Every finding on record at Comfortbrook Hospice LLC

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients with hospice aide services, the agency did not ensure that the hospice aide received clear and specific written instructions, thus leaving the hospice aide to make decisions outside the hospice aide's scope of practice. Clinical Record 11: The patient elected hospice care on 02/28/2022. The hospice aide plan of care documented by the Registered Nurse (RN) on 02/28/2022 assigned the hospice aide to change linen as needed. The hospice aide plan of care did not provide the hospice aide with instructions regarding the frequency of the linen changes. During an interview on 10/25//23, the Regional Quality Manager stated that the aide plan of care lacked specific written instructions for the hospice aide's assignment.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; [and] consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide provided services included in the hospice aide plan of care. Clinical Record 10: The patient elected hospice care on 03/08/23. The hospice aide plan of care initiated on 03/08/23 assigned the hospice aide the task: change linen weekly. The hospice aide visit notes dated 03/13/23 and 03/16/23 documented that the linen was changed, twice for the week. During an interview on 10/25/26, the Regional Quality Manager stated that the hospice aide did not follow the plan of care initiated by the IDG. No further information was provided.

Based on medical record review, policy review, and interview, the facility failed to monitor controlled substances and investigate discrepancies in controlled substance counts (L700).

Based on medical record review, policy review, and interview, the facility failed to monitor controlled substances and investigate discrepancies in controlled substance counts for two of three patients reviewed (Patient #1 and #2). The agencys census was 84. Findings include: --- Review of the facilitys Disposal of Controlled and Non-Controlled Mediations policy (undated) revealed: A. In the state of Ohio: It is the policy of this hospice to follow the Ohio Revised Code 3712.062 and 3712.3. This policy requires that the disposal be documented by a program employee and conducted in any of the following ways: i. Performed by a program employee and witnessed by the patient or patient's family member; ii. Performed by the patient or patient's family member and witnessed by a program employee; iii. Performed by a program employee and witnessed by another program employee. Maintain records of controlled substances containing opioids prescribed to the patient and included in the patient's interdisciplinary plan of care, including accurate counts of the numbers dispensed and used; Monitor the use and consumption of controlled substances containing opioids prescribed to the patient and included in the patients interdisciplinary plan of care, including prescription refills, for signs of diversion; Investigate any sign of suspected diversion in accordance with rules adopted under division (A)(5) of section 3712.03 of the Revised Code. Report the results of an investigation of suspected diversion to the local law enforcement agency with jurisdiction over the territory in which the hospice patient's home is located in accordance with rules adopted under division (A)(6) of section 3712.03 of the Revised Code; 1. Patient #1 was ordered Morphine Sulfate 10 milligrams (mg) – 20 mg hourly as needed for air hunger and every two hours as needed for pain or shortness of breath on 02/16/23. Patient #1 was ordered Morphine Sulfate controlled release tablets 15 mg every eight hours as needed for pain and dyspnea on 02/16/23. Patient #1 went from having 27 Morphine Sulfate controlled release tablets on 09/07/23 to none on 09/11/23. Patient #1 went from having 85 Morphine Sulfate controlled release tablets on 09/18/23 to 19 tablets on 09/21/23. There was no count documented for Patient #1's Morphine Sulfate controlled release tablets for the 09/28/23 visit. The findings were shared with Staff A on 10/03/23 at 10:34 AM and confirmed in an interview. Staff C was interviewed on 10/03/23 at 1:12 PM. Staff C reported that the agency nurses should be counting each controlled substance every time the nurses were in the patients homes. There was no evidence the discrepancies were investigated by the agency. 2. Patient #2 was ordered Morphine. Review of the patient's record revealed no evidence nursing staff counted Patient #2s Morphine on the 08/02/23, 08/10/23, 08/16/23, 08/23/23, 08/30/23, 09/08/23, 09/13/23, and 09/29/23 visits. The findings from Patient #2s record review was shared with Staff A on 10/03/23 at 12:18 PM and confirmed in an interview. This deficiency represents non-compliance investigated under Substantial Allegation 100827.