration received. Wound # 3 Location left lateral ankle Stage 1 clean with NS... Change dressing every M, W, F and prn... Caregiver may perform wound care when return demonstration received. Review of the SN Visit Notes (SNVN's) dated 2/2/22, 2/4/22, 2/9/22, 2/11/22, 2/15/22, 2/18/22, 2/22/22, 2/24/22, 3/1/22 and 3/3/22 revealed there was no documentation of weekly blood sugar monitoring as directed per the physician's orders. Review of the SNVN's dated 2/4/22, 2/11/22, 2/18/22, 2/24/22, and 3/3/22 revealed there was no documentation the SN assessed for signs/symptoms of hypo/hyperglycemia as directed per the physician's orders. Further review of the SNVN's dated 2/4/22, 2/9/22, 2/11/22, 2/15/22, 2/18/22, 2/22/22, 2/24/22, 3/1/22 and 3/3/22 revealed there was no documentation the caregiver performed a return demonstration of wound care as directed per the physician's orders. An interview was conducted on 3/10/22 at 11:18 AM with Employee Identifier (EI) # 1, Agency Administrator, who confirmed the staff failed to follow the physician's orders for monitoring blood sugars weekly, assessing for signs/symptoms of hypo/hyperglycemia and ensuring the caregiver performed a return demonstration of wound care. 2. HV # 1 was admitted to the agency on 2/11/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the Hospice Plan of Care dated 2/11/22 to 4/11/22 revealed SN frequency of 2 visits per week. Review of the Care Plan Change Order dated 2/15/22 revealed wound # 1 upper left ankle, clean wound with wound cleaner, pat dry with gauze. May apply skin prep periwound. Apply medihoney to wound bed with a wet to dry dressing. Secure with tape. Change every 3 to 5 days and PRN for soiled/dislodged dressing. Caregiver may provide wound care once return demonstration has been obtained. Further review of the Care Plan Change Order dated 2/15/22 revealed wound # 2 left ankle, clean wound with wound cleaner, pat dry with gauze. May apply skin prep periwound. Apply medihoney to wound bed with a wet to dry dressing. Secure with tape. Change every 3 to 5 days and PRN for soiled/dislodged dressing. Caregiver may provide wound care once return demonstration has been obtained. Review of the Wound Assessments dated 2/11/22, 2/14/22 and 3/1/22 revealed, "Patient/Family/Caregiver instructed to perform dressing change" and wound care/dressing change for wound # 1 and wound # 2 performed by "self". Further review of the MR for the certification period dated 2/11/22 to 4/11/22 revealed no documentation of a return demonstration of wound care. An interview conducted on 3/10/22 at 11:30 AM with EI # 1 confirmed the patient/caregiver performed the wound care and a return demonstration was not obtained as ordered.

Based on review of agency policy and procedure, observation and interviews, it was determined the staff failed to perform hand hygiene per policy on 1 of 3 Home Visits (HV) performed and did affect HV # 1 and had the potential to affect all patients served by the hospice. Findings include: Agency Policy: Hand Hygiene Policy Number: H906 Revised Date: April 1, 2020 Policy: To prevent the transmission of microorganisms from patient to patient and from inanimate surfaces to patients by the hands of all healthcare providers... Procedure: Gloves and Hand Hygiene: ...the use of gloves does not eliminate the need for hand hygiene. 1. Wear gloves when contact with blood or other potentially infectious materials (other body fluids, secretions and excretions), mucous membranes, non-intact skin and contaminated items will or could occur. 2. Change gloves during patient care if moving from a contaminated body site to a clean body site. 3. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient. 4. Decontaminate hands after removing gloves. 1. HV # 1 was admitted to the agency on 2/11/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. A HV was conducted on 3/8/22 at 12:05 PM to observe Employee Identifier (EI) # 3, Registered Nurse (RN) perform wound care. After cleaning the wounds on the left foot, EI # 3 doffed gloves and donned clean gloves without performing hand hygiene (HH) and applied medihoney to the first wound. EI # 3 then doffed gloves and donned clean gloves without performing HH and opened a new package of Q-tips and applied medihoney to the second wound. EI # 3 then doffed gloves and donned clean gloves without performing HH and obtained gauze wet with sterile water to apply to the wounds. EI # 3 then doffed gloves and without performing HH, donned clean gloves and applied the wet to dry dressing and taped the dressing with paper tape. EI # 3 then doffed gloves, performed HH and donned clean gloves and applied a foam boot to the left foot, discarded used wound care supplies in the garbage, then doffed gloves and without performing HH or donning clean gloves, covered the patient with bed covers and placed his/her hands on his/her hips, then performed HH. An interview conducted on 3/10/22 at 11:30 AM with EI # 1, Administrator confirmed EI # 3 did not follow their policy for hand hygiene.

