Every finding on record at Comfortbrook Hospice LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by observation, clinical record review, document review, and interview. Agency policy "Medication Administration Policy" (revised 7/16) stated in part, "The agency will maintain the current medication list and administration record...The ongoing monitoring occurs to evaluate the continued use of medication in its current regimen." In 2 of 4 (50%) home visits observed, the agency did not ensure the patient's current medications were included in the medication review and on the patient's medication profile. Home Visit 1/Clinical Record 4: The patient elected the hospice benefit on 6/19/2023 and resided in an Assisted Living Facility (ALF). During the home visit on 9/19/2023, a review of the agency's medication profile dated 9/19/2023 and the facility's medication profile revealed the agency's medication profile documented, "Clonazepam 0.5 mg. give one (1) tablet daily every six (6) hours as needed (PRN) for anxiety/agitation." The facility's medication profile documented, "Clonazepam 0.5 mg., give one (1) tablet daily eight (8) hours as needed (PRN) for anxiety/agitation." The facility's medication profile documented the medication "Vitamin C 500 mg., give one (1) tablet by mouth daily," with an effective date of 9/1/2023 and an end date of 10/1/2023. The agency's medication profile did not include documentation of the Vitamin C and the current frequency of administration for Clonazepam. There was no evidence that Vitamin C was included in the patient's medication regimen review. The Administrator at the visit confirmed the agency was unaware the patient was taking Vitamin C. Home Visit 4/Clinical Record 1: The patient elected the hospice benefit on 7/27/2023 and resided in an ALF. During the home visit on 9/19/2023, a review of the agency's medication profile dated 9/19/2023 and the facility's medication profile revealed the agency's medication profile documented, "Miralax 17 grams, give 17 grams orally two (2) times daily." The facility's medication profile documented, "Miralax 17 grams per scoop, give 17 grams as needed (PRN) one (1) time per day." In addition, the facility's medication profile documented, "Tramadol 50 mg., give one (1) tablet by mouth (PO) as needed (PRN) every eight (8)hours." The agency's medication profile did not include documentation of the Tramadol and the current frequency of administration for the Miralax. The Administrator at the visit confirmed the agency was unaware the patient was taking Tramadol. During a joint record review and interview on 9/19/2023, the Administrator confirmed the agency's medication profiles were inaccurate.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) home visits observed, the agency did not ensure all drugs needed for the palliation and management of the patient were included in the plan of care. Agency policy "Interdisciplinary Group Plan of Care Policy" (revised 7/16) stated in part, "The Plan of care will contain the following but is not limited to ..drugs and treatments necessary to meet the needs of the patient." Home Visit 1/Clinical Record 4: The patient elected the hospice benefit on 6/19/2023 and resided in an Assisted Living Facility (ALF). During the home visit on 9/19/2023, a review of the agency's medication profile dated 9/19/2023 and the facility's medication profile revealed the facility's medication profile documented the medication "Vitamin C 500 mg., give one (1) tablet by mouth daily," with an effective date of 9/1/2023 and an end date of 10/1/2023. The agency's medication profile did not include documentation of the Vitamin C .The Administrator at the visit confirmed the agency was unaware the patient was taking Vitamin C and Vitamin C was not documented on the plan of care. Home Visit 4/Clinical Record 1: The patient elected the hospice benefit on 7/27/2023 and resided in an ALF. During the home visit on 9/19/2023, a review of the agency's medication profile dated 9/19/2023 and the facility's medication profile revealed the facility's medication profile documented, "Tramadol 50 mg., give one (1) tablet by mouth (PO) as needed (PRN) every eight (8)hours." The agency's medication profile did not include documentation of the Tramadol. The Administrator at the visit confirmed the agency was unaware the patient was taking Tramadol and Tramadol was not documented on the plan of care..

It is required that each patient’s individualized written plan of care Includes all services necessary for the palliation and management of the terminal illness, including the following: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Interdisciplinary Group Plan of Care Policy" (revised 7/16) stated in part, "The Plan of care will contain the following but is not limited to …Medical Supplies and appliances necessary to meet the needs of the patient." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the plan of care (POC) included all medical supplies necessary to meet the patient's needs. Clinical Record 10: The patient elected hospice care on 7/6/2022. A clinical record review revealed that nephrostomy tubes were placed during a hospital stay on 1/19/2023. The hospice Registered Nurse provided routine assessments of the nephrostomy sites during the comprehensive assessments. The plans of care for the benefit periods dated 3/3/2023 through 5/1/2023, 5/2/2023 through 6/30/2023, 7/1/2023 through 8/29/2023 and 8/30/2023 through 10/28/2023 did not include nephrostomy supplies. During an interview and a joint review of the clinical record on 9/20/2023, the Administrator provided documentation of a supplier invoice dated 5/24/2023 referencing the patient's hospice benefit election date of 7/6/2023. The invoice documented the hospice agency was providing "Biliary/Nephrostomy drain bags." After a joint record review and an interview on 9/20/2023, the Clinical Manager confirmed the nephrostomy bags were not listed on the past or current plans of care.

