Every finding on record at Comforting Care Services

Observed in Patient Home. In 3 of 3 home visits conducted, it was noted that the advance directives policy was not in the home folder in home visit #1,2 and 3. While the organization presented an admission information packet to the surveyor with all required information this was not found in any of the home visits. This was discussed with the alternate administrator.

Observed in Record Review. In 5 of 12 patient records reviewed, it was noted that the organization that prior to care, did not inform verbally and in writing of the covered and non-covered services and the charges for which they might be responsible. For example, in record reviews #5, 6 and 7 and home visit #1, #2 an old version of the consent form which did not contain any charges was provided to the patient and scanned into the record. This was discussed with the alternate administrator.

Observed in Record Review. In 2 of 12 patient records reviewed, it was noted that the plan of care was not revised or updated to reflect changes in the patient condition. For example in record review #2 the patient began having pain issues and gastric issues was documented as using pain medication and a new medication for gastric distress however these problems were not added to the plan of care to include interventions or goals. In another example, in record review #7 the patient developed paratosis and was ordered an antibiotic, compresses and lozenges however this problem was not added to the plan of care to include interventions or goals. This was discussed with administrator and alternate administrator.

Observed in Record Review. In 1 of 12 patient records reviewed, it was noted in record review for home visit #1 that no skilled nursing visits were made over a period of 14 days. Skilled nursing visits were ordered weekly. This was discussed with the alternate administrator.

Observed in Tracer Visit. In 3 of 3 home visits conducted, it was noted in home visit #1 that the LVN did not perform hand hygiene after glove removal and prior to donning new gloves. For example, in one instance he removed only his left hand glove and did not perform hand hygiene prior to donning a new glove. In another example, he removed his gloves prior to listening to lung sounds and did not perform hand hygiene. In home visit #2 and home visit #3, the RN was observed in three different instances of applying hand gel and flapping and waving her hands until they were dry. This was discussed with alternate administrator. Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted in home visit #1 that the LVN cleaned his equipment after patient use with Clorox wipes and immediately placed them back into the storage containers/bags and then directly into the nursing bag. There was no dry time or contact time. This was discussed with the alternate administrator. Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted in home visit #1 that the LVN did not follow agency guidelines or accepted standards of practice related to bag technique. For example, the LVN was observed placing the nursing bag directly on the floor. This was discussed with the alternate administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for bereavement services it was noted in bereavement record review that there was no documentation of a care plan. This was discussed with the administrator and alternate administrator.

Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that in home visit #3 the medication list in the record did not accurately reflect the medication the patient was actually taking. For example, Baclofen was state as a once daily medication however the bottle stated to be used PRN, Hydralazine Hcl was listed on the medication sheet as 100mg TID, however the bottle in the home stated 25 mg every 6 hours and lastly the medication sheet listed Hydroxazine HCL 25 mg every 6 hours PRN for itching however this medication was not in the home. Lastly, the patient stated that he had not been taking the Hydralazine HCL, Nifidipine or Losartan for the past 7 months however all of these medications were on the medication sheet as current. This was discussed with the Alternate Administrator.

Observed in Record Review. In 2 of 6 patient records reviewed, the organization did not assess the severity of symptoms. In RR #1 and RR #5, the surveyor noted the nurse identified depression on admission; however, the assessment did not include the severity of this symptom. This was confirmed with the Administrator and DPCS Designee.

Observed in Record Review. In 2 of 6 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In RR #4, the surveyor noted the patient was identified as having dysphagia; however, the plan of care did not include interventions to address this symptom. This was confirmed with the administrator/DPCS designee. In RR #5, the surveyor noted the patient was identified as having mild anxiety and depression on admission; however, the plan of care did not include interventions to address these symptoms. This was confirmed with the administrator/DPCS designee.

