Every finding on record at Comfort-Focused Hospice Care Inc.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients, the hospice nurse surveyor noted that in HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#4, RR#5, RR#6, RR#7, and RR#8 the comprehensive assessment did not include a spiritual assessment. Additionally, HV#2/RR#2, RR#4, and RR#7, did not include a psychosocial assessment. Findings were verified by the Director of Patient Care Services.

Observed in Record Review. In 3 of 8 patient records reviewed, for active patients in HV#2/RR#2, RR#4, and RR#7, the Hospice Surveyor noted the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the Director of Patient Care Services.

Observed in Record Review. In 8 of 8 patient records reviewed, for active patients the nurse surveyor noted that the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. Finding was verified by the Director of Patient Care Services.

Observed in Record Review. In 8 of 8 patient records reviewed, of active patients the surveyor noted that goals were not measurable or individualized. Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, a few were to be accomplished in a month or did not have a time frame at all. This was verified by the Director of Patient Care Services.

Observed in Tracer Activities. The organization is collecting data on various elements such as infections, patient falls, medication errors, etc., however over the last eight months data has not been compiled and analyzed to determine performance trends or variations. This was verified by the Director of Patient Care Services.

Observed in Tracer Activities. Since the organization has not compiled and analyzed data over the last eight months to determine performance trends or variations they have not been able to identify or act on any improvement activitis. This was verified by the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HV#1/RR#1 with the skilled nurse she changed gloves at least four times without performing hand hygiene per policy. Additionally, she double gloved four times and cleaned her gloves with alcohol several times while providing care. During HV#2 the skilled nurse removed one glove without performing hand hygiene and went into her nursing bag which is not in compliance with agency policy. The first visit was performed by the Director of Patient Care Services who validated the breaks and the second visit was performed by the Director of Patient Care Services Designee who acknowledged the break.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: 418.54.