Every finding on record at Comfort Care Hospice Providers

Observed in Individual Tracer. In 4 of 5 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the plan of care goals were all dated for the end of the certification period and were changed to the end date for each certification period, since admission. The surveyor noted that all the goals for (HV#2 and HV#3) and DRR#2, were established with a time frame for the end of the certification periods. This was confirmed with the director of nursing.

Observed in Record Review. In 1 of 5 patient records reviewed, The hospice nurse surveyor noted that (DRR#2) care was not provided according the plan of care. The surveyor noted that the nursing frequency orders were RN 5 x week + 3 prn; however there was only an initial nursing assessment documented for the first week of care. The next nursing visit was seven days after admission, and another 5 days after that (3 visits total in the first 12 days of service). This was confirmed with the director of nursing.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The hospice nurse surveyor noted (HV#3) that the nurse failed to follow the organizations Bag Technique policy, after use of equipment. The surveyor noted that the policy indicated that all equipment was to be cleaned with soap and water or an approved disinfectant; however, the nurse failed to cleanse either the thermos-scan or blood pressure cuff before returning it the bag. This was confirmed with the director of nursing.

Observed in HR File Review. In 1 of 8 HR files reviewed, The hospice nurse surveyor noted that the personnel file of HHA 2, did not include evidence that a competency evaluation was completed through observation of the aide performing tasks with a patient when she was hired in January, or since. The only documents included written tests to evaluate required subject areas. The surveyor noted that the aide was providing patient care. This was confirmed with the compliance officer.

Observed in Record Review. In 1 of 2 discharge records reviewed, The hospice nurse surveyor noted (DRR#2) that the record did not contain continuous care notes. The surveyor confirmed with the director of nursing, that the nurse had documented the care in a notebook; however the entries were not recorded in the electronic medical record nor on a organizations acceptable paper format (since March). Also, there was no documentation of the home death pronouncement in the record. This was confirmed with director of nursing.

Observed in Record Review. The hospice nurse surveyor noted (DRR#1) that the patient was transferred to another hospice; however there was no evidence that the hospice provided the receiving facility with a summary of the patient's stay. The patient was only on service for four days, so a comprehensive care plan was not available to provide. This was confirmed with the director of nursing.