Based on agency policy and procedure, review of medical records (MR) and interviews it was determined the agency failed to ensure the Hospice Aide (HA) Care Plan was individualized to meet the needs of the patient to include care of an indwelling catheter. This affected 1 of 2 patients with an indwelling catheter receiving HA services and inlcuded MR # 6. This deficient practice had the potential to affect all patients with a catheter receiving aide services. Findings include: Agency Policy: Hospice Aide/Homemaker Services Policy Number: H504 Revised: February 1, 2022 Policy: Comfort Care Hospice, L.L.C., offers Hospice Aide/Homemker services for patients needing personal care assistance and light housekeeping duties. Hospice Aides and Homemakers work under the supervision of a Registered Nurse (RN) and will follow the plan of care for all patient assignments. Procedure: 4. Hospice Aide/Homemaker Responsibilities d. The RN assigns the Hospice Aide/Homemaker duties based on identified patient needs and creates the Plan of Care (POC) for the Hospice Aide... MR # 6 was admitted to the agency 2/8/22 with diagnoses including Chronic Obstructive Pulmonary Disease With Acute Exacerbation and Neuromuscular Dysfunction of Bladder. Review of the Hospice POC dated 2/8/22 revealed the Skilled Nurse (SN) was to visit 2 times per week and change the change suprapubic (indwelling) catheter monthly. Hospice Aide services were declined. Review of the physician's order dated 2/15/22 revealed Hospice Aide services to begin 2 times per week starting the week of 2/13/22. Review of the Hospice Aide Care Plan dated 2/15/22 revealed no indication the patient had a suprapubic catheter. An interview conducted 3/10/22 at 12:11 PM with Employee Identifier # 1, Agency Administrator, confirmed the aide care plan did not include the suprapubic catheter.

Based on a review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure the staff: 1. Documented accurate endocrine/diabetic assessments in the clinical record. 2. Documented accurate wound care in the clinical record. This affected 3 of 10 active records reviewed including MR # 3, home visit (HV) # 1, MR # 8 and had the potential to negatively affect all patients served by this agency. Findings include: Policy: Documentation Policy Number: H202 Revised: April 1, 2020 Policy: Documentation will be maintained in the individual clinical record for every patient in accordance with professional standards: federal, state, and local laws. The purpose of the policy is to promote documentation that is a true and accurate account of the patient's status and the care provided. Procedure: 1. Staff will complete and submit all direct care documentation within 48 hours of the patient visit... 1. MR # 3 was recertified to the agency from 2/2/22 to 4/1/22 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Type 2 Diabetes Mellitus Without Complications. Review of the Recertification Plan of Care (POC) Order dated 2/1/22 to 4/1/22 revealed, "SN (Skilled Nurse): 2V x 9W (2 visits times 9 weeks) starting week of 02/01/2022". Review of the Skilled Nurse Visit Notes (SNVN's) dated 2/2/22, 2/9/22 and 2/15/22 revealed, "Endocrine... Diabetes... Able to draw and administer insulin: Yes". Review of the "Medications" list printed 3/8/22 at 10:24 AM revealed, "Metformin 500 mg (milligrams) 1 tab (tablet) daily, discontinued on 10/6/21". There was no documentation on the "Medications" list and in the MR that MR # 3 was on Insulin. The staff failed to accurately document endocrine/diabetic assessments in the MR. An interview was conducted on 3/10/22 at 11:18 AM with Employee Identifier (EI) # 1, Agency Administrator, who verified MR # 3 was not on Insulin. EI # 1 further verified the staff failed to accurately document endocrine/diabetic assessments per agency policy. 2. HV # 1 was admitted to the agency on 2/11/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the POC Order dated 2/11/22 revealed a SN frequency of 2v x 9w (two visits per week for 9 weeks) and the following wound care for wound # 1 and wound # 2 on the left ankle: Clean with wound cleanser, pat dry with gauze, may apply skin prep periwound. Apply medihoney to wound bed with a wet to dry dressing. Secure with tape. Change every 3 to 5 days and as needed for soiled/dislodged dressing. Review of the SNVN dated 2/14/22 revealed, "Ace wrap removed and wound care completed." There was no documentation of what wound care was provided during the visit. An interview conducted on 3/10/22 at 11:30 AM with EI # 1 confirmed there was no documentation of what wound care was provided by the nurse. 