Every finding on record at Comprehensive Hospice and Palliative Care, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/13/2025. The nursing recertification assessment dated 10/01/2025 read in part "Patient is at risk for falling". The plans of care dated 08/13/2025 through 10/11/2025, 10/12/2025 through 12/10/2025, and 12/11/2025 through 02/08/2026 did not include fall precautions or interventions related to the patient being at risk for falling. During a joint record review and interview on 12/18/2025, the Administrator confirmed the above finding, stating "Fall precautions are not on the plan of care but they should be".

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 3 of 17 (18%) clinical records reviewed with hospice aide services provided, the agency did not ensure that all written patient care instructions were included in the hospice aide care plan. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/27/2025. A physician's order dated 04/28/2025 read in part "Oxygen 2 liters via nasal cannula continuously". The plans of care dated 04/27/2025 through 06/25/2025, 06/26/2025 through 08/24/2025, 08/25/2025 through 10/23/2025, and 10/24/2025 through 12/22/2025 ordered "Hospice aide (HA) 2 times per week". The current hospice aide care plan dated 04/27/2025 included relevant instructions of "Shower every visit". The hospice aide care plan was not updated to include instructions on what the Hospice Aide should do with the patient's oxygen during the shower. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/13/2025. The plans of care dated 08/13/2025 through 10/11/2025, 10/12/2025 through 12/10/2025, and 12/11/2025 through 02/08/2026 ordered seizure precautions. The plans of care also ordered "HA 4 times per week". The hospice aide care plan dated 08/15/2025 did not include instructions for seizure precautions. CLINICAL RECORD 17: The patient elected the hospice benefit on 06/26/2025. A physician's order dated 08/30/2025 ordered wound care with a wound dressing to a wound on the patient's left thigh. The plan of care dated 06/26/2025 through 09/17/2025 ordered "HA 2 times per week". The hospice aide care plan dated 06/27/2025 included relevant instructions of "Bed Bath every visit". The Hospice Aide care plan was not updated to include instructions on what the hospice aide should do if the wound dressing becomes wet or dislodged during the bed bath. During joint record reviews and interview on 12/18/2025, the Administrator confirmed the above finding, stating "There are no instructions for the patient's oxygen, seizure precautions, or wound dressing instructions on the aide care plans".

It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed with hospice aide services provided, the agency did not ensure that hospice aide supervisory visits were completed no less frequently than every 14 days. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/15/2025. The plans of care dated 01/15/2025 through 04/14/2025 and 04/15/2025 through 07/13/2025 ordered " hospice aide 1 time weekly". The first hospice aide visit was dated 01/16/2025. Hospice aide supervisory visits were dated 01/22/2025, 02/03/2025, 02/17/2025, 02/24/2025, 03/03/2025, 03/17/2025, and 03/25/2025. The next hospice aide supervisory visit was dated 04/10/2025, a total of 16 days later and 2 days outstanding. CLINICAL RECORD 4: The patient elected the hospice benefit on 04/27/2025. The plans of care dated 06/26/2025 through 08/24/2025 and 08/25/2025 through 10/23/2025 ordered " hospice aide 2 times weekly". The first hospice aide visit was dated 06/27/2025. Hospice aide supervisory visits were dated 07/05/2025 and 07/10/2025. The next hospice aide supervisory visit was dated 07/25/2025, a total of 15 days later and 1 day outstanding. Hospice aide supervisory visits were then dated 08/07/2025, 08/21/2025, 09/04/2025, 09/18/2025, and 09/30/2025. The next Hospice Aide supervisory visit was dated 10/20/2025, a total of 20 days later and 6 days outstanding. During joint record reviews and interview on 12/18/2025, the Administrator confirmed the above findings that hospice aide supervisory visits were completed no less frequently than every 14 days.

It is required that the written Patient Bill of Rights includes the right to be informed and receive written information concerning the hospice’s policy on advance directives, including state law and regulation. This standard was not met as evidenced by document review and interviews. A review of the agency's sample admission folder revealed it did not include or provide patients or their representatives with the agency's advance directive policy, including state law and regulation. Agency policy number PC. A130 titled, "Advance Directives" with an original date of March 2011 and no revision date, stated in part under subtitle Procedure (1) "During the admission interview, and prior to receiving care, the hospice nurse or Social Worker provides written information and instruction on advance directives to the patient. If the patient is unable to understand this information, it is given to the patient's legal health representative or proxy. The written information given to the patient or legal representative includes: (a) the hospice's policies on the implementation of the patient's advance directives including any limitations; (b) a description of the patient's rights under State law, including the patient's right to formulate an advance directive and the right to accept or refuse medical or surgical treatment, including do not resuscitate (DNR) orders. The sample admission folder included agency form #234 (06-11) titled, "Advance Directives", a copy of the advance directive education resource from www.caringinfo.org. The form provided patients and representatives with general information about advance directives, including living wills, medical power of attorney, life-sustaining treatments, cardiopulmonary resuscitation (CPR), Do Not Resuscitate (DNR) orders, Do Not Intubate (DNI) orders, artificial nutrition and hydration, and other information about advance directives. The form did not include State specific education on advance directives; however, the sample admission folder included the State-specific yellow DNR order form. In an interview on 2/16/2023, the Executive Director agreed that the agency's advance directive policy was not included in the admission folder and was not provided to patients or their representatives. A review of the agency's sample admission folder revealed that it did not include or provide patients or their representatives with the agency's advance directive policy.

