Ez Comfort Hospice Care

Quality assessment & performance improvement (42 CFR 418.58)

Rule L0559. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“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.”

Rule L0651. Condition-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(i))

“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.”

Rule L0505. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(7))

Rule L0531. Standard-level.

Content of plan of care (42 CFR 418.56(c)(3))

Rule L0548. Standard-level.

Program scope (42 CFR 418.58(a)(1))

“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.”

Rule L0561. Standard-level.

Program data (42 CFR 418.58(b)(2)(ii))

“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.”

Rule L0564. Standard-level.

Program activities (42 CFR 418.58(c)(1)(iii))

“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.”

Rule L0568. Standard-level.

Performance improvement projects (42 CFR 418.58(d))

“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.”

Rule L0571. Standard-level.

Prevention (42 CFR 418.60(a))

“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.”

Rule L0579. Standard-level.

Control (42 CFR 418.60(b)(1))

“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.”

Rule L0580. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“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.”

Rule L0581. Standard-level.

Recruiting and retaining (42 CFR 418.78(c))

“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.”

Rule L0645. Standard-level.

Content (42 CFR 418.104(a)(3))

Rule L0674. Standard-level.

Use and mintenance of equipment and supplies (42 CFR 418.106(f)(2))

“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.”

Rule L0702. Standard-level.