Every finding on record at Comprehensive Hospice Care, Inc.

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 clinical record review and interview. In 3 of 14 (21%) clinical record reviewed revealed the agency did not ensure an initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/11/2024. The hospice consent stated, “ I understand that a registered nurse will case manage all services, and I have accepted the following services: RN or LVN/LPN, Hospice aide, social worker, and chaplain were selected.” However, on the form titled Admission Report, it stated "none" for both the social worker and chaplain frequencies. A social worker (SW) phone call note dated 09/27/2024 stated that the IDG reported the patient presented with signs and symptoms of loneliness and isolation. She called the patient, and the patient is accepting of social worker visits. The Chaplain's initial visit was done on 10/04/2024 (23 days). CLINICAL RECORD 3: The patient elected the hospice benefit on 05/22/2024. The initial nursing assessment was completed on 05/22/2024, the Social Worker was completed on 05/26/2024, and the Chaplain's missed visit was completed on 05/30/2024 (8 days) due to the patient refusing services. The clinical record did not contain any other attempts or contacts before 05/30/2024. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/08/2024. The initial nursing assessment was completed on 05/08/2024, the Social Worker assessment was completed on 05/14/2024 (6 days), and the Chaplain's assessment was declined. During an interview with the administrator (personnel record 6) on 09/18/2025 she stated that she does not know why the visits were not done within the 5 days. She also said that she will provide additional education to the clinical staff on the importance of completing the initial visits within five days.

It is required that medical social services are provided by a qualified social worker per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed for patients who had social worker services revealed that the agency did not ensure the social worker provided services per the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/26/2022 with diagnosis of Alzheimer's Disease with late onset. The plan of care (POC) dated 03/19/2024 to 05/17/2024 included an order for the social worker frequency at one (1) time a month for two (2) months (1M2). A review of the benefit period 03/19/2025-05/17/2025 did not include any documented evidence that the social worker performed visits as ordered on the POC. During an interview with the administrator (Personnel Record 6) on 09/18/2025 she stated that social worker services had been declined, and the order was present for the following benefit period, but she did not know why it was not done during this benefit period.

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 1 of 7 (14%) clinical records reviewed for patients who elected hospice aide services revealed that the agency did not ensure a supervised on-site visit by the registered nurse no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 2: The clinical record review lacked evidence of an aide supervisory visit during every 14 days during the benefit period 07/17/2024 to 09/14/2024. The hospice aide supervisory visits were dated 08/26/2024 and 09/13/2024 (18 days). During an interview with the administrator (Personnel Record 6) on 09/18/2025, she stated that she could not determine why the aide's supervisory visit was not completed within the 14-day timeframe.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviewed revealed the agency did not ensure physician orders where in the patient's chart. CLINICAL RECORD 3: The patient’s election of benefits was 05/22/2025 with diagnosis of Malignant Neoplasm of Sigmoid colon. A review of the benefit period dated 05/22/2025-08/19/2025 included a skilled nurse(SN) note dated 07/31/2025. The SN documented Foley catheter 16FR with a drainage bag and irrigation with 60 ml of normal saline every 2 weeks, however there was no documented physician order for the foley catheter. The Foley catheter was inserted on 07/31/2025. There was no documented evidence of a physician order for the foley catheter or irrigation. During an interview with the supervising nurse (Personnel Record 1) on 09/18/2025 she stated she does not know how she missed writing the order, but that she would do a late entry clarification order by the end of the day.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by a review of clinical records. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure that the written plan of care was followed. Clinical Record 6: was reviewed and identified the patient elected hospice services on 10/18/22. The plan of care ordered the Medical Social Worker (MSW) "3m3." Review of the clinical record revealed the MSW visits were scheduled as "1m3." There was one MSW visit completed in October. The actual frequency of MSW visits for October was 1 time a month. There was no evidence the MSW visit frequency was changed from the frequency ordered in the plan of care "3m3."

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments to include all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records. 2 of 11 (18%) clinical records reviewed revealed that the hospice did not ensure the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: was reviewed and revealed the patient elected hospice services on 7/4/22. For the benefit period dated 10/5/22, chaplain services were ordered 1 time a month. There was no care plan created for this patient after the spiritual assessment to reflect patient and family goals and interventions based on the needs found. Clinical Record 4: was reviewed and revealed the patient elected hospice services on 8/29/22. After the initial assessment, chaplain visits were ordered "2 times a month." Two chaplain visits were made in September and one chaplain visit was made in October, with one documented missed visit for October. There was no care plan created for this patient after the initial spiritual assessment to reflect patient and family goals and interventions based on the needs found.

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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records reviews. 1 of 5 (20%) applicable records, in which the hospice aide was accepted, revealed the agency RN did not provide specific instructions for tasks on the hospice aide care plan. Clinical Record 7: was reviewed and identified the patient elected hospice services on 6/30/22. The clinical record did not include evidence of an aide care plan. The patient revoked services on 7/5/22.

It is required that a hospice aide provides services that are ordered by the interdisciplinary group, included in the plan of care This standard was not met as evidenced by a review of clinical records. 1 of 5 (20%) clinical records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that the hospice aide provided services that were ordered by the interdisciplinary group, included in the plan of care. Clinical Record 7: was reviewed and identified the patient elected hospice services on 6/30/22. The plan of care ordered aide services 2 times a week. Review of the clinical record revealed no evidence that the aide visits were scheduled and completed. The patient revoked hospice services on 7/5/22.