It is required that the written Patient Bill of Rights includes the right to voice grievances to the hospice, CHAP, or a state entity without fear of discrimination or reprisal and voice grievances regarding treatment or care that is—or fails to be—provided. This standard was not met as evidenced by a review of documents and interviews. A review of the agency's sample admission folder revealed that it did not include or provide patients or their representatives with the contact information for contacting CHAP to voice grievances. The sample admission folder included agency form #223 (03/2020) titled " Patient Rights and Responsibilities" which stated in part under the subtitle To File a Complaint or Grievance, "Make your complaint known to your nurse case manager, social worker, or the hospice Administrator. If a resolution is not readily made, the complaint or grievance must be put in writing and delivered to the attention of the hospice Administrator. Once the written complaint is received a response will be made within five working days. The Management Team of (agency name) will be notified of all such complaints. In the event the hospice Administrator is unable to resolve the complaint, a representative of the Management Team will personally contact the individual to try to reach a satisfactory resolution. If a satisfactory resolution is not found, a formal complaint may be filed with (State name) at Department of Health Services (phone number included and hearing-impaired phone number included.)" In an interview on 2/16/2023, the Executive Director agreed that CHAP contact information for voicing grievances was not included in the admission information provided to patients and families. A review of the agency's sample admission folder revealed that it did not include or provide patients or their representatives with the contact information for CHAP to voice grievances.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 13 (8%) records reviewed revealed the spiritual care initial comprehensive assessment was not completed within five (5) calendar days after the election of hospice care. Agency Policy Number PC. A140 titled, " Assessment - Comprehensive Assessment of the Patient" with an original date of March 2011 and no revision date, stated in part under subtitle Procedure... (2) "The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit." Clinical Record 6: The patient elected the Hospice Benefit on 12/20/2022 and accepted spiritual care services. The initial spiritual assessment was not completed until 12/27/2022. In an interview during joint record review on 2/16/2023, the Executive Director agreed that the spiritual care initial comprehensive assessment was not completed within 5 calendar days after the election of hospice care.

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 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 a review of clinical records, interviews and observations. 1 of 3 (33%) home visits where medication reconciliations were completed revealed the agency medication profile was not updated accurately compared to the patient's current regimen. Home Visit Observation (2): The patient (Record 6) elected the Hospice Benefit on 12/20/2022. On 2/15/2023, a home visit was observed with the registered nurse (RN) (Staff 2). The patient’s primary diagnosis is senile degeneration of the brain and she lived with her son who is her primary care provider. During the home visit on 2/15/2023, a medication reconciliation was conducted by comparing the medications on the agency medication profile to the medications in the home. The medication profile listed diazepam 2 mg tablet; take one (1) tablet by mouth two (2) times a day for anxiety. However, the son reported his mother had not taken that medication for at least two (2) months because of the side effects. The agency medication profile listed amlodipine 5 mg tablet; take one (1) tablet by mouth daily. The bottle in the home was labeled amlodipine 10 mg, and the directions on the bottle said to take one (1) tablet by mouth daily. The son reported he cuts the amlodipine 10 mg in half (1/2) each day and gives his mother amlodipine 5mg by mouth daily. The RN was present for the reconciliation and confirmed the patient had not taken diazepam 2 mg tablet for "quite some time" due to side effects. In an interview and review of home visit findings on 2/15/2023, the Executive Director agreed that the patient’s medication profile was inaccurate and included a medication that had been discontinued.

