Comforting Care Hospice, Inc.

“Based on interview and record review, the hospice agency failed to ensure medications were reconciled to reflect current medications taken for one of four sampled patients (Patient 16).This failure had the potential to result in medication errors which could affect the care and services provided to Patient 16. During a review of Patient 19’s “Face sheet (FS),” dated [undated], the “FS” indicated, “80-year-old male admitted to hospice on 4/4/25 with the diagnosis of Cerebral infarction (brain tissue death caused by a blockage of blood flow to the brain.”During a review of “Victoria Care Center Order Summary Report (MED1),” dated 8/19/25, the “MED1” indicated, “Lidocaine (pain reliever) External Patch 4% (Lidocaine) Apply to Right Shoulder topically one time a day for Right Shoulder pain *12H off and remove per schedule. Order date 5/16/25”During a review of “Current Treatment/Medication/DME List (MED2),” dated [undated], “MED2” indicated, Lidocaine not listed.During an interview on 8/20/25 at 2:23 p.m. with the Assistant Administrator (AADM), AADM agreed, the registered nurse should have caught the missing medication not listed in hospice list of lidocaine, during medication reconciliation for Patient 16.During a review of the facility’s policy and procedure (P&P) titled, “Medication Profile,” dated 11/23, indicated, “…POLICY Patients receiving medication administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiled will be updated for each change to reflect current medications and new and/or discontinued medications…””

“Based on record review and interview, the hospice agency failed to ensure the hospice plans of care (POC - a personalized, written document created to meet an individual’s specific health, social, and psychological needs, outlining services, goals, and expected outcomes to ensure comprehensive, coordinated support) were revised to accurately reflect care and services ordered by the physician for three of 19 sampled patients (Patients 1, 12, and 13) when: 1) Patient 1’s POC indicated home visits to be conducted by a licensed vocational nurse (LVN) but none were documented in the patient’s clinical record. 2) Patient 12’s POC indicated the frequency of hospice aide (HA) visits as outlined in the POC was not followed.3) Patient 13’s POC indicated the frequency of registered nurse (RN) and LVN visits as outlined in the POC was not followed.These failures had the potential to affect the delivery of care and services to current and prospective patients. Findings:1) During a review of Patient 1’s “Face Sheet (FS),” undated, the FS indicated Patient 1 was a 75-year-old female who was admitted to the agency on 7/11/24 with a primary admitting diagnosis of Alzheimer’s disease (a progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes that interfere with daily life). During a review of Patient 1’s “POC” for the hospice recertification period of 5/7/25 – 7/5/25, the POC indicated the frequency of visit order, “LVN: 2 per week + 3 PRN (as needed) Visits….” During a review of Patient 1’s clinical records, the “Monthly Schedule (a monthly calendar schedule showing ordered & completed home visits according to discipline),” and “Visit Notes” for May, June, and July 2025, failed to indicate documentation that LVN visits to Patient 1 were conducted. During a concurrent interview and record review on 8/20/25 at 2:07 p.m. with the agency’s Administrator (ADM) and Assistant Administrator (AADM), Patient 1’s clinical record was reviewed. ADM verbalized that Patient 1’s family declined the ordered LVN services but was never documented in the patient’s clinical record. ADM and AADM acknowledged that Patient 1’s POC should have been revised to accurately reflect that LVN services were declined. 2) During a review of Patient 12’s “Face Sheet (FS),” undated, the FS indicated Patient 12 was a 84-year-old male who was admitted to the agency on 5/6/25 with the primary diagnosis of Alzheimer’s disease (a progressive brain disorder that causes memory loss, cognitive decline, and behavioral changes that interfere with daily life).During a review of Patient 12’s POC for the certification period of 5/6/25 to 7/4/25, the POC indicated the frequency of visit order, “HA: visits twice a week.”During a review of Patient 12’s clinical records, the “Monthly Schedule (a monthly calendar schedule showing ordered & completed home visits according to discipline),” The HA visits failed to follow the POC frequency of visits.During a concurrent interview and record review on 8/20/25 at 3:30 p.m. with the agency’s ADM and AADM, Patient 12’s clinical record was reviewed. ADM and AADM acknowledged that Patient 12’s HA actual visits did not follow the POC frequency of visits as ordered. 3) During a review of Patient 13’s “Face Sheet (FS),” undated, the FS indicated Patient 13 was a 87-year-old female who was admitted to the agency on 4/25/25 with the primary diagnosis of Cerebral Infarction (a condition where blood flow to the brain is interrupted, leading to damage or death of brain cells).During a review of Patient 13’s POC for the certification period of 4/25/25 to 7/23/25, the POC indicated the frequency of visit order for skilled nurse (SN): Daily for wound care…During a review of Patient 13’s clinical records, the “Monthly Schedule (a monthly calendar schedule showing ordered & completed home visits according to discipline),” The registered nurse (RN) and LVN visits failed to follow the POC frequency of visits.During a concurrent interview and record review on 8/20/25 at 3:35 p.m. with the agency’s ADM and AADM, Patient 13’s clinical record was reviewed. ADM and AADM acknowledged that Patient 13’s RN and LVN actual visits did not follow the POC frequency of visits as ordered.During a review of the agency’s policy and procedures (P&P) titled, “The Plan of Care,” revised 11/2023, the P&P indicated in part, “POLICY… A written individualized patient and family/caregiver plan of care will be established for each individual admitted to the hospice program. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process… PROCEDURE… 8) Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes….””

