Every finding on record at Comforts of Home Healthcare LLC

Based on record review, observation and interview the agency failed to provide hospice care consistent with patient and family needs and goals, with patient needs and goals as priority for 2 of 9 hospice patients (Patient #1 & #5) whose records were reviewed, in that the agency failed to ensure each of these patients understood hospice eligibility requirements as well as the services provided through the Medicare hospice benefit. This failure prevented these patients from fully understanding that they needed to be terminally ill and that hospice provides end of life care. --- Findings Include: Review of the clinical record for Pt #1 revealed a start of care date of 12/06/2024 with a diagnosis of Cerebrovascular Disease. This disease encompasses a variety of conditions which can affect the blood vessels and blood supply to the brain. Review of the plan of care for the certification period 03/06/25 – 05/03/2025 revealed orders: Skilled Nursing- 1 time per week for 13 weeks & prn, Homemaker- 1 time per week, and Social Worker- 1 time per month. Review of a coordination note dated 04/23/2025 read, “LMSW #2 called patient leaving (a) message requesting (a) visit. There was no answer. LMSW #2 called (RNCM) RN #2 requesting time for her for visit. RNCM states patient was seen yesterday briefly and patient was confused as to why she has hospice services. LMSW will meet with RNCM today at 1pm for joint visit.” Review of LMSW visit note dated 04/23/2025 read, “Patient has pain in her hip, minimally today. Sometimes patient has more increased pain. Patient is going to La Grange on Saturday and San Antonio on Monday. Patient has a ride to and from LaGrange but will be driving herself to San Antonio.” 05/08/2025 at 9:30 AM – A home visit was conducted with RN #1, NP #1 and Pt #1. Surveyor observed RN #1 and NP #1 conduct the recertification assessment and face to face visit. Pt #1 stated she did not want or need hospice services. Pt stated she was a massage therapist and has been looking for a holistic primary care physician. Pt #1 stated she does not take medications because she doesn’t want any chemicals in her body. Pt #1 stated she has some memory loss but is otherwise denied any health concerns. Pt stated she sleeps 6-8 hours per day, walks her dogs around the apartment complex 4-5 times per day for exercise. Pt denied any falls. RN #1 asked pt if she used any assistive devices such as a cane. Pt stated, “No I don’t. Are you trying to make me scared of walking? Don’t treat me like an invalid.” RN #1 advised pt she was attempting to educate her about fall risks. Pt stated, “Okay. I’ll accept being treated like an invalid.” RN #1 asked Pt #1 if she was eating okay. Pt stated she usually eats 2-3 meals per day. Pt denied any problems swallowing. RN #1 asked if she any signs and symptoms of urinary infections or sores. Pt #1 stated, “No. I haven’t even had a cold or flu for 2 years.” Pt became more upset at the questions being asked. RN #1 asked when she last had a bowel movement. Pt #1 stated, “This morning.” RN asked her if it was normal. Pt held out her hands about 12 inches apart and stated, “It was this long and this big around.” Pt made a circle to demonstrate the diameter of the stool. Pt was weighed. RN #1 told her she weighed 156 lbs. RN advised her last weight was 150 lbs. Surveyor interviewed Pt #1 after the assessment was completed. Surveyor asked if she felt she needed hospice services. Pt #1 stated, “No I don’t. I told them that before.” Surveyor asked if she would like a referral for an assessment for home health services. Pt #1 stated, “Yes. I would like that. I don’t really need anything now, but it would be nice to have someone check on me once in a while.”5/08/2025 at 9:50 AM- An interview was conducted with RN #1 and NP #1 after the home visit with Pt #1. Surveyor asked if they felt Pt #1 was qualified for hospice services. NP stated, “She is on services for cognitive memory decline as well as CVD (Cerebrovascular Disease). NP and RN acknowledged Pt #1 requested a referral for home health and to revoke the hospice benefit. RN stated she would contact CM to coordinate care. Surveyor asked RN #1 and NP #1 if they had ever felt pressured to admit patients who may not be qualified for hospice care. RN and NP both stated no.  05/08/2025 at 2:00 PM- While reviewing records at the agency, surveyor overheard a telephone conversation on speaker phone with CM, LMSW #1 and Pt #1. LMSW #1 called and reported she was at Pt #1’s home with revocation papers but the Pt was not sure if she wanted to revoke. Pt #1 stated, “I don’t need hospice. I’m not terminally ill or dying.” CM stated, “If you want to revoke hospice we will do that. Let me give you 2 scenarios. #1- You get sick. You have to go to the hospital, get a bunch of treatments and get a bunch of tests run. Or #2- If you get sick you can stay in your home and we will come and take care of you there. Which would you prefer?” Pt then agreed to stay on hospice care.05/08/2025 at 2:15 PM- An interview was conducted with CM regarding the phone conversation with Pt #1 and LMSW. Surveyor asked her to discuss the content of the conversation. CM stated, “I told her she could revoke if she wanted to, but she decided to stay on service. Surveyor reviewed the “2 scenarios” offered to Pt #1. Surveyor asked if CM felt her questions may have been framed to lead the pt to illicit a particular response, in this case to stay on service whether or not the pt wanted hospice services. CM stated, “No, not all. I told her we would revoke her if that’s what she wanted. I will send the LMSW again tomorrow to make sure she still wants to be on service”. 