It is required that the hospice designates a registered nurse to ensure that hospice care and services are provided in accordance with the individualized POC. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 9 (22%) clinical records reviewed revealed the agency did not ensure that services were provided as ordered on the POC. Clinical Record 1: Patient elected the Hospice Benefit on 12/20/2020, was admitted to hospice services with a primary diagnosis of Alzheimer's disease and resided in an assisted living facility. On the 2/7/2023 visit, the registered nurse (RN) documented a wound assessment which identified a skin tear located anteriorly of the second (2nd) finger of the right hand. A physician order dated and signed by the RN on 2/7/2023, and signed by the physician on 2/8/2023, included orders to clean the wound with soap and water daily, pat dry, apply triple antibiotic ointment, and cover with a bandage. On the 2/13/2023 visit, the RN documented provision of the wound care. There was no additional documentation that the RN completed the wound care daily per the physician's order. The physician order and the plan of care did not state that facility staff or the primary caregiver were to assist with wound care. In an interview on 2/16/2023, the Executive Director agreed that the hospice nurse did not provide wound care daily in accordance with the physician’s order. Clinical Record 5: The patient elected the Hospice Benefit on 12/9/2022 and accepted spiritual care services. The 1/23/2023 frequency order for the chaplain stated monthly visits (1xM) and two (2) as needed (PRN) visits. The agency provided a missed visit report for the 1/29/2023 chaplain visit, however there was no documentation in the clinical record that the physician was notified of the missed visit. The 2/28/2023 IDT meeting minutes did not include documentation of the missed visit. In an interview on 2/16/2023 during joint review of clinical records, the Executive Director confirmed there was a missed chaplain visit on 1/29/2023 and agreed that the physician and IDT were not notified about the missed visit and that the plan of care was not followed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments includes all services necessary for the palliation and management of the terminal illness, including the medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed where durable medical equipment (DME) and medical supplies were being provided to a patient, revealed the agency did not include the medical supplies in the POC. Clinical Record 1: This patient (Clinical Record 1) elected the Hospice Benefit on 12/9/2020 and was admitted to Hospice services with a primary diagnosis of Alzheimer’s disease. The 12//9/2022-2/16/2022 POC included documentation of the following functional limitations: bowel/bladder incontinence, contractures, hearing, endurance, speech, and being legally blind. The POC included documentation that the following DME was provided to the patient: hospital bed, a ROHO wheelchair cushion, a wheelchair, and a bedside table. The POC did not include documentation of medical supplies used by the patient and provided by the agency including incontinence briefs, wipes, and peri wash. In an interview during joint record review on 2/15/2023, the Executive Director stated the agency did provide the patient (Record 1) with incontinence briefs, wipes, and peri wash, but these supplies were not included in the POC.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by a review of document reviews, interviews and observations. 1 of 1 (100%) home visits where direct contact with bodily fluids occurred revealed the agency did not adhere to its infection control policy and procedures for hand hygiene. Agency Policy Number PC.I055 titled "Infection Control - Handwashing" with an original date of August 2011 and no revision date, stated in part under subtitle Procedure: (1) "All personnel, clinical and nonclinical will wash their hands: (a) after entering the patient's home, or after entering the patient's room in a care facility; (b) before performing an invasive or sterile procedure; (c) after any patient care or treatment that involves touching body fluids or open wounds; (d) after handling contaminated materials, dressings or equipment; (e) after completing patient care." Home Visit Observation (3): This patient (Clinical Record 13) elected the Hospice Benefit on 1/18/2023 and was admitted to Hospice services with a primary diagnosis of pulmonary fibrosis. During the home visit observation on 2/16/2023, the Hospice aide (Staff 7) performed hand hygiene with soap and water, then donned gloves before showering the patient. It was observed that soon after the shower began, the aide with donned gloves opened a cabinet to retrieve clean supplies without removing the soiled gloves. In addition, the aide waited until the end of the shower to shampoo the patient's hair and did not change gloves or perform hand hygiene after washing the patient's perineal area and prior to washing hair. The aide stated, "I wait until the end to shower to shampoo my patient's hair, so they don't get cold." The hospice aide did not change gloves or perform hand hygiene after washing the patient and went from a dirty area of the body (perineal) to a clean area (hair). During an interview on 2/16/2023 and after a review of home visit findings, the Executive Director agreed that the aide did not follow agency hand hygiene and infection control practices.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, documents and interviews. 