It is required that counseling services include spiritual counseling. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) clinical records reviewed of patients who accepted Chaplain services, the agency did not ensure that spiritual counseling was provided to meet the needs of the patients and families. Clinical Record 4: The patient elected hospice care on 6/19/2023. The initial plan of care dated 6/19/2023 through 9/16/2023 ordered Chaplain services "1M1, 2M2,1M1, 3PRN." A clinical record review revealed Chaplain visits completed on 6/21/2023 and 8/28/2023 and evidence of a documented missed Chaplain visit dated 8/8/2023. There were no Chaplin visits or evidence of documented missed visits for July. During the joint record review and interview on 9/20/2023, the Clinical Manager confirmed no Chaplain visits in July. Clinical Record 7: The patient elected hospice care on 4/25/2023. On 6/29/2023, the physician ordered spiritual care services "1 M1, 2M2, 5 PRN for spiritual support." The patient received a Chaplain visit on 6/29/2023. There were no Chaplin visits or evidence of documented missed visits for July. During a joint record review and interview on 9/20/2023, the Clinical Manager confirmed the hospice agency did not provide Chaplain visits to the patient in July.

It is required that The hospice is primarily engaged in providing the following care and services in a manner consistent with accepted standards of practice: medical supplies (including drugs and biologicals) and medical appliances related to the palliation and management of the terminal illness and related conditions as identified in the care plan. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 1 (100%) clinical record review of a patient residing in a skilled nursing facility (SNF), the agency did not ensure all medications related to the management of the patient's terminal illness were provided to the patient while under hospice care. Clinical Record 4: The patient elected hospice care on 6/19/2023 and resided in a skilled nursing facility (SNF). The Certificate of Terminal Illness (CTI) dated 6/19/2023 documented the patient's terminal diagnosis of protein Calorie Malnutrition and documented: "Related conditions include dementia, diabetes, liver cirrhosis, anxiety, hyperlipidemia, A-Fib, SS." The medication profile dated 6/19/2023 documented, "Metformin 500 mg. take one tablet daily by mouth for diabetes. Pravastatin 20 mg. take one (1) tablet daily for hyperlipidemia." The hospice medication profile documented the patient was financially responsible for the medications related to Diabetes and Hyperlipidemia because they were unrelated to the terminal diagnosis. The diagnosis list in the patient information and demographic section of the hospice agency's electronic medical record (EMR) identified the diagnoses of "Diabetes Mellitus" and "Hyperlipidemia" as related to the terminal diagnosis. The hospice Interdisciplinary Group (IDG) note dated 6/26/2023 documented the diagnoses of Diabetes and Hyperlipidemia as "related to the terminal condition." During a joint record review and interview on 9/19/2023, the Clinical Manager confirmed the two diagnoses of "Diabetes Mellitus and Hyperlipidemia" were identified as related to the terminal condition on the CTI and IDG notes, but the hospice medication profile did not match as the medication profile stated "not related and the patient is financially responsible). The Clinical Manager confirmed the hospice agency was not paying for the medications Metformin and Pravastatin.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy "Documentation Policy" stated in part, "The clinical staff documents the care provided to the patient on the same day the care or service is rendered...Clinical staff submit documentation of care at a minimum, daily." In 2 of 19 (11%) clinical records reviewed, the agency did not ensure documentation was completed by the clinical staff per the agency's policy. Clinical Record 9: The patient elected hospice care on 6/30/2023. The Social Worker completed a visit on 8/3/2023. The SW documented the visit on 8/12/2023, nine (9) days after the SW service was rendered. During an interview, the Clinical Manager confirmed the agency's standard practice that documentation is to be completed within twenty-four (24) hours following the visit, and the Social Worker did not follow the agency's policy. Clinical Record 15: The patient elected hospice care on 6/22/2023. The Social Worker completed a visit on 7/11/2023. The SW documented the visit on 7/16/2023, five (5) days after the SW service was provided. During an interview and a joint record review, the Clinical Manager confirmed the Social Worker documentation of the 7/11/2023 visit on 7/16/2023 did not follow the agency's documentation policy of twenty-four (24 ) hours.