05/08/2025 at 6:00 PM- A telephone interview was conducted with Identifier #1. Surveyor asked her about her business and the services she provided. Identifier #1 stated she started a business to help poor and homeless people navigate and apply for services. Surveyor asked what types of services she assisted people to obtain. Identifier #1 stated, “I help them find housing, clothing, food banks, transportation, and medical care such as visiting physicians, home health, rehabilitation and long-term care. I also help them apply for Medicaid.” Surveyor asked how the business generated income. Identifier #1 stated, “I don’t get paid. I provide assistance for free. I am trying to open an NGO (nongovernmental organization) and get help writing (applying for) government grants.” Surveyor asked if she referred individuals to the agency. Identifier #1 stated, “Yes.” Surveyor asked if she received compensation for the referrals. Identifier #1 stated “No.” Surveyor asked if she made referrals to other hospice agencies. Identifier #1 stated she refers to Hospice- A and Hospice- B.                                                              05/12/2025 at 9:10 AM- A telephone interview was conducted with FM #1 regarding the allegations in the intake (#1006814). FM #1 stated Identifier #1 referred Patient #2 to the agency. FM #1 stated she referred Patient #1 to the agency because she felt she needed an extra level of care because she had a history of seizures. FM #1 stated “I told RDS I didn’t think Patient #1 was terminally ill. FM #1 stated agency staff RDS told her they would give her a diagnosis to qualify her for hospice care. FM #1 alleged the agency is admitting patients who are not qualified for hospice by enticing low income and homeless people with offers of “free housekeeping services”. 05/13/2025 at 9:05 AM- An interview was conducted with CM. CM stated “I have been thinking all weekend about the phone call with Pt #1 on 05/08/2025. I can see where you’re coming from. I think we just need to change our verbiage. We also added a new form in the consents clarifying it’s hospice (care).” 05/13/2025 at 9:15 AM- A telephone interview was conducted with LMSW #2. Surveyor asked if she conducted a LMSW visit on 05/08/2025 with Pt #1. LMSW #2 stated, “No. LMSW #1 saw her that day because I was off. She is my assigned Pt and I have seen her several times. I visited her on Friday (05/09/2025) and she still wanted to stay on services.” Surveyor asked about the circumstances for making visit as a LMSW had conducted a visit the day before. LMSW #2 stated, “CM called and asked me to make a focused visit for hospice education and make sure she understood what she agreed to. Pt #1 is very wishy washy. She has asked to revoke approximately 6 times. She still drives and recently took trips to LaGrange and San Antonio.” Surveyor asked if she felt Pt #1 was appropriate for hospice services. LMSW #2 stated, “Yes. (Pt #1) complained of forgetfulness and verbalized she wanted to stay on service.” 05/13/2025 at 9:25 AM- A telephone interview was conducted with LMSW #1. Surveyor asked her to discuss her visit with Patient #1 on 05/08/2025. LMSW #1 stated, “CM asked me to visit Patient #1 because she was interested in revocation. That visit was the first time I saw her. She’s not normally my patient but LMSW #2 was not working that day. She had some cognitive decline and seemed to be in denial about her condition. She verbalized she understood she wasn’t going to get better. I asked her if she got sick would she want to go to the hospital to be treated or stay at home and we would take care of her. She agreed to stay on service.”                                                Review of the clinical record for Pt #5 revealed a start of care date of 06/17/2022 with a diagnosis of Other Cerebrovascular Disease. Pt #5 resided at ALF #1. Review of the plan of care for the time period 03/03/2025 – 5/1/25 included orders: Skilled Nursing- 1 time per week for 9 weeks and 3 prn, Home Health Aide 3 times per week for 8 weeks, then 2 times per week for 1 week, Chaplain 1 time per month for 2 months. 05/13/2025 at 10:50 AM- A telephone interview was conducted with ALF ED regarding the status (decline) of Patient #5. ALF ED stated, “She’s actually doing very well. They (Agency) are going to discharge her from hospice on the 16th. Surveyor asked why she was being discharged. ALF ED stated, “They (Agency) said she has stabilized.” Surveyor stated she would like to visit and conduct an interview with Patient #5. ALF ED stated, “No. She has late-stage Alzheimer’s Disease. She is not interviewable.”05/14/2025 at 11:18 AM- A telephone interview was conducted with MD #2. MD #2 confirmed she was the Associate Medical Director. Surveyor asked what criteria she used to determine if an individual had a terminal diagnosis. MD #2 stated, “I review the assessment findings. I review any medical history, FAST (Functional Assessment Staging) scores, PPS (palliative performance scale), weight loss, weakness, mobility, assistance with ADLs (activities of daily living), etc. Surveyor asked if she considered any additional factors. MD stated, “Not really unless something is brought to my attention.”05/14/2025 at 1:46 PM- A telephone interview was conducted with MD #1. MD #1 confirmed he was the hospice Medical Director. Surveyor asked what factors he considered when making a terminal diagnosis. MD #1 stated, “I would consider weight loss, recent falls, emergency room visits, cognition, confusion, combativeness, physical and mental decline and medications.” Surveyor asked if any additional information would be included. MD #1 stated, “If there were additional records such as office visits or hospital records.” Surveyor asked MD #1 if he was acquainted with Identifier #1. MD stated he had heard her name but had never met her. MD stated, “I am aware of her referrals. I am a taxpayer too and I’m glad they (patients) are receiving services, but they need to be the right services.” Surveyor asked MD what the process would be for a new referral. MD #1 stated “the agency RN does the initial assessment and calls me to report her findings. If the person qualifies, I will admit them. When they get to the recertification assessment then we have more data to work with and we can determine if there has been a decline in health status.” Surveyor asked if MD was aware there were allegations that some patients were not qualified for hospice care and some patients were not aware they were on hospice services. MD #1 stated, “About a month ago I discussed this in the IDT meeting about making sure they (patients) understood. I told them to say ‘Would you be surprised if you died within 6 months? I told them they needed to use the word ‘dying’. I try to make sure all patients are appropriate.” Review of the agency’s policy and procedure manual included a policy titled “Plan of Care Process- PC.30, reviewed:090124”, which read “The POC includes, but is not limited to: The IDT’s documentation of the patient’s or representative’s level of understanding, involvement, and agreement with the POC in the clinical record. The revised POC will include: Determination if hospice services are still appropriate and wanted. Documentation will support the patient receives the appropriate level of care and services as indicated by the interdisciplinary assessments, in order to avoid under-utilization or over-utilization.”

