Every finding on record at Ez Comfort, Inc.

Observed in Record Review. In 1 of 2 patient records reviewed, of discharged hospice patients the surveyor noted that while the organization had a clear process in place that respects the patient's right to elect and revoke hospice care, the signed revocation notice could not be found for RRDC # 8. There was documentation of two telephone calls and voice mails left with no response however no further follow up was documented. This was validated with the Administrator/DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. In review of the medical record for RRNHV # 4 there was no evidence that the spiritual assessment had been completed. There was documentation by the Chaplain that the family wanted spiritual care services however the patient's husband had COVID at the time of admission. There was no evidence of follow up in the medical record to arrange a time for the spiritual assessment although the chaplain did make a routine visit approximately 4 weeks later. This was validated with the Administrator/DPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization did not comply with their policy no. 2-010.1 Bereavement Services which states a bereavement risk assessment will be completed by the hospice social worker at the time of admission. In review of the medical record for RRNHV #1 there was no evidence that a bereavement risk assessment had been completed. Additionally, the organization did not complete the post death bereavement assessment in accordance with their policy which states that the post death bereavement assessment will be completed 3-5 weeks following the death. In review of the medical record for RRBR #10 the post death bereavement assessment was completed two days following the death and for RRBR #11 the post death bereavement assessment was completed four days following the death. This was validated with the Administrator/DPCS.

Observed in Record Review. In 3 of 10 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. In review of the medical record RRNHV #1 the plan of care had not been updated with to reflect a problem of elevated SBP of 170/102 where a new order was received for Losartan 50mg 1 tablet PO daily. Also for RRNHV # 2 the plan of care failed to address wound care for the left buttock. Additionally, in review of the medical record for RRNHV #4 the plan of care failed to address the high risk for aspiration. This was validated by the Administrator/DPCS.

Observed in Data Session. The organization's quality assessment and performance improvement program (QAPI) did not reflect the complexity of the organization and its services or involves all services provided by the organization, including those provided under contract or arrangement and did not focus on indicators that are related to improved palliative outcomes. For example, in review of the 2025 QAPI plan the organization had one indicator for unwanted hospitalizations but nothing related to palliative outcomes and the QAPI plan failed to address durable medical equipment (DME), pharmacy, bereavement or volunteer services. This was validated with the QA Nurse and Administrator/DPCS.

Observed in Data Session. The organization's quality assessment and performance improvement (QAPI) program was not focused on the indicators related to improved palliative outcomes and hospice services. In review of the organization's QAPI program the surveyor noted that the performance improvement projects selected by the organization were focused on reducing unwanted hospitalizations and were not focused on palliative outcomes including improving a patient's quality of life and reducing suffering from life-threatening illnesses. This was validated with the Administrator/DPCS.

Observed in Data Session. The organization did not analyze and compare internal data over time to identify levels of performance, patterns, trends, and variations. In review of the organization's infection control plan the surveyor noted that although the organization had collected data they had not trended the data to identify opportunities for improvement. This was validated with the QA Nurse and Administrator.

Observed in Data Session. The hospice did not select performance improvement activities that affect palliative outcomes, patient safety, and the quality of care and that are based on the incidence, prevalence, and severity of problems in its high-volume, high-risk, and problem-prone areas. In review of the organization's quality assessment and performance improvement (QAPI) program the surveyor noted that the organization had selected a focus of unwanted hospitalizations for 2025 and 2023. This was validated with the Administrator/DPCS.

Observed in Data Session. The organization had not documented the reasons for conducting performance improvement projects, and the measurable progress achieved on them. In review of the organization's performance improvement projects (PIP) the surveyor noted that the organization's process is to focus on one PIP each year however they had selected unwanted hospitalizations for 2023 and again in 2025 with the same results. This was validated with the QA Nurse and Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, hospice staff failed to comply with the organization's policy no. 9-009.1 Hand Hygiene. For RRHV #1 the LVN failed to perform hand hygiene before donning gloves in accordance with the organization policy. Also, for RRHV #2 the Chaplain failed to perform hand hygiene following contact with the patient, the patient's surroundings and before leaving the home at the end of the visit. This was discussed with the Chaplain and validated with the Administrator/DPCS.

Observed in Leadership Session. The organization's infection prevention and control program was not organizationwide and an integral part of the organization’s quality assessment and performance improvement program. In review of the organization's infection control plan the surveyor noted that it was not integrated into their overall QAPI plan. The organization had collected infection surveillance data however it did not include the type infection and it was not trended or analyzed over time. This was validated with the QA Nurse and Administrator/DPCS.

Observed in Data Session. The organization's Hand Hygiene program included staff education, competency assessment completed at the office and a post test completed by the staff however there was no evidence that the organization assessed compliance with hand hygiene by observations of staff providing patient care year to date 2025, 2024 or 2023. This was validated with the Quality Coordinator and Administrator/DPCS.

