Comprehensive Hospice Care Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical record reviewed revealed the agency did not ensure an initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/11/2024. The hospice consent stated, “ I understand that a registered nurse will case manage all services, and I have accepted the following services: RN or LVN/LPN, Hospice aide, social worker, and chaplain were selected.” However, on the form titled Admission Report, it stated “none” for both the social worker and chaplain frequencies. A social worker (SW) phone call note dated 09/27/2024 stated that the IDG reported the patient presented with signs and symptoms of loneliness and isolation. She called the patient, and the patient is accepting of social worker visits. The Chaplain’s initial visit was done on 10/04/2024 (23 days). CLINICAL RECORD 3: The patient elected the hospice benefit on 05/22/2024. The initial nursing assessment was completed on 05/22/2024, the Social Worker was completed on 05/26/2024, and the Chaplain’s missed visit was completed on 05/30/2024 (8 days) due to the patient refusing services. The clinical record did not contain any other attempts or contacts before 05/30/2024. CLINICAL RECORD 5: The patient elected the hospice benefit on 05/08/2024. The initial nursing assessment was completed on 05/08/2024, the Social Worker assessment was completed on 05/14/2024 (6 days), and the Chaplain’s assessment was declined. During an interview with the administrator (personnel record 6) on 09/18/2025 she stated that she does not know why the visits were not done within the 5 days. She also said that she will provide additional education to the clinical staff on the importance of completing the initial visits within five days.”

“It is required that medical social services are provided by a qualified social worker per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed for patients who had social worker services revealed that the agency did not ensure the social worker provided services per the plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/26/2022 with diagnosis of Alzheimer’s Disease with late onset. The plan of care (POC) dated 03/19/2024 to 05/17/2024 included an order for the social worker frequency at one (1) time a month for two (2) months (1M2). A review of the benefit period 03/19/2025-05/17/2025 did not include any documented evidence that the social worker performed visits as ordered on the POC. During an interview with the administrator (Personnel Record 6) on 09/18/2025 she stated that social worker services had been declined, and the order was present for the following benefit period, but she did not know why it was not done during this benefit period.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed for patients who elected hospice aide services revealed that the agency did not ensure a supervised on-site visit by the registered nurse no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 2: The clinical record review lacked evidence of an aide supervisory visit during every 14 days during the benefit period 07/17/2024 to 09/14/2024. The hospice aide supervisory visits were dated 08/26/2024 and 09/13/2024 (18 days). During an interview with the administrator (Personnel Record 6) on 09/18/2025, she stated that she could not determine why the aide’s supervisory visit was not completed within the 14-day timeframe.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical record reviewed revealed the agency did not ensure physician orders where in the patient’s chart. CLINICAL RECORD 3: The patient’s election of benefits was 05/22/2025 with diagnosis of Malignant Neoplasm of Sigmoid colon. A review of the benefit period dated 05/22/2025-08/19/2025 included a skilled nurse(SN) note dated 07/31/2025. The SN documented Foley catheter 16FR with a drainage bag and irrigation with 60 ml of normal saline every 2 weeks, however there was no documented physician order for the foley catheter. The Foley catheter was inserted on 07/31/2025. There was no documented evidence of a physician order for the foley catheter or irrigation. During an interview with the supervising nurse (Personnel Record 1) on 09/18/2025 she stated she does not know how she missed writing the order, but that she would do a late entry clarification order by the end of the day.”