Comfort Care Hospice

“Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- The comprehensive assessment must take into consideration the following factors; * Complications and risk factors that affect care planning; * Drug profile – A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy; * Drug side effects; and * Actual or potential drug interactions. Findings included: Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- The comprehensive assessment must take into consideration the following factors; * Complications and risk factors that affect care planning; * Drug profile – A review of all the patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy; * Drug side effects; and * Actual or potential drug interactions. Review of the provider’s policy titled, “Initiating/updating care plans (guidelines)”, reviewed 05/05/2025, showed in part:- “Named” hospice staff will initiate hospice care plans in the “named” electronic medical record (EMR) upon admission and will update hospice care plans with each change/update to ensure continuity of care;- The admitting nurse will initiate the hospice care plans in the “named” EMR system; and- “Each visit, the hospice care plans (guidelines) will be updated/changed as necessary in the system and in addition the case manager will be responsible for verifying that care plans have been updated weekly or as changes arise”. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse.Review of the RN initial assessment, dated, 03/12/2025, showed, in part:- The patient had a fall resulting in a fracture to the left hip that required surgery prior to requesting to be placed back on hospice services;- The patient had a “sx dressing vacuum sealed” on the left hip during the comprehensive assessment; - There was an “allyven dressing present” to the patient’s coccyx that was “covering a thin fragile area of skin with one small 0.5cm (centimeter) slit;”- The integumentary assessment showed “sx incision to left hip with clean, dry intact vacuum sealed dressing. Allyven to coccyx for prevention of further skin breakdown from thin fragile skin area”;- The plan of care problems sections of the integumentary assessment showed, “there are no problems to display for this section”; - The patient had edema to bilateral lower extremities; - The patient required assistance with most activities of daily living (ADLs); - Was incontinent of bowel and bladder at times; - The patient had a history of constipation that was treated with Miralax (stool softener); - Appetite was fair; and- Regular diet with thin liquids. Review of the initial POC showed, in part:- Problem of impaired skin integrity identified on 03/12/2025 with interventions to assess for changes in skin integrity, teach and/or demonstrate good preventative skin care, provide/educate on wound care as ordered, and teach and/or encourage repositioning every two (2) hours as tolerated by the patient;- Problem of pain secondary to left hip fracture and repair was identified on 03/12/2025 with interventions to administer pain medication(s) as ordered;- The POC failed to include: * The patient’s diet of regular with thin liquids as noted in the initial assessment * Wound care interventions for the coccyx * Interventions for the patient’s left hip surgical incision * Interventions for edema * Interventions for occasional incontinence of bowel and bladder * The problem of constipation and patient-specific interventions. Review of the Aide care plan, dated 03/12/2025, showed, in part that the patient was to take sponge baths only due to post-op (operation) surgery dressing. The initial POC failed to include post-op interventions and/or orders for the patient to take sponge baths only. Review of the RN skilled nursing visit note, dated 03/14/2025, showed in part, that the patient had requested strawberry ensure and the nurse delivered it to the patient during the visit. Review of the clinical record failed to show an updated POC that showed the patient’s nutritional supplement of ensure with the flavor preference of strawberry. Review of the RN skilled nursing visit note, dated 03/18/2025, showed, in part:- The patient reported “using wedge/ortho boot while s/p L hip fx repair, to prevent legs from crossing”; and- The nurse assessed the patient’s surgical site and there were no signs or symptoms of infection around the dressing (The dressing was not removed to assess the patient’s surgical incision). Review of the clinical record failed to show orders for the use of wedge/ortho boot and/or an updated POC with interventions related to the use of wedge/ortho boot while sleeping. Review of the RN skilled nursing visit note, dated 03/21/2025, showed in part, that the patient was instructed to leave the dressing on until it comes off per discharge instructions. The clinical record failed to show discharge instructions related to the patient’s surgical incision and dressing and the POC failed to include interventions for the surgical site. Review of the Aide care plan, dated 03/21/2025, showed, in part, left hip precautions included, “no adduction, internal rotation, or flexion greater than 90 degree. May ambulate patient in home with use of walker and gait belt”. The clinical record failed to show orders for hip precaution and the POC failed to include left hip precautions and use of a gait belt. Review of a document titled “Skilled nursing SOAP visit, dated 03/22/2025, showed in part: - The “pt/cg called on-call nurse that worked the previous night shift to report they found d/c paperwork from (named) hospital with instructions to remove dressing at doctor’s discretion”; - “PCP (primary care provider) contacted and gave instructions to remove the dressing and assess for