Upon patient record review, 1 of 19 (Patient # 11) did not contain a current comprehensive medication profile: Patient # 11: The RN SOC assessment reflected that the patient was on oxygen. However, this was not included on the medication profile.

Upon patient record review, 1 of 19 (Patient # 4) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient # 4: During surveyor attended home visit on 02/04/2025 it was noted that patient was utilizing a wheelchair. This DME was not included on the POC dated 01/22/2025 - 03/22/2025.

Upon client record review, 1 of 19 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient # 9: The POC dated 10/16/23 included, "Volunteer 1m1", and did not include the intended scope of volunteer services. During certification period 04/06/2024 - 06/04/2024, 16 volunteer visits were made without volunteer orders on the POC. During certification period 06/05/2024 - 08/03/2024, 8 volunteer visits were made without volunteer orders on the POC. During the dates of 07/09/2024 - 07/27/2024 a physician order was obtained for volunteer 2w3. These visits were completed. During certification period 08/04/2024 - 10/02/2024, 14 volunteer visits were made without volunteer orders on the POC. During certification period 10/03/2024 - 12/01/2024, 14 volunteer visits were made without volunteer orders on the POC. During certification period 12/02/2024 - 01/30/2025, 11 volunteer visits were made without volunteer orders on the POC.

Upon patient record review 3 of 19 (Patients # 1, 2, 14) did not have documented evidence an RN had made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs: Patient # 1: An aide supervisory visit was completed on 12/31/2024 and there is no further documented aide supervisory visits up to and including 2/4/2025. Patient # 2: An aide supervisory visit was completed on 01/15/2025 and there is no further documented aide supervisory visits up to and including 2/4/2025. Patient # 14: An aide supervisory visit was completed on 01/13/2025 and not again until 01/31/2025.

Upon patient client record review, 2 of 19 (Patient #8, 11) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient # 8: Upon surveyor review of patient record the medical record contained a physician signed DNR order. However, the patient's POC and demographic EMR header stated patient was a full code. Patient #11: The Hospice's Informed Consent/Election of Hospice Benefit Statement was signed by the patient at the time of admission to services. However, this signature was not dated.

Upon patient record review, 2 of 11 (Patient #1, 8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient #1, 8- The medication profile included diclofenac sodium 1% topical gel, "apply to affected area". The location to be applied was not indicated.

Upon patient record review, 3 of 11 (Patient #1, 8, 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1, 8- The plan of care included diclofenac sodium 1% topical gel, "apply to affected area". The location to be applied was not included in the order. Patient #9- The plan of care included orders for foley catheter 16fr to be changed by SN. The order did not include the catheter balloon size.