Every finding on record at Comfort Choice Hospice Inc

Upon patient record review, 12 of 14 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs Patients #1, #2, #3: The MSW and SC visit frequency read "Evaluation only then PRN"; no evidence of a routine frequency. Corrected on Site. Patients #5, #6, #8, #9, #14: The MSW and SC visit frequency read "Evaluation only then PRN"; no evidence of a routine frequency. Patient #4: The SC visit frequency read "Evaluation only then PRN"; no evidence of a routine frequency. Patient #7, #10, #12: The MSW visit frequency read "Evaluation only then PRN"; no evidence of a routine frequency.

Upon patient record review, 3 of 14 (Patients #1, #2, #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had a bed, wheelchair. This was not included on the Plan of Care. Corrected on Site. Patient #2: This patient had a nebulizer machine. This was not included on the Plan of Care. Corrected on Site. Patient #10: The record reflected that this patient had a nebulizer treatment. The nebulizer machine was not included on the Plan of Care.

Upon patient record review, 2 of 14 (Patients #11, #12) did not have evidence the hospice offers bereavement counseling that includes: • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #11: Patient passed on 2/27/24. The record reflects the one month mailer was sent on 8/30/24. Additionally, there was no evidence of letters sent at three month or six month intervals per frequency of Bereavement Plan of Care. Patient #12: Patient passed on 2/10/24. The record reflects the one month mailer was sent on 8/5/24 and the three month letter sent on 8/10/24. The frequency intervals per frequency of Bereavement Plan of Care were not consistent with patient death.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The POC listed Aide visit frequency of two times per week (9/6/24). There were no visits on first benefit week.

Upon patient record review, 10 of 14 (Patients #4, #5, #6, #7, #8, #9, #10, #11, #12, #14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #4, #5, #6, #7, #8, #9, #10, #11, #12, #14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information or Notice of Non Coved Items addendum information. The agency had been using old Election Statement form. This was self corrected with most recent admissions.

Upon patient record review, 5 of 14 (Patients #4, #5, #6, #7, #8) did not have evidence that the discharge summary includes all required information. Patients #4, #5, #6, #7, #8: Did not include all elements required for discharge. There was no evidence the current Plan of Care was provided at discharge.