Observed in Document Review. During review of admission documents it was noted that the organization did not provide the patient with written information concerning its policies on advance directives. This was discussed with the administrator and alt administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted that a comprehensive assessment was not completed by the RN. For example, in home visits #2 and #3 the RN did not conduct a skin assessment of the patient. Both patients, were essentially bed bound, incontinent and wearing diapers. This was discussed with the nurse following the visits and with the administrator and alt administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that the RN did not visit the patient at least every 15 days to complete a comprehensive assessment. For example, in record review #1, 2, 3, 7, and 8 the only visit made by the RN was the initial assessment. All other nursing visits were made by the LVN for multiple certification periods. This was discussed with the administrator and alternate administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that the goals on the plan of care were not measurable or timed. For example, in review of record #3 the goals for wounds were stated as follows, no signs and symptoms of infection, and will heal to maximum potential and for constipation the goal was stated as, express understanding of new/existing medications and side effects -Patient will not have discomfort associated with not having a bowel movement. In record review #2 the following goal was stated, Promote optimal rest status for Pt/Family/PCG. -Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. for a patient with insomnia and Pt will verbalize and/or express decreased episodes of SOB at rest for a respiratory goal. In review of record for home visit #1 the following goal was stated for weakness, increase strength/energy for optimal functional activities. In review of record for home visit #2 it was noted that a psychosocial issue had a stated goal of family and pt. to express feelings and emotions. -Pt/Family/PCG will receive emotional support to adequately cope with illness/death by the msw, however the MSW was seeing the patient only at recert. In record review #5 the goal for MSW interventions was stated as, Improve family relations and for edema, prevent discomfort dur to edema. In record review #8 the cardiac goal was stated as, No discomfort due to hypertensive symptoms. This was discussed with administrator and alt administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted that for the Skilled Nurse visit frequency open ended PRN visits were ordered without indication. For example, SN weekly and 1 PRN as needed. This was observed in record review #1, 2, 3, 4 and record review for home visit #1 and was discussed with leadership, administrator and alt administrator.Additionally, in record review #2 and #3 it was noted that a wound care nurse was visiting the patient's several times per week and performing debridement and routine wound care. Neither the visits or the treatment orders were included on the plan of care. This was discussed with administrator and alt administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that there were no orders for all care and treatment provided. For example, in record review #3 there were no orders for medihoney wound care treatment which was documented as being used by the wound care nurse. In record review #1 there was no order to discontinue a foley catheter additionally in this record there were two different ointments ordered both with orders to apply daily as needed to affected areas. This was discussed with administrator and alt administrator.

Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that hand hygiene was not performed using standard precautions. For example, in home visit #1 the CHHA was observed washing her hands using patient soap and drying her hands on a hand towel. She stated she had not been provided with soap or paper towels. Additionally throughout the visit she was observed reaching into her bag with gloved hands and when she removed her gloves did not perform hand hygiene. This was discussed with alt administrator and administrator. Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that cleaning of equipment was not done per policy. For example, in home visit #2 the RN was observed cleaning the equipment and placing the clean items into a clean plastic bag, then touching the used equipment and cleaning it and reaching back into the bag. This was discussed with the RN during the visit and then with the administrator and alt. administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that the RN did not update the aide plan of care when changes were made. For example in review of record #1, the patient had a foley upon admission with aide assignment to provide foley care, empty bag and record output however the patient removed the foley and the plan of care was not updated. In another example, in review of record for home visit #1 it was noted that the patient had a G-tube however this was not noted on the aide care plan in terms of care for this area during the shower. This was discussed with the administrator and alt administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the CHHA supervision had not taken place at least every 14 days. This was noted in record review #1 and 3. There were no RN visits made over the period of two months and no documentation of any telephone supervisory inquiry. In another example, in record review for home visit #1 it was noted that there were periods of 21 days and 17 days in July and August 2021 where no supervisory visits were made. This was also noted in record review #2 where no supervisory visits were made between July and December 2020. This was discussed with the administrator and alt administrator.

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, 418.56 and 418.100.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted that the medication sheet did not reflect the medications that the patient was currently taking. For example, the following medications were no longer being used, some for many months and others for a few weeks; Acetaminophen, Benadryl, Mathanamine Hippurate, Arnica ointment, Acetaminophen with Codeine, Albuterol Inhaler and Lomotil. This was confirmed by the nurse present on the visit and discussed with the alt administrator and administrator.

Observed in Document Review. In review of contract with Skilled Nursing Facility it was noted that the contract did not contain a provision that the hospice may use the SNF/NF or ICF/IID nursing personnel where permitted by State law and as specified by the SNF/NF or ICF/IID to assist in the administration of prescribed therapies included in the plan of care only to the extent that the hospice would routinely use the services of a hospice patient’s family in implementing the plan of care. This was discussed with the alt administrator.

Observed in Document Review. In review of contract with Skilled Nursing Facility it was noted that the contract did not contain the provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation. This was discussed with alt. administrator.