Care Comfort Hospice, LLC

“Based on review of clinical records (CR), agency developed plan of correction, hospice policies, hospice complaint tracking, and staff interviews, the hospice failed to investigate all alleged violations in accordance with established agency procedure for one (1) five (5) CR reviewed (CF 2). Findings included:Review of Hospice policy on 8/25/25 at approximately 10:30am revealed:”...Grievance/Complaint Procedure...Additionally, patients and loved ones will be encouraged to voice their grievances to the hospice staff so their concerns can be addressed on a prompt and timely basis...Procedure, Th following is the internal protocol regarding receipt of a grievance: 1. The staff member who receives a concern or grievance, is to immediately attempt to resolve the issue if it is within their ability/scope of knowledge or authority to do so and document the concern or outcome and inform that document to the Patient Care., 2. Administrator, The appropriate IT members will be notified of the concern or grievance and its outcome., 3. If the staff member is unable to resolve the concern, or if the concern is serious in nature, the grievance is referred to their supervisor within 2 working days of its occurrence., 4. The supervisor will initiate investigations of the issue within 2 working days of receipt of the grievance and attempt to resolve it if it is within their ability/scope of knowledge or authority to do so. The supervisor will document their investigation and outsomce.,5. If there is no resolution and/or the concerned is not satisfied, the grievance is referred immediately to the next highest level of management for investigations/resolution., 6. The supervisor will initiate an investigation into the grievance within 2 working days of receipt of the grievance., 7. Throughout the grievance/complaint procedure, the patient and family will be involved in the decision-making process through mutual discussion, problem solving, and resolution of the issue, as appropriate., 8. All actions taken to resolve the issue will be documented and kept on file. The patient Care Administrator will maintain all documentation...”Review of complaint form on 8/25/25 at approximately 10:45am revealed date and time of complaint received by agency to be 8/11/25 at 9:55pm. Attached to the agency complaint form was an email dated 8/11/25 at 9:55pm from the complainant to the agency owner stating multiple concerns, including supplies, medications, and staff visits/interventions. Two days later, 8/13/25, at 5:15pm, the email was forwarded from the owner to the Administrator requesting, “please review, put in complaint binder and complete follow up...” Email from clinical director 8/13/25 at 6:10pm to owner and administrator providing Clinical Manager understanding of each concern. The complaint failed to include investigation, resolution, or follow up. The concern was originally received by the owner and no follow up or resolution documented within 2 working days, per agency policy. No documentation that the patient and family were involved in the decision-making process through mutual discussion, problem solving, and resolution of the issue, per agency policy. Exit interview with Administrator, Clinical director, and Registered Nurse on 8/24/25, at approximately 4:00pm confirmed findings.”

“Based on review of clinical records (CR), and staff interviews, the hospice failed to provide services only as ordered by a physician for one (1) of five (5) CR reviewed (CR 2). Findings included: CR review conducted on 8/25/25 at approximately 2:00pm revealed: CR2, start of service (SOS) 5/9/23, benefit period reviewed 6/27/25-8/25/25. Plan of Care (POC) included skilled nurse frequency of 1week8, effective 6/29/25 and an aide frequency of 1week1, 4week1, 5week7, 1week 1 effective 6/27/25. CR revealed 3 aide visits conducted the week of 7/20/25-7/26/25, 1 visit less than expected frequency. The week of 8/10/25-8/16/25 3 aide visits conducted, 2 visits less than expected frequency. The week of 8/17/25-8/23/25, no skilled nurse visits conducted, 1 visit less than expected frequency.interview with Clinical Director on 8/25/25 at approximately 2:15pm confirmed the aide called off 8/11/25 and 8/12/25 and there was no replacement or communication to patient/family. Exit interview with Administrator, Clinical director, and Registered Nurse on 8/24/25, at approximately 4:00pm confirmed findings.”

“Based on review of clinical records (CR) and staff interviews, the hospice failed to ensure the Plan of Care (POC) included the medical supplies and appliances necessary to meet the needs of the patient for five (5) of five (5) CR reviewed (CR 1-5). Findings included: CR review conducted on 8/25/25 at approximately 2:00pm revealed: CR1, start of service (SOS) 7/30/25, benefit period reviewed 7/30/25-10/27/25. Plan of Care (POC) documentation stated “None” for DME (durable medical equipment) and Supplies. Review of patient record revealed incontinent supplies needed.CR2, SOS 5/9/23, benefit period reviewed 6/27/25-8/25/25. POC documentation stated “None” for DME and Supplies. Review of patient record revealed oxygen concentrator and supplies, catheter supplies, incontinent supplies, nebulizer machine and supplies, suction machine and supplies, and wound care supplies needed. CR3, SOS 8/5/25, benefit period reviewed 8/5/25-11/2/25. POC documentation stated “None” for DME and Supplies. Review of patient record revealed oxygen concentrator and supplies, catheter supplies needed.CR4, SOS 6/10/25, benefit period reviewed 6/10/25-8/8/25. POC documentation stated “None” for DME and Supplies. Review of patient record revealed oxygen concentrator and supplies, incontinent supplies, and nebulizer machine and supplies needed.CR5, SOS 8/14/25, benefit period reviewed 8/14/25-11/11/25. POC documentation stated “None” for DME and Supplies. Review of patient record revealed incontinent supplies needed. Exit interview with Administrator, Clinical director, and Registered Nurse on 8/24/25, at approximately 4:00pm confirmed findings.”

“Based on a review of personnel files (PF), agency policies, and employee interview, the agency failed to follow agency staff Competency Program for three (3) of seven (7) PF reviewed (PF 2, 5, & 7). Findings included: Review of agency policy on 8/25/25 at approximately 12:30pm revealed:”Staff Competency Program...PURPOSE, To define the staff competency program...PROCEDURE, 1. Patient care staff will be competency assessed at defined intervals: For each new employee 9including contract employees) during orientation...3. Hospice has established competency criteria for each job category. Qualified individuals will observe the employee during competency evaluation. The competency evaluation checklist will be completed and retained in the employee’s record. PF review conducted on 8/25/25 at approximately 11:30am revealed: PF2, date of hire (DOH) 7/14/25, failed to include evidence of Initial Competency.PF5, DOH 5/6/25, failed to include evidence of Initial Competency.PF7, DOH6/30/25, failed to include evidence of Initial Competency. Exit interview with Administrator, Clinical director, and Registered Nurse on 8/24/25, at approximately 4:00pm confirmed findings.”

“Based on review of agency policy/procedure, clinical records (CR) and staff interviews, the hospice failed to ensure that each patient’s record included clinical notes for one (1) of five (5) CR reviewed (CR 2). Findings included: Review of agency policy on 8/25/25 at approximately 3:00pm revealed:”Timely Submission of patient Documentation, POLICY, Hospice will ensure timely and proper submission of patient documentation...PROCEDURE...2. Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding 3 business days...” CR review conducted on 8/25/25 at approximately 2:00pm revealed: CR2, start of service (SOS) 5/9/23, benefit period reviewed 6/27/25-8/25/25. Cr contained evidence of a narrative not dated 8/23/25. No skilled nursing note in CR to document visit 8/23/25. interview with Clinical Director 8/25/25 at approximately 2:15pm stated “there was no visit made 8/23/25. I (Clinical Director) made a visit 8/18/25.” No documentation in CR of a visit conducted 8/18/25. Clinical Director reports that documentation has not been submitted yet, as of 8/25/25, 7 day/5 business days later. Exit interview with Administrator, Clinical director, and Registered Nurse on 8/24/25, at approximately 4:00pm confirmed findings.”