Comfort Care Hospice

“Based on interview and record reviews, the agency failed to implement the agency’s emergency preparedness plan for developing individualized patient emergency plans for 15 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15) of 15 sampled patients reviewed for individualized emergency preparedness plan requirements Findings: Review of the agency’s Emergency Plan, with an approved date of 01/20/2026, revealed, in part, each patient would have a patient emergency preparedness plan (Patient Disaster Plan Identification Card-Tab 9) included as part of the comprehensive patient assessment which must be conducted at admission. Review of the agency’s Patient Disaster Plan Identification Card (Tab 9) revealed the following information was required, in part, listing of required durable medical equipment, supplier name, pharmacy name, the number of persons needed to evacuate with the patient, the evacuation destination, and the alternate evacuation destination. Review of Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15’s records revealed no evidence that the above mentioned individualized emergency plan had been implemented The agency presented no evidence of individualized emergency plans for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, and Patient #15 when asked on 06/04/2026 at 2:10PM and 2:30PM. In an interview on 06/04/2026 at 12:43PM, S1Administrator/Director of Nursing (DON) indicated the agency did not implement their emergency preparedness plan to ensure the Patient Disaster Plan Identification Card-Tab 9 was part of their comprehensive patient assessment which must be conducted at admission for the above-mentioned patients as required.”

“Based on interview and record reviews, the agency failed to ensure the chaplain completed the spiritual assessment within five calendar days of admission for 1 (Patient #14) of 15 sampled patients reviewed for comprehensive assessments requirements. Findings: Review of Patient #14’s Hospice Interdisciplinary Plan of Care dated 03/27/2026 revealed, in part, Patient #14 had an admission date of 03/27/2026. Further review revealed Patient #14 required chaplain services. Review of Patient #14’s record revealed no evidence of a chaplain initial assessment or evidence an initial chaplain assessment was attempted within 5 days of Patient #14’s admission date of 03/27/2026. In an interview on 06/04/2026 at 1:46PM, S1Administrator/Director of Nursing indicated the chaplains failed to ensure the initial spiritual assessment was attempted and/or completed within 5 days of admission.”

“Based on interviews and record reviews, the agency failed to ensure the chaplain communicated with the patient’s case manager regarding the patient’s request to discontinue chaplain services for 3 (Patient #4, Patient #6, Patient #12) of 15 sampled patients reviewed for coordination of care requirements. Findings: Patient #4 Review of Patient #4’s Hospice Interdisciplinary Plan of Care dated 11/21/2025 revealed Patient #4 was to receive chaplain services once a month. Review of Patient #4’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month. In an interview on 06/04/2026 at 1:50PM, S1Administrator/Director of Nursing (DON) indicated Patient #4’s caregiver cancelled multiple home visits with the chaplain and ultimately decided to cancel all chaplain services. S1Administrator/DON further indicated the chaplain failed to communicate Patient #4 wanted to discontinue chaplain services to Patient #4’s case manager so chaplain services could be removed from Patient #4’s plan of care. Patient #6Review of Patient #6’s Hospice Interdisciplinary Plan of Care dated 10/02/2025 revealed Patient #6 was to receive chaplain services once a month. Review of Patient #6’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month. Review of Patient #6’s Interdisciplinary Group (IDG) Progress Note dated 02/20/2026 revealed, in part, Patient #6’s son requested hospice to stop chaplain services for now. In an interview on 06/04/2026 at 1:33PM, S1Administrator/DON indicated the chaplain failed to communicate to Patient #6’s nurse case manager for the chaplain services to be removed from the plan of care. Patient #12Review of Patient #12’s Hospice Interdisciplinary Plan of Care dated 10/01/2025 revealed Patient #12 was to receive chaplain services once a month. Review of Patient #12’s Updated Plan of Care from admission to 05/06/2026 revealed, in part, the interdisciplinary team was documenting chaplain services were required once a month. Review of Patient #12’s IDG Progress Note dated 10/04/2025 revealed, in part, Patient #12 declined chaplain services. In an interview on 06/04/2026 at 1:40PM, S1Administrator/DON indicated the chaplain failed to communicate Patient #12 wanted to discontinue chaplain services to Patient #12’s nurse case manager so chaplain services could be removed from Patient #12’s plan of care.”

