Every finding on record at Comfort Hospice Care, Inc

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients that resided in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 5: This patient elected the hospice benefit 06/28/2024 with a terminal diagnosis of Alzheimer's Disease and resided in a skilled nursing facility (SNF). This patient expired 07/02/2024. The Registered Nurse (RN) initial comprehensive assessment dated 06/28/2024 documented that the patient had a gastrostomy tube (G-tube) with orders to provide G-tube care every visit. The plan of care was reviewed for the dates of 06/28/2024-07/02/2024 and did not specify which provider was responsible for performing the functions of G-tube care. The Administrator was interviewed on 04/29/2025 and agreed that the plan of care did not specify if the hospice or the skilled nursing facility was responsible for the care of the G-Tube.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. Two of 5 (40%) clinical records reviewed in which a hospice aide (HA) provided care, revealed that the care provided by the HA was not consistent with the HA plan of care (POC). Record #42417: election of hospice benefit dated 1/4/21. On 1/6/22, 1/7/22, 1/12/22, 1/14/22, and 1/27/22 the HA documented that she shaved the patient, provided passive range of motion (ROM), and emptied the trash. There were no orders in the clinical record or included in the HA POC (dated 1/4/21 and signed by the RN) that provided instructions for the HA to shave the patient, provide passive ROM or empty the trash. Patient #52723: election of hospice benefit dated 10/16/21. On 10/21/22, 10/26/22, and 10/28/22 the HA documented that she shaved the patient. There were no orders in the clinical record or included in the HA POC (dated 10/21/22 and signed by the RN) that provided instructions for the HA to shave the patient. Interview and record review with the CEO/Administrator on 3/15/2022 confirmed this finding.