3. MR # 8 was recertified for hospice from 2/1/22 to 5/1/22 with diagnoses including COVID-19 and Pneumonia Due to Coronavirus Disease 2019. Review of the POC Order dated 2/1/22 to 5/1/22 revealed SN to obtain return demonstration from patient/caregiver on correct procedure of obtaining blood sugar and patient/caregiver will give adequate return demonstration of insulin injection. Review of the SNVN dated 2/15/22 revealed, "...patient averages one insulin injection per week." Review of the SNVN dated 2/22/22 revealed, "Patient Cg (Caregiver) using dexicom to monitor BS (Blood Sugar) continuously and is averaging one injection per week for elevated BS. Further review of the MR dated 2/1/22 to 5/1/22 revealed no documentation of the BS results that were being monitored and no documentation of what BS results prompted the administration of insulin. An interview conducted on 3/10/22 at 11:30 AM with EI # 1 confirmed the SN did not document the BS results obtained by the caregiver to monitor the BS and should have.

Based on a review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure the staff: 1. Signed and dated all documentation, including visit notes per agency policy. 2. Completed all documentation within the agency timeframes. This affected 4 of 10 active records reviewed including MR # 3, MR # 9, MR # 2, MR # 8 and 1 of 3 discharge records reviewed, including MR # 10, and had the potential to negatively affect all patients served by this agency. Findings include: Policy: Documentation Policy Number: H202 Revised: April 1, 2020 Policy: Documentation will be maintained in the individual clinical record for every patient in accordance with professional standards: federal, state, and local laws. The purpose of the policy is to promote documentation that is a true and accurate account of the patient's status and the care provided. Procedure: 1. Staff will complete and submit all direct care documentation within 48 hours of the patient visit. 2. Staff will document all other care-related events after the evaluation of the situation and/or communication with others within 48 hours. ...8. All documentation should be dated and signed the date it is entered into the medical record ... 1. MR # 3 was recertified to the agency from 2/1/22 to 4/1/22 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Type 2 Diabetes Mellitus Without Complications. Review of the Recertification Plan of Care (POC) dated 2/1/22 to 4/1/22 revealed the SN (Skilled Nurse) was to visit 2 times per week. Review of the Interdisciplinary Team (IDT) meeting dated 2/18/22 revealed the Hospice Aide (HA) was to visit 3 times per week beginning week of 2/6/22, with assistance of a secondary aide for total of 6 HA visits per week. Review of the SN Visit Note (SNVN) dated 2/4/22 revealed the SN digitally signed the SNVN on 2/11/22, which was 7 days later. Review of the SNVN dated 2/9/22 revealed the SN digitally signed the SNVN on 2/13/22, which was 4 days later. Review on 3/8/22 of the SNVN dated 2/11/22 revealed no signature and date by the nurse which was 25 days after the visit. Review of the HA Visit Note (HAVN) dated 2/17/22 revealed the HA digitally signed the HAVN on 2/21/22, which was 4 days later. An interview was conducted 3/10/22 at 11:18 AM with Employee Identifier (EI) # 1, Agency Administrator, who confirmed the visit note's were not signed, dated, and completed within 48 hours of the visit's as directed per agency policy. 2. MR # 9 was admitted to the agency on 2/11/22 with diagnoses including Malignant Neoplasm of Pancreatic Duct and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Review of the Hospice POC dated 2/11/22 to 5/11/22 revealed the SN was to visit 1 time per week for 1 week, then 2 times per week. Review of the SNVN dated 2/12/22 revealed the SN digitally signed the SNVN on 2/15/22, which was 3 days later. Review of the SNVN dated 3/3/22 revealed the SN digitally signed the SNVN on 3/6/22, which was 3 days later. An interview conducted 3/10/22 at 11:12 AM with EI # 1 confirmed the visit note's were not signed within 48 hours of the visit as directed in agency policy. 