“Based on observation, interviews, and record reviews, the agency failed to ensure the nurse followed infection control standards of practice during a patient’s wound care for 1 (Patient #1) of 1 sampled patients observed for wound care infection control requirements. Findings: Review of the agency’s Personal Protective Equipment policy, with a revision date of January 2005, revealed, in part, disposable gloves would be removed and discarded after contact with each person, fluid item, surface, or when their ability to function as a barrier was compromised. Further review revealed the employee’s hands must be washed immediately after removal of gloves. Review of Patient #1’s physician order dated 05/05/2026 revealed, in part, clean Patient #1’s sacral wound with normal saline or wound cleanser, apply zinc barrier cream to Patient #1’s sacral wound, and cover with a silicone foam dressing once a week and as needed. Observation on 06/02/2026 at 9:06AM, revealed S2Assistant Director of Nursing (ADON) performed a patient assessment, repositioned Patient #1, and then removed the patient’s sacral wound dressing without removing gloves or performing hand hygiene. S2ADON then used the same gloves to assess the wound by using her left gloved finger to press on the wound, cleaned the wound, and then proceeded to apply zinc cream (medicated cream used to protect skin and promote healing). After completing wound care, S2ADON removed her gloves, performed hand hygiene, and applied a clean dressing. In an interview on 06/02/2026 at 9:30AM, S2ADON indicated she should have changed her gloves and performed hand hygiene after touching things in the environment, Patient #1, and between removing the soiled bandage, cleaning the wound, and prior to applying the zinc cream. In an interview on 06/02/2026 at 12:10PM, S1Administrator/Director of Nursing (DON) indicated S2ADON should have followed infection control standards of practice.”

“Based on interviews and record reviews, the agency failed to ensure a registered nurse measured wounds weekly to assess for the healing status of the wound for 2 (Patient #5, Patient #13) of 4 sampled patients reviewed for weekly wound care measurements. Findings: Review of the Wound Ostomy and Continence Nurses Society’s Guidelines revealed the assessment and documentation of wound status included comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Further review revealed comprehensive wound assessment included: dimensions and depth, presence, location and depth of any sinus tracts or undermining areas, status and characteristics of the wound bed, volume, color, and odor of exudates, and evidence of infection in surrounding tissues. Further review revealed when recorded over time, this information can be used to track the progress of wound healing. Patient #5Review of Patient #5’s Nursing Note dated 05/07/2026 revealed, in part, Patient #5 was assessed with redness to Patient #5’s coccyx (area of the upper buttock) and a blister to the right lower extremity. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #5’s Nursing Note dated 05/14/2026 revealed, in part, Patient #5 was assessed with a skin tear to the right shin. Further review revealed no evidence of wound care measurements being obtained. In an interview on 06/04/2026 at 1:30PM, S1Administrator/Director of Nursing indicated the agency was unable to locate documentation of the weekly wound care measurements were obtained for the above mentioned wounds for the above mentioned dates. Patient #13Review of Patient #13’s Nursing Note dated 06/25/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #13’s Nursing Note dated 06/30/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities. Further review revealed no evidence of wound care measurements being obtained. Review of Patient #13’s Nursing Note dated 07/09/2025 revealed scattered blisters to the right arm and bilateral (both) lower extremities and a skin tear to Patient #13’s penis. Further review revealed no evidence of wound care measurements being obtained. In an interview on 06/04/2026 at 1:42PM, S2Assistant Director of Nursing (ADON) indicated she did not realize all wounds needed to be measured weekly, and was under the understanding a registered nurse only had to measure pressure ulcers weekly. S2ADON further indicated Patient #13’s blisters and skin tear were not measured weekly, as required.”