Every finding on record at Comfort Hospice, Inc.

Observed in Individual Tracer. In 1 of 3 home visits conducted, The surveyor noted (RRHV#2) that the nurse did not follow the policy for medication reconciliation. The nurse did not have a copy of the plan of care or the current medication profile available, when completing the medication reconciliation during the home visit. The nurse looked at all the medications; however, did not compare them to any document to insure the medication list was complete and accurate. The organizational policy required that a medication reconciliation be complete each SN visit, comparing the medications to the medication list. This was confirmed with the administrator.

Observed in Individual Tracer. In 2 of 10 patient records reviewed, The surveyor noted (RRHV#1) that there was no evidence in the patient record that the nurse or IDT assessed for the need for volunteer services to offer support or respite to the patient, family, or other caregivers. This was also noted in (RRHV#2). This was confirmed with the director.

Observed in Record Review. In 1 of 10 patient records reviewed, The surveyor noted (RRNHV#8) that the nursing assessment of August indicated that the patient was experiencing new onset shoulder pain rated at 10/10 on a scale of 1 to 10. There was no evidence in the plan of care or IDG meeting notes that the plan of care was updated with goals and interventions to manage the pain, as required by policy 9.12.3. This was confirmed with the director.

Observed in Data Session. In 3 of 3 years, The surveyor noted that the organization had identified a process improvement goal for improvement in hand hygiene for 2024 and 2025; however there was no evidence in the QAPI data that hand hygiene compliance had improved. There was no evidence in any of the data collected that any outcomes had been evaluated for effectiveness or improved over time, for the last three years. This was confirmed with the administrator.

Observed in Competency Session. In 2 of 12 HR files reviewed, The surveyor noted that the credentials were not verified that the employee had the credentials required by the job description for the chaplain or the social worker when hired (HR#10BCCH) and (HR#11MSSW). The files only contained copies of diplomas and a credential card with no evidence of verification that they were authentic. This was confirmed with the HR manager and corrected on site.

Observed in Record Review. In 4 of 6 active patient records reviewed, During HV# 1, HV# 2, RR# 1, and RR# 2's plans of care review it was noted the organization had not ensure the plans of care were based on the patient's goals and time frames, settings, and services required to meet those goals. For example: review of HV# 1's plan of care revealed a Gastrointestinal Goal, Patient will have adequate bowel care resulting in normal bowel elimination and comfort. However, there was no documentation of what normal bowel elimination was for HV# 1 or what comfort was for HV# 1. Review of HV# 2's plan of care revealed Chaplain visits monthly with no documented goals for the Chaplain/Spiritual. Review of RR# 1's plan of care revealed a Spiritual Goal, Patient will continue to maintain dignity and optimum quality of life AEB verbalization of spiritual and existential well-being through positive view of relations with God. However, review of the Spiritual Assessment and the plan of care revealed documentation that RR# 1 did not believe in God. Further review of RR# 1's plan of care revealed no goal for respiratory and RR# 1's terminal diagnosis was Chronic Obstructive Pulmonary Disease (COPD). Review of RR# 2's plan of care revealed MSW and Chaplain visits every recertification. Further review of the plan of care revealed no documented goals for MSW or Chaplain/Spiritual. This was reviewed, discussed, and validated with the Patient Care Coordinator and Administrator,

Observed in Record Review. In 6 of 6 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 3's record review it was noted the organization had not ensured the plans of care included a detailed statement of the scope and frequency of services. For example: review of the patients' plans of care revealed as needed and prn orders for either Skilled Nurse, MSW, or Chaplain with no indication when to utilize the PRN visits. This was reviewed, discussed, and validated with the Administrator.

Observed in Patient Home. In 1 of 2 home visits conducted with Skilled Nurse, During HV# 2's home observation it was noted the organization had not ensured it provided the patient with care, treatment, or services according to the patient's plan of care. For example: review of HV# 2's plan of care revealed an order to assess skin integrity every visit and to include boney prominences as HV# 2 was at risk for skin breakdown. During HV# 2's home observation the Registered Nurse assessed the coccyx area for skin breakdown. However, the RN did not remove the patient's socks to assess the feet or assess the skin of the upper back per the plan of care. This was observed, discussed, and validated with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 2's home observation it was noted the organization had not implemented infection prevention and control activities when performing disinfection of medical supplies and devices. For example: during HV# 2's home observation the Registered Nurse (RN) was observed using a lemon scented Lysol Disinfecting wipe to clean the automatic arm B/P cuff, thermometer, pulse oximetry, and stethoscope and placed each piece of the equipment immediately into the nurse bag without following the contact time of the disinfectant manufacturer's IFUs that stated 4 minutes of contact time. During HV# 1's home observation the Licensed Vocational Nurse (LVN) was observed using alcohol pads to clean the automatic wrist B/P cuff, thermometer, pulse oximetry, and stethoscope and placed each piece of the equipment immediately into the nurse bag without following the organization's Exposure Control Plan: OSHA Regulations policy that stated the equipment was to be allowed to air dry. This was observed and discussed with the Administrator and validated. Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 2's home observation it was noted the organization had not ensured the Licensed Vocational Nurse (LVN) and the Registered Nurse (RN) followed the organization's Bag Technique policy. For example: the LVN performing HV # 1 and the RN performing HV # 2 were observed to clean equipment before returning to the clinical bag, however neither nurse performed hand hygiene after cleaning the equipment before returning the equipment to the bag as required by the organizations bag technique policy. This was observed, discussed, and validated with the Administrator. Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 3's home observation it was noted the organization had not ensured the Home Health Aide (HHA) performed hand hygiene according to the organization's Hand Hygiene policy that included using paper towels to dry the hands. For example: during HV# 3's home observation the HHA was observed using the toilet paper in the patient's bathroom to dry his/her hands. This was observed and discussed with the Administrator and validated.