“Based on interview and record review, the hospice agency failed to ensure nursing supervisory visits were conducted every 14 days for two of 15 sampled patients (Patients 6 and 9) receiving hospice aide (HA) services.This failure had the potential to result in Patients 6 and 9 not receiving quality care. During a review of Patient 6’s “Face sheet (FS),” dated [undated], the “FS” indicated, “73-year-old female admitted to hospice on 5/28/25 with the diagnosis of Cerebrovascular disease (condition that impacts the brain’s blood flow).”Certification Review period of 6/30/25-8/28/25During a review of Patient 6’s “POC (Plan of Care)/IDG (Interdisciplinary Group) Review, (POC)),” dated 7/31/25, the “POC” indicated, “…Frequency of Visit: HA (health aide) 2 per week…”During a review of Patient 6’s “History of Nursing Assessment-electronic health record (HNA),” dated [undated], the “HNA” indicated, no nursing supervisory visits done for the week of 8/10/25.During an interview on 8/20/25 at 2:10 p.m. with the Assistant Administrator (AADM), AADM agreed, missing supervisory note for the week of 8/10/25 for Patient 6. During a review of Patient 9’s “FS,” dated [undated], the “FS” indicated, “71-year-old female admitted to hospice on 5/19/25 with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (lung disease that block airflow and make it difficult to breathe).”Certification Review period of 5/19/25-8/16/25During a review of Patient 9’s “POC,” dated 6/19/25, the “POC” indicated, “ Frequency of Visit: HA 2 per week…”During a review of Patient 9’s “HNA,” dated [undated], the “HNA” indicated, nursing supervisory visits only done on 7/6/25.During an interview on 8/20/25 at 3:00 p.m. with the AADM, AADM agreed, to the inconsistent supervisory notes, there were registered nurse notes but not listed as supervisory notes, supervisory note section not done and no indication of supervisory notes listed in narratives for Patient 9.During a review of the facility’s policy and procedure (P&P) titled, “Responsibilities/Supervision of Clinical Services,” dated 11/23, indicated, “…7. A. Hospice aides 1. Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse…””

“Observed in Record Review. In 10 of 10 patient records reviewed, Confirmed by the Administrator. The plan of cares had not been individualized to reflect the interventions and problems identified during the initial assessment. Example: During review of HOSv#2 the home health aide care provided had only documented the frequency on the plan of care ,but had not included interventions or goals. Confirmed by the Administrator. The plan of care had not been based on the patient’s assessed needs. Example: During review of HOSrr#1 the assessment had identified dysphagia with history of aspiration. The plan of care had not identified interventions or goals to address dysphagia or safety needs to prevent aspiration. 
Patient goals had not been measurable: Example; During review of HOSrr#1 the pain goal had documented that pain will remain at a comfortable level for the next 30 days.”