Every finding on record at Comfort Care Hospice of Middle Tennessee, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the comprehensive assessment was completed within 5 days after the election of benefits. CLINICAL RECORD 10: The patient elected hospice care on 07/14/2025 with a diagnosis of malignant neoplasm of the prostate. The skilled nursing (SN) initial comprehensive assessment documented that the patient would receive nursing, Social Work (SW), Chaplain (SC), and Hospice Aide (HA) services. The plan of care dated 07/14/2025 ordered Chaplain (SC) services "1m1." The SC assessment was completed on 07/25/2025, ten (10) days after the patient's election of hospice care. A clinical record review revealed no documentation to support the late SC assessment. During an interview and a joint record review on 09/11/2025, the Administrator confirmed that the Chaplain's assessment was late and that there was no documented evidence to explain the delay.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care reflected the patient's and family's goals and identified planned interventions based on the identified problems. CLINICAL RECORD 1: The patient elected hospice care on 05/08/2025 with diagnoses of cerebral ischemia and dependence on supplemental oxygen. The plans of care with effective dates of 05/08/2025 and 08/08/2025 ordered oxygen at 2 liters per minute (LPM) via nasal cannula, as well as oxygen precautions and supplies. The plan of care did not include interventions or goals related to the patient's oxygen dependence. During an interview and a joint record review on 09/10/2025, the Administrator stated, "No, there are no respiratory interventions."

It is required that the hospice designates a Registered Nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records reviewed revealed that the agency did not ensure that the plan of care was implemented as ordered. Clinical Record 12: The Plan of Care dated 12/7/2022 reads, "SN effective 12/7/2022 1WK9, 3 PRN. The Agency Medicare week of Sunday through Saturday. The patient was not seen by Skilled Nursing from 12/7/2022 through 12/10/2022. The Clinical Manager stated in an interview on 12/14/2022, " I see what happened. The patient is seen once a week, and she saw the patient on Tuesday that week and was not thinking about certification periods. 1 of 13 (7%) of clinical records reviewed revealed that the agency did not ensure that that the plan of care was implemented as ordered.

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. 7 of 13 (54%) clinical records with aide services reviewed revealed that the agency did not ensure that the aide care plan provided specific care instructions to meet the patient's needs and allow the aide to function within the scope of service. Clinical Record 3: Start of Care (SOC) assessment on 11/23/2022 notes that the patient is prescribed oxygen. The Aide care plan dated 11/23/2022 does not include instructions to the aide related to oxygen. Clinical Record 2: SOC assessment revealed that the patient has a Peg tube and a trach. The Aide care plan does not include any information or instruction to the aide related to peg tube or trach. Clinical Record 1: Skilled Nursing (SN) assessment on 10/14/2022 notes that oxygen was ordered at 4L per NC. The Aide care plan dated 10/14/2022 does not include any mention of Oxygen to the aide. Clinical Record 12: SN Assessment on the start of care on 6/10/2022 reveals that the patient is on oxygen at 2 L per N/C. The Aide care plan dated 6/10/2022 with no updates through 12/14/2022 does not include any mention of oxygen. Clinical Record 11: SN assessment at the start of care revealed that the patient is oxygen dependent. The Plan of Care includes oxygen. However, there is no mention of oxygen on the Aide care plan dated 11/10/2022. Clinical Record 6: SN start of care assessment and Plan of care 10/17/2022 revealed that the patient has a sacral ulcer with a foam dressing applied. The Aide care plan dated 10/17/2022 with no further updates does not contain any information or instruction to the aide related to sacral wound or bandage. Clinical Record 8: SN Assessment and Plan of Care dated 9/16/2022 revealed that the patient has two stage 2 pressure ulcers on the buttocks with foam dressing applied and a dressing on the shin wound. The Aide care plan dated 9/16/2022 does not include instructions to the aide related to wound dressings. The Clinical Manager stated in an interview on 12/13/2022, "Oh, I understand. Oxygen and other things like dressing changes need to be on there. But no oxygen is not on the aide care plan now." In an interview with Regional Executive Director on 12/14/2022, she stated, "I want you to see this. We contacted the EMR and they have added these tasks, Oxygen, wound care, and feeding tubes, to the care plan template." 7 of 13 (54%) clinical records with aide services reviewed revealed that the agency did not ensure that the aide care plan provided specific care instructions to meet the patient needs and allow the aide to function within the scope of service.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties. Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. This standard was not met as evidenced by a review of interviews and personnel records. In 1 of 8 (12%) personnel records reviewed, the agency did not ensure that the initial orientation addressed the employee's specific job duties. Staff #4: The chaplain was hired on 7/15/2021. The personnel record contains eight pages of orientation that addresses roles and responsibilities that are blank. There is no evidence that the content was reviewed with the employee. In an interview on 12/14/2022 with the Clinical Manager, she said, "I can see the blank forms, but I was not here, so I can't speak to it." Administrator said, "We will get that addressed," 1 of 8 (12%) of personnel files reviewed revealed that the agency did not ensure that the initial orientation addressed the employee's specific job duties.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by a review of interviews and personnel records. In 1 of 8 (12%) personnel records reviewed, the agency did not ensure that all employees were assessed for skills competency. Staff #4: The chaplain hired on 7/15/2021 did not have a skills competency assessment for job role upon hire. In an interview on 12/15/2022, the Clinical Manager stated, "I am going to take him with me and re-orient him to make sure he understands. I was not here when he was hired." 1 of 8 (12%) personnel records revealed that agency did not ensure that all employees were assessed for skills competency.