Observed in Data Session. During Leadership and Data Management Session it was noted the organization had not ensured the Infection Control Plan included goals for limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was reviewed, discussed, and validated with the Quality Assurance Nurse and the Administrator.

Observed in Record Review. In 4 of 6 active patient records reviewed with Home Health Aide, During HV# 3, RR# 1, RR# 2, and RR# 3's patient records review it was noted the organization had not ensured the Registered Nurse (RN) provided complete written patient care instructions for the hospice aide. For example: review of HV# 3, RR# 1, RR# 2, and RR# 3's written patient care instructions revealed the task ROM [range of motion]-active -passive every visit. However, there were no instructions on if the hospice aide should complete active or passive ROM and which joints the ROM should be completed. This was reviewed, discussed, and validated with the Administrator. Observed in Patient Home. In 1 of 1 home visits conducted with Home Health Aide, During HV# 3's home observation it was noted the organization had not ensured the registered nurse (RN) provided complete written patient care instructions for the Home Health Aide (HHA). For example: HV# 3 was receiving 2L continuous oxygen via nasal cannula during the home observation due to a need for oxygen. During the home observation the HHA removed the oxygen for the duration of the bed bath for approximately 40 minutes. Review of the HHA written instructions revealed no instructions regarding if the oxygen could be removed for the bath. This was observed and discussed with the Administrator and validated.

Observed in Patient Home. In 1 of 1 home visits conducted with Home Health Aide, During HV# 3's home observation it was noted the organization had not ensured the Home Health Aide (HHA) provided care according to the hospice plan of care. For example: during HV# 3's home observation the HHA was observed applying hydrogen peroxide on a cotton ball and then cleaning around the supra-pubic catheter site with the cotton ball. Review of the HHA written instructions revealed no written instructions for the HHA to complete this task. Review of the plan of care revealed an order to clean the supra pubic catheter site with normal saline. This was observed, discussed, and validated with the Administrator.

Observed in Record Review. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.60, §418.100, §418.102, and §418.116

Observed in Record Review. In 1 of 6 active patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the Medical Director reviewed the clinical information and signed the initial certificate of terminal illness (CTI) at the beginning of the certification period/start of care. For example: review of RR# 1's patient record revealed an initial CTI signed by the Medical Director 32 days after the start of care. This was reviewed, discussed, and validated with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed with recertification, During HV# 1 and HV# 2's patient records review it was noted the organization had not ensured the Medical Director reviewed the clinical information and signed the certificate of terminal illness (CTI) prior to the recertification. For example: review of HV# 1's patient record revealed HV# 1 was in the third benefit period. Review of HV# 1's CTI for the second and third benefit periods revealed the Medical Director signed the CTIs two days after the certification periods ended. Review of HV# 2's patient record revealed HV# 2 was in the third benefit period. Review of HV# 2's CTI for the second and third benefit periods revealed the Medical Director signed the CTIs two days after the certifications ended. This was reviewed, discussed, and validated with the Administrator.

Observed in HR File Review. In 4 of 4 HR files reviewed for staff hired in the last 3 years, During HR# 3, HR# 8, HR# 9, and HR# 10's personnel file review it was noted the organization had not ensured a criminal background check was completed on the applicants as required by law. For example: review HR# 3, HR# 9, and HR# 11's personnel file revealed criminal background checks completed with Been Verified. Review of the cover letter to the criminal background check revealed do not use for employment purposes. Review of HR # 8's personnel file revealed a criminal background check completed 10 months prior to the date of hire with the name of a different Home Health Organization as the requested party. Further review of HR# 8's personnel file revealed no documented criminal background check completed for the organization. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 4 of 6 active patient records reviewed, During HV# 2, and HV# 3's patient records review it was noted the organization and not ensured it complied with law and regulation. For example: review of HV# 2 and HV# 3's patient record revealed the patient representative requested that the organization provide an addendum detailing items that would not be covered by the organization. Further review of the patients' records revealed no addendum or documentation an addendum was provided. This was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services designee. Observed in Record Review. During RR# 4 and RR# 8's patient records review it was noted the organization had not ensured it complied with law and regulations. For example: review of RR# 4 and RR# 8's patient records revealed both patients had been discharged due to extended prognosis. Further review of RR# 4 and RR# 8's patient records revealed no documentation a Notice of Medicare Non-Coverage (NOMNC) had been explained or provided to the patient or patient representative. This was reviewed, discussed, and validated with the Administrator and Director of Patient Care Services designee.