3. MR # 10 was admitted to the agency on 12/7/21 with a diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of the Hospice POC dated 12/7/21 revealed the "Spiritual" (Chaplain) was to visit 1 time per month. Review of the Spiritual Assessment dated 12/7/21 revealed the Chaplain digitally signed the visit note on 12/19/21, which was 12 days later. An interview conducted 3/10/22 at 11:11 AM with EI # 1 confirmed the visit note was not signed within 48 hours of the visit as directed in agency policy. 4. MR # 2 was admitted 2/4/22 with diagnosis of Alzheimer's Disease. Review of the Hospice Plan of Care dated 2/4/22 revealed the SN was to visit 2 times per week. Review on 3/9/22 of the SNVN dated 2/11/22 revealed no signature and date by the nurse completing the visit which was 27 days after the visit. An interview conducted 3/10/22 at 12:02 PM with EI # 1 confirmed the visit note was not signed within 48 hours of the visit as directed in agency policy. 5. MR # 8 was recertified for hospice 2/1/22 to 5/1/22 with diagnosis including COVID-19 and Pneumonia Due to Coronavirus Disease 2019. Review of the Hospice Plan of Care dated 2/1/22 to 5/1/22 revealed the SN was to visit 2 times per week. Review of the SNVN dated 2/3/22 revealed the SN digitally signed the SNVN on 2/14/22 which was 11 days after the visit. Review on 3/9/22 of the SNVN dated 2/8/22 revealed no signature or date by the SN which was 29 days later. Review of the SNVN dated 2/15/22 revealed the SN digitally signed the SNVN on 2/22/22 which was 7 days later. Review of the SNVN dated 2/18/22 revealed the SN digitally signed the SNVN on 2/22/22 which was 4 days later. Review of the SNVN dated 2/22/22 revealed the SN digitally signed the SNVN on 3/2/22 which was 8 days later. Review of the SNVN dated 2/24/22 revealed the SN digitally signed the SNVN on 3/2 which was 6 days later. Review of the SNVN dated 3/1/22 revealed the SN digitally signed the SNVN on 3/8/22 which was 7 dates later. Review of the SNVN dated 3/3/22 revealed the SN digitally signed the SNVN on 3/7/22 which was 4 days later. An interview conducted on 3/10/22 at 11:30 AM with EI # 1 confirmed the visit notes were not signed within 48 hours of the visit as directed in the agency policy.

Based on observation, agency policy and procedure, Hospice Admission Booklet, and interview, it was determined the agency failed to ensure oxygen was secured safely in 1 of 3 home visits (HV) conducted with patients receiving Oxygen (O2) therapy. This had the potential to affect all patients receiving O2 therapy and did affect HV # 3. Findings Include: Agency policy: Safety Policy number: H1000 Revised: April 1, 2020 Purpose ...4. Develop processes to: a. Prevent accidents and injuries to patients and staff. b. Promote a safe and secure environment. Policy/Procedure 8. The agency educates patients, families, and caregivers about ways to decrease hazards and perform safety procedures in the home environment. a. Staff provides safety education and education resources for patients, families, and caregivers about: ... Storage, handling, and access to medical gases and related supplies, as appropriate ... Hospice Admission Packet Section 7: Home Safety Oxygen Safety ... Place the oxygen cylinders in appropriate stand to prevent tipping, or secured to the wall or placed on their side on the floor ... 1. HV # 3 was recertified to hospice from 1/22/22 to 3/22/22 with diagnoses including Parkinson's Disease, and Unspecified Combines Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Review of the Hospice Plan of Care Order dated 1/22/22/ to 3/22/22 revealed the SN (Skilled Nurse) frequency of 2v x 8w, 1v x 1w (2 visits times 8 weeks, 1 visit times 1 week). A HV was conducted on 3/8/22 at 3:08 PM to observe care provided by Employee Identifier (EI) # 5, Medical Social Worker. Prior to the HV, the surveyor was provided a current "Medications" list printed 3/8/22 at 8:47 AM, which included O2 at 2 - 4 Liters Per Minute) Inhalation per Nasal Cannula prn (as needed), start date of 5/11/21. During the HV, the surveyor observed an O2 tank which was leaning at an angle against a wall. The tank was unsecured to prevent tipping as directed per the agency home safety policy. An interview was conducted on 3/10/22 at 11:14 AM with EI # 1, Agency Administrator, who confirmed staff failed to ensure the safe storage of the O2 tanks.