sutures/staples that may need removed”;- “PRN (as needed) visit to remove surgical dressing and assess”;- “Dressing removed per PCP’s instructions on this date. Surgical incision site healing well with approximated edges, no surrounding redness/warmth, and no drainage. Education provided to pt on s/s to report, continued activity restrictions, and pt informed (he/she) can now take full shower with assistance”; - The PCP was updated following the dressing removal and no additional orders were received; and - The POC failed to show any activity restrictions. Review of the RN skilled nursing visit note, dated 05/06/2025, showed in part, that the nurse set up the patient’s pillbox for the next week. The POC failed to include interventions for the nurse to fill the patient’s pillbox. During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The POC did not include interventions for the patient’s left hip; - The referral did not contain orders for the left hip surgical site; - He/she informed the admitting nurse prior to the start of care that he/she needed to contact the physician to obtain orders for the left hip; - The admitting nurse never contacted the physician to obtain orders as instructed; - There were not any orders for sponge baths only and that is why the POC did not include that intervention; - The POC failed to include that POC and ensure but should have;- Interventions for bowel and bladder incontinence was not on the POC and should have been; - The patient purchased the wedge and ortho boot on their own and informed the nurse of it after using them but there was not an order received; and - The POC did not include the intervention for the nurse to fill the patient’s pillbox but they (staff) would start adding it to the POC.”

“Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s non-pharmacological interventions to manage pain, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Pain: Assessment, Documentation, Interventions and Follow Up,” reviewed 05/05/2025, showed in part: - To provide on the assessment of pain for all patients by addressing individual needs with respect to acute and chronic pain, initiating appropriate strategies and interventions, providing learning opportunities for staff, patients and families and monitoring and evaluating patient outcomes; - Care Plan; * Include specific goals; * Interventions updated on each visit; * Pharmacological and non-pharmacological interventions; * Medication use documentation; and * Effectiveness of medication use and non-pharmacological interventions. Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse. Review of the registered nurse (RN) skilled nurse (SN) visit note, dated 03/28/2025, showed in part, that instruction was provided for the use of ice as needed to help with pain to the left hip, wrapping the ice in a towel prior to applying, and never to apply the ice directly to the skin. Review of the clinical record failed to show orders for ice treatment. During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - There were not orders for ice treatment; and - He/she didn’t think that they (staff) realized that they had to have orders for ice treatment.”

“Based on job description review, policy review, record review, and interview, the hospice provider failed to ensure a complete, individualized written plan of care (POC) that included all of the patient’s medical equipment in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives. Findings included: Review of the provider’s job description titled, “Registered Nurse (Supervising Nurse),” reviewed 03/12/2025, showed the supervising registered nurse (RN) job functions and responsibilities included, in part:- Maintain open communication with patients, families, physicians, and other team members and the interdisciplinary team to coordinate care;- Collaborate with other healthcare professionals on the interdisciplinary team, including physicians, social worker, and chaplain;- Attend interdisciplinary team meetings to coordinate plan of care; and- Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated. Review of the provider’s policy titled, “Initiating/Updating Care Plans (Guidelines),” reviewed 05/05/2025, showed in part: - The hospice staff will initiate hospice care plans in the electronic medical record (EMR) system upon admission and will update hospice care plans with each change/update to ensure continuity of care; - The admitting nurse will initiate the hospice care plans in the EMR system; - Each visit, the hospice care plans will be updated/changed as necessary in the system and in addition the case manager will be responsible for verifying that care plans have been updated weekly or as changes arise;- the Hospice care plans will be reviewed by the team and/or updated at minimum every 14 days in the system and signed electronically; and- all core services can update the Hospice care plans every 14 days. Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part: - The physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives; and - If the order is not a medication the nurse must document in physician orders under the appropriate order title and in IDG. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse. Review of the medical social worker (MSW) visit note, dated 05/09/2025, showed in part, that a sit to stand lift and an air mattress would be ordered. Review of the clinical record failed to show the medical equipment on the POC. During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The electronic medical record system does not allow medical equipment updates to the POC until the next recertification period; and - He/she would figure out a different way to have the equipment added to the POC.”