2 of 2 (100%) clinical records reviewed with bereavement services did not ensure that bereavement plans of care included frequency of service delivery. Agency Policy Number PC. B060 titled, "Bereavement Services", with an original date of March 2011 and no revision date, stated in part under subtitle Procedure... (3) "The bereavement services and frequency of services provided are based on the assessed needs of the deceased's survivors and are in accordance with a bereavement plan of care formulated after the patient's death..." Agency Policy Number PC. B030 titled, " Bereavement Care Planning", with an original date of March 2011 and revision date of August 2013, stated in part under subtitle Procedure... (3) "The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery that honors the caregiver's choices regarding bereavement." Clinical Record 9: The patient elected the Hospice benefit on 3/22/2022 and expired on 3/22/2022 while on the agency’s service. The bereavement care plan dated 3/25/2022 identified the bereaved as low risk and documented the following four (4) interventions that did not include frequencies for service delivery: condolence call, condolence card, introduction letter, and assessment call. The following bereavement services did include frequencies for service delivery: 3-month letter, 6-month letter, 9-month letter, anniversary card, and 13-month card. Clinical Record 10: This patient elected the Hospice benefit on 4/8/2022 and expired on 7/22/2022 while on agency service. The bereavement care plan dated 7/5/2022 identified the bereaved as low risk and documented the following four (4) interventions that did not include frequencies for service delivery: condolence call, condolence card, introduction letter, and assessment call. The following bereavement services did include frequencies for service delivery: 3-month letter, 6-month letter, 9-month letter, anniversary card, and 13-month card. In an interview on 2/16/2023 during joint record review, the Executive Director agreed that some of the services on the bereavement care plans did not include frequencies for bereavement service delivery.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. During a review of the volunteer program's retention and recruitment efforts, it was revealed the agency did not document recruitment and retention efforts for the previous three years. Document 1: The agency binder titled, "Volunteer Recruitment & Retention Training, Education, and Contact Info 2019", included documentation of volunteer retention and recruitment activities for the year 2019. The agency could not provide documentation of volunteer retention or recruitment activities for the last three years. In an interview on 2/17/2023, the Volunteer Coordinator stated that volunteer retention and recruiting activities had been conducted during the previous three years but had not been recorded. The agency was not able to demonstrate ongoing efforts to recruit and retain volunteers. During a review of the volunteer program's retention and recruitment efforts, it was revealed the agency failed to document its recruitment and retention efforts for the last three years.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (8%) records reviewed with certification terminal illness (CTI) narratives composed by the medical director revealed the documented primary diagnosis did not correspond with the diagnosis on the CTI physician narratives. Clinical Record 4: The patient was admitted to Hospice services on 7/28/2021 with a primary diagnosis of Parkinson's disease. Effective with the 7/28/2021 Hospice Benefit election through the certification period beginning 1/19/2023, the CTI narratives composed by the medical director did not include the patient’s primary terminal diagnosis of Parkinson’s disease. Each CTI completed by the medical director stated the patient had "senile degeneration of the brain, nutritional deficiency, coronary artery disease (CAD), hypertension (HTN) and muscle weakness.” In an interview on 2/16/2023 during joint clinical record review, the Executive Director agreed that the patient's primary terminal diagnosis was Parkinson's disease, and the physician CTI narratives did not include this diagnosis.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by a review of interviews and observations. An inspection of the medical supply room on 2/17/2023 that the Executive Director witnessed revealed the following expired items: twenty (20) safety winged blood collection sets hinged with needles measuring 23 gauge, 3/4 inches, 12 inches, had expired on 06/30/2021; two (2) PleurX valve caps expired on 7/14/2019; one (1) smallbore extension set with micro-Clave clamp and rotating Luer measuring 14 inches and 0.44 mL, expired on 06/2020; two (2) leg bag straps expired on 04/2022; one hundred (100) venipuncture needle-pro needle protection devices expired 11/14/202;, and one (1) 12 fluid-ounce bottle of saline solution expired on 09/01/2020. The Executive Director agreed on 2/17/2023 that the supplies identified in the findings were expired. An inspection of the medical supply room on 2/17/2023 that the Executive Director witnessed revealed the following expired items: twenty (20) safety winged blood collection sets hinged with needles measuring 23 gauge, 3/4 inches, 12 inches, had expired on 06/30/2021; two (2) PleurX valve caps expired on 7/14/2019, one (1) smallbore extension set with micro-Clave clamp and rotating Luer measuring 14 inches and 0.44 mL, expired on 06/2020; two (2) leg bag straps expired in 04/2022, and one hundred (100) venipuncture needle-pro needle protection devices expired 11/14/2022, and one (1) 12 fluid-ounce bottle of saline solution expired on 09/01/2020. The Executive Director confirmed on 2/17/2023 that the items were expired and were removed from circulation from the medical supply room.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document reviews and interviews. 3 of 13 (23%) contracts reviewed revealed the agency did not ensure that the contract included criminal background check requirements for staff with direct patient contact or access to patient records. Contract 7: The agency contract titled, "Interpreting Service Agreement", with an effective date of 2/23/2011 did not include a clause requiring criminal background checks on all contracted employees with direct patient contact or access to patient records. Contract 5: The agency contract titled, "Transportation Services Agreement", without an effective date, did not include a clause requiring criminal background checks on all contracted employees with direct patient contact or access to patient records. Contract 4: The agency contract titled, "Laboratory Service Agreement", with an effective date of 12/2012 did not include a clause requiring criminal background checks on all contracted employees with direct patient contact or access to patient records. in an interview and joint contract review on 2/17/2023, the Regional Director of Operations agreed that the clause requiring criminal background checks on contracted staff was missing in Contract 4, Contract 5, and Contract 7.