Observed in Data Session. The organization failed to document its efforts to recruit and retain volunteers. In discussion with the Volunteer Coordinator and the Administrator/DPCS there was no evidence that the hospice had documented their recruitment and retention efforts.

Observed in Data Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level findings at 418.58 and 418.60. This was discussed with the Administrator/DPCS.

Observed in Patient Home. In 2 of 2 home visits conducted, with hospice nursing staff, the patient record contained errors and was inaccurate. For RRHV #1 the medication list in the home provided by the hospice included Tramadol 50g 1 tab PO every 8 hours as needed however the patient has not been given that medication in the 8 months she has been on hospice. Also, the medication list included Senna 8.6 mg PO 1 tablet daily however the husband is giving the patient Senokot gummies for the past 2 months. The patient is also receiving Melatonin gummies which were not on the medication list. Additionally, for RRHV #3 who resided in an assisted living facility the hospice medication list included Melatonin 1 mg 1 tab daily at bedtime prn however the Med Tech from the facility reported that the medication has never been giving to the patient also the facility medication list included Ibuprofen 600mg PO four times a day as needed however the medication was not on the hospice medication list and the hospice medication list included Tramadol 50mg 1 tablet PO twice a day however the facility has not been giving the medication. This was validated with the hospice nursing staff and the Administrator/DPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided information and education to the patient/family/caregiver on the handling and storage of medical gases and supplies. For RRHV #2 who had been on the hospice program for more than 19 months the surveyor noted that there were three e-tanks stored in a closet with two oxygen tanks standing upright unsecured. This was validated by the Administrator/DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care did not include all interventions to meet the patient's needs. According to organizational policy Plan of Care No. 2-044, the plan of care will include individualized interventions. Upon review of the record for HV#1, it was noted the patient was identified as a fall risk; however, on review of the plan of care, there were no interventions established related to safety. The patient was on warfarin with PT/INR monitoring; however, on review of the plan of care, there were no interventions established related to anti-coagulation management. The patient was receiving psychosocial support; however, on review of the plan of care, there were no interventions established addressing the patient's/families’ psychosocial needs. Upon review of the record for HV#2, HV#3, RR#4, RR#5, and RR#6, it was noted the patients were receiving psychosocial support; however, on review of the plan of care, there were no interventions established addressing the patient's/families’ psychosocial needs. The patients were identified as a fall risk; however, on review of the plan of care, there were no interventions established related to safety. Upon review of RR#5, it was noted the patient was receiving spiritual support; however, on review of the plan of care, there were no interventions established addressing the patient's/families’ spiritual needs. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, medication orders were incomplete. According to organizational policy Verification of Physician Orders No. 2-046, a complete medication order will include the indication for use, dosage, frequency, and route of administration. Upon review of RR#10 and the plan of care, it was noted the patient had an order for Humalog insulin written as follows: Humalog Insulin Pen Inject 2 to 12 units three times a day; however, the order did not include specific instructions related to the dosage and the exact number of units to be administered. Upon review of RR#4, it was noted the patient had an order for amlodipine for hypertension and on review of nursing documentation, parameters were in place to hold if systolic blood pressure was less than 120; however, the medication order did not include these parameters and was written as follows: amlodipine 10 mg 1 tab daily. This was reviewed and validated with the Administrator. Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include all treatments to meet the patient's needs. According to organizational policy Plan of Care No. 2-044, the plan of care will include all treatments necessary to meet the patient's needs. Upon review of RR#9, it was noted the patient had a diagnosis of Amyotrophic Lateral Sclerosis (ALS) and was using a Continuous Positive Airway Pressure (CPAP) machine; however, on review of the plan of care, this treatment was not addressed. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization’s infection prevention and control activities related to disinfection of equipment were not implemented. According to organizational policy No.9-014 Bag Technique, reusable equipment will be cleaned with alcohol or soap and water prior to being returned to the bag. During HV#2, the clinician was observed cleaning her vital sign equipment with Microkill wipes and placed the equipment immediately back into the nursing bag without observing the 1-minute wet time indicated on the manufacturer’s instructions. During HV#3, the clinician was observed cleaning her vital sign equipment using a Benzethonium Chloride disinfecting wipe. This was discussed with the Administrator following the visits. Observed in Patient Home. In 2 of 3 home visits conducted, standard precautions were not used to reduce the risk of infection. According to organizational policy No.9-014 Bag Technique, hand hygiene will be performed prior to entering the bag. During HV#2 and HV#3, the clinicians were observed entering their bag to remove supplies without first performing hand hygiene. According to organizational policy No. 9-009, hand hygiene should be performed after glove removal. During HV#2 and HV#3, the clinicians were observed removing their gloves and moving on to the next task without first performing hand hygiene. This was discussed with the Administrator following the visits.

Observed in Record Review. In 1 of 7 patient records reviewed with aide services, complete written patient care instructions were not prepared by the RN. Upon review of the record for HV#1, it was noted the patient was on anti-coagulant therapy; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding bleeding precautions. This was reviewed and validated with the Administrator.