“Based on policy review, registered nurse (supervising nurse) job description review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) maintained responsibility for coordinating and supervising the care and services of the patient, in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Respite Care Policy and Procedure,” reviewed 03/05/2025, showed in part the hospice designee will coordinate the transfer of the patient from respite setting to the home care setting at the end of the respite period. Findings included: Review of the provider’s policy titled, “Initiating/Updating Care Plans (Guidelines),” reviewed 05/05/2025, showed that the hospice staff will initiate hospice care plans in the electronic medical record (EMR) system upon admission and will update hospice care plans with each change/update to ensure continuity of care. Review of the provider’s job description titled, “Registered Nurse (Supervising Nurse),” reviewed 03/12/2025, showed the supervising registered nurse (RN) job functions and responsibilities included, in part:- Maintain open communication with patients, families, physicians, and other team members and the interdisciplinary team to coordinate care;- Collaborate with other healthcare professionals on the interdisciplinary team, including physicians, social worker, and chaplain;- Attend interdisciplinary team meetings to coordinate plan of care; and- Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with a primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that has developed in the prostate gland) and resided at home with his/her spouse. Review of a patient communication note dated 04/08/2025, showed in part: - A written prescription for oxycodone was received; and- “Will go ahead and have oxycodone filled as patient will be traveling next week and may not have enough hydrocodone to last until (he/she) gets back home.” Review of the IDG plan of care (POC) failed to show any documentation and/or communication of the patients planned trip to Florida. Review of the routine skilled nurse visit note on 04/18/2025 (11 days after the previous SN visit on 04/07/2025), showed in part: - The patient stated that he/she was taking pain medication every three (3) hours while in Florida; - The patient stated that while he/she was in Florida, he/she had a couple episodes where he/she was walking, became short of breath, and his/her legs became very shaky; and - The patient did not think that he/she would make it back to his/her condo. Review of the clinical record failed to show: - Documentation of communication with the IDG that the patient planned to travel to Florida; - Documentation of when the patient planned to leave and return from Florida; - Documentation that the IDG directed and coordinated the care of the patient while the patient was in Florida; and - Instructions provided to the patient and/or family regarding how to address any issues while the patient was in Florida. During an interview on 05/14/2025 that began at 10:00 AM, the RN coordinator stated that:- The patient went to Florida for five (5) days sometime between the nursing visits on 04/07/2025 and 04/18/2025 but he/she was unsure of the exact dates the patient was gone;- The nursing visits were arranged so the patient wouldn’t miss any nursing visits while away; - The IDG discussed the patient’s plans for travel through (a named messaging system) and during morning meetings, but the discussions were not documented in the patient’s chart; - Medications were provided to ensure that the patient had enough while away; - If the patient was to have any issues while in Florida then he/she would have gone to the ER (emergency room); and- The education that was provided to the patient and spouse was not documented.”

“Based on job description review, policy review, record review, and interview, the hospice provider failed to ensure that the nursing needs of the patient were met as identified in the patient’s initial, comprehensive assessment, and updated assessments, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Job Description,” reviewed 03/12/2025, showed in part:- The supervising registered nurse (RN) is responsible in overseeing the clinical care provided to hospice patients by other nursing staff, including hospice aides, ensuring quality care is delivered according to the patients plan of care, managing staff schedules, coordinating with other healthcare professionals on the interdisciplinary team, and maintaining compliance with regulations, all while providing leadership and guidance with other nursing staff involved in patient care; - Essential job functions/responsibilities; * Delegate tasks to hospice aides; and * Coordinate patient care and referrals, assuring patient needs are continually assessed and individualized plan of care is developed, implemented and updated. Review of the provider’s policy titled, “Comprehensive Assessment,” reviewed 05/05/2025, showed in part:- to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the Hospice patients well-being, comfort and dignity throughout the dying process; - The comprehensive assessment must take into consideration the following factors; * The nature and condition causing admission; * Complications and risk factors that affect care planning; and * The need for referrals and further evaluation by appropriate health professionals. Review of the provider’s policy titled, “Physician Orders,” reviewed 05/05/2025, showed in part the physician order will be documented in the Interdisciplinary Group (IDG) communication this includes medications, treatments, and preventatives. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a primary diagnosis diffuse large B-cell lymphoma (a fast-growing blood cancer that involves changes in your B cells, a particular type of white blood cell called lymphocyte) and resided in an apartment with his/her spouse. Review of the RN initial assessment, dated, 03/12/2025, showed, in part:- The patient had a fall resulting in a fracture to the left hip that required surgery prior to requesting to be placed back on hospice services;- The patient had a “sx dressing vacuum sealed” on the left hip during the comprehensive assessment; - There was an “allyven dressing present” to the patient’s coccyx that was “covering a thin fragile area of skin with one small 0.5cm (centimeter) slit;”- The integumentary assessment showed “sx incision to left hip with clean, dry intact vacuum sealed dressing. Allyven to coccyx for prevention of further skin breakdown from thin fragile skin area”;- The plan of care problems sections of the integumentary assessment showed, “there are no problems to display for this section”; and- The RN failed to show documentation that the left hip dressing was not to be removed in order to assess the incision and there was no documentation that the physician was contacted for orders to remove the dressing to the left hip and assess the surgical site incision. Review of the plan of care failed to show interventions for the left hip surgical site. Review of the clinical record failed to show: - Orders for the surgical incision dressing and assessment included in the referral; - Documentation of the physician being contacted to receive orders for the left hip surgical incision; and - An assessment of the surgical incision from 03/12/2025 to 03/22/2025. During an interview, on 05/14/2025 beginning at 10:00 AM, the RN coordinator stated that: - The referral did not contain orders for the left hip surgical site; - He/she informed the admitting nurse prior to the start of care that he/she needed to contact the physician to obtain orders for the left hip; and - The admitting nurse never contacted the physician to obtain orders as instructed.”

“Based on policy review, record review, and interview, the hospice provider failed to prepare a complete and accurate hospice aide assignment in one of three records reviewed of patient’s that were receiving hospice aide services (Record/Patient #4). This deficient practice has the potential to affect the quality of care of all the provider’s patients who are receiving aide services. Findings included: Review of the provider’s policy titled, “Aide Care Plan,” reviewed 05/05/2025, showed in part the aide is to follow the aide care plan when providing care and update the nursing staff if there are any discrepancies during the visit. Findings included: Review of the provider’s policy titled, “Aide Care Plan,” reviewed 05/05/2025, showed in part:- The aide is to follow the aide care plan when providing care and update the nursing staff if there are any discrepancies during the visit; and- All sections of the aide care plan will be completed that pertain to the patient. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/09/2025 with a terminal diagnosis of inclusion body myositis (a degenerative muscle disease that causes gradual and painless weakening of your muscles). The patient resided in a long-term care facility (LTCF). Review of the aide care plan dated 04/06/2025 showed, in part:- Interventions: provide nail care two times weekly;- Notify nurse if there is any bleeding during cares; and- The aide care plan failed to identify that clipping/trimming the patient’s nails was contraindicated due to the patient being on an anticoagulant (blood thinning medication). During an interview on 05/14/2025 at 10:25 AM the administrator stated that he/she:- Would have expected the aide care plan to be specific about not trimming/clipping the patient’s nails; and- Would have expected all safety precautions to have been on the aide care plan.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite discharge in one of one respite record review (Record/Patient #6). This deficient practice has the potential to affect the coordination of respite care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Respite Care Policy and Procedure,” reviewed 03/05/2025, showed in part the hospice designee will coordinate the transfer of the patient from respite setting to the home care setting at the end of the respite period. RECORD/PATIENT #6:Review of the clinical record showed in part:- The patient was admitted to hospice services on 09/23/2024 with a terminal diagnosis of senile degeneration of the brain (a progressive decline in cognitive abilities that occurs with aging). The patient lived at home with their child, adult grandchild, and a great grandchild;- The patient began inpatient respite services on 10/21/2024 related to caregiver fatigue;- The patient completed five consecutive days of respite care;- The patient was discharged from inpatient respite on 10/25/2024; and- The clinical record failed to contain a discharge summary from the respite facility. During an interview on 05/14/2025 at 10:30 AM, the administrator stated that:- They (hospice provider) did not have a copy of the discharge summary from the inpatient respite provider; - They would expect to receive a discharge summary from the inpatient respite provider at the time of discharge;- It requires a lot of follow-ups to obtain the discharge summary from the respite provider; and- He/she could add that to a checklist to make sure that it would get completed.”