Every finding on record at Comfort Care Hospice, LLC

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 which revealed the agency did not ensure that volunteer hours met the Medicare requirement of at least 5% of total patient-care hours as required under 42CFR 418.78(e) A joint review of the agency report titled "Hospice Volunteer Requirement Report" with the Volunteer Coordinator on 12/15/2025 revealed that volunteer utilization was 0.08% for the period 01/01/2024 through 12/31/2024. The annual volunteer report for calendar year 2025, 01/01/2025 through the review date 12/15/2025, revealed volunteer utilization was 0.45%. During an interview on 12/15/2025, the Volunteer Coordinator stated, "We have not had a Volunteer Coordinator. We have had challenges recruiting Volunteers because of the high crime rate in this city, we had one volunteer but, she had surgery and has been out sick for a while that is why we did not meet the 5% requirement. We are currently in the process of recruiting more volunteers." The Volunteer Coordinator provided documentation of the active volunteer recruitment and retention program. They had implemented an performance improvement plan PIP) that was started on 04/01/2024 and is in progress. No further informtion was provided. The agency did not ensure that volunteer hours met the Medicare requirement of at least 5% of total patient-care hours as required under 42CFR 418.78(e)

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 the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document review and interviews. 1 of 2 (50%) applicable clinical records of patients who were live discharges from the hospice agency did not evidence that the discharge summary was forwarded to the patient's attending physician. Hospice Discharge from Care Policy Number 17.12 (Original Policy Date: 12/1/21) states in part, "Discharge Summary 2. If a patient revokes the election of Hospice care or is discharged from Hospice due to no longer terminally ill, Hospice will forward to the patient's attending physician, a copy of: The Hospice discharge summary; the patient's record if requested." Clinical Record 12: The patient elected the hospice benefit on 10/12/2022 and revoked hospice services on 11/4/2022. There was no evidence in the clinical record that the discharge summary was forwarded to the attending physician. The Administrator and Clinical Manager were interviewed on 1/31/2022 and agreed that there was no documentation in the clinical record that the discharge summary was forwarded to the patient's attending physician.

Based on policy and procedures, medical record (MR) reviews, and interviews it was determined the agency failed to ensure the Hospice Aide (HA) notified the Registered Nurse (RN) of no Bowel Movements (BM) in three days and inability to complete assigned tasks due to patient refusal. This affected two of ten medical records reviewed with HA services, including MR # 4 and MR # 5 and had the potential to negatively affect all patients that receive HA services with the agency. Findings Include: Policy: Hospice Aide/Homemaker Services Agency Policy Number: H504 Date Revised: 2/1/22 Policy: Comfort Care Hospice, L.L.C., offers Hospice Aide/Homemaker services for patients needing personal care assistance... Hospice Aides...work under the supervision of a Registered Nurse (RN) and will follow the plan of care for all patient assignment. Procedure: ...4. Hospice Aide/Homemaker Responsibilities: a. The HA will make visits as assigned by the Patient Care Coordinator (PCC) or designated RN. b. The HA is supervised by an RN. c. The HA will communicate abnormal signs and symptoms to the RN and will document communication on HA Visit Note. d. The RN assigns the HA duties based on identified patient needs and creates the Plan of Care (POC) for the HA. Any deviation from the POC from the HA will be communicated to the RN, and the RN will review the patient and family needs to determine the need of any changes to the HA services... --- 2. MR # 5 was admitted on 6/7/2022 and recertified on 9/5/22 with diagnoses including Atherosclerosis Heart Disease of Native Coronary Artery without Angina Pectoris and Pain, Unspecified. Review of the Episode Detail Report included the Plan of Care orders updated for period dated 9/5/2022 to 12/3/22 revealed the Skilled Nurse (SN) visit frequency scheduled for one time a week for thirteen weeks. The HA visit frequency was scheduled for three times a week for thirteen weeks. Review of the HA care plan dated 9/5/22 to 12/3/22 revealed the HA assigned duties to document patient's date of last Bowel Movements (BM) and notify nurse if no BM in three days. Review of seven HA Visit Note Reports revealed no documentation the RN was notified of no BM in three days per orders as follows: Review of VNR dated 9/5/22 last BM on 9/2/22, which was three days. Review of VNR dated 9/12/22 last BM on 9/8/22, which was four days. Review of VNR dated 9/14/22 last BM on 9/8/22, which was six days. Review of VNR dated 9/23/22 last BM on 9/19/22, which was four days. Review of VNR dated 10/10/22 last BM on 10/5/22, which was five days. Review of VNR dated 10/21/22 last BM on 10/16/22, which was five days. Review of VNR dated 11/4/22 last BM on 10/31/22, which was four days. In an interview conducted on 11/17/22 at 9:59 AM with Employee Identifier (EI) # 2, confirmed there was no documentation that the HA notified the SN of no BM's in three days per the HA's care plan assignment. 1. MR # 4 was admitted to the agency on 10/19/2022 and certified for care 10/19/22 to 1/16/23 with diagnoses including Malignant Neoplasm of Colon, Unspecified and Secondary Malignant Neoplasm of Other Specified Sites. Review of the Hospice Certification and POC dated 10/19/22 revealed SN visits three times a week for thirteen weeks and Hospice Aide (HA) visits two times a week for 13 weeks. Review of Physician's Order dated 10/24/2022 revealed to increase SN visits daily for wound care and increase aide visits to daily. Review of Physician's Order dated 11/9/22 revealed to decrease SN visits to every other day and decrease HA frequency to every other day. Review of the HA Care Plan Report revealed Activities of Daily Living (ADL) to be performed every visit: Bed Bath, Hair Care, Skin Care, Routine Catheter Care, Perineal Care, Oral Care, File nails, Clean Nails, Dressing, Routine Ostomy Care, Apply Deodorant every visit. Also, Empty Trash, Empty Urinary Drainage Bag every visit. Change Linens every week or at caregiver (CG) request. Review of two HA Visit Note Reports (VNR) revealed no documentation that the HA notified the RN of services not performed by the HA or services refused by the patient including: Review of VNR dated10/29/22 revealed the patient refused bed bath, hair care, skin care, routine catheter care, perineal care, oral care, file nails, dressing and to apply deodorant. There was no documentation the RN was notified. Review of VNR dated 11/2/22 revealed the patient refused bed bath, skin care, perineal care, oral care, nail care, dressing and to apply deodorant. There was no documentation the RN was notified. An interview was conducted on 11/17/22 at 10:36 AM with EI # 2, Quality Assurance Coordinator, who confirmed there is no documentation the HA notified the RN of deviations from the Aide POC.