Comfort Care Home Health and Hospice

“Based on interview, document review, and policy review, the hospice agency failed to have volunteer hours that equaled five percent of total patient care hours. This had the potential to cause 22 of 22 active patients to have unmet needs. Findings include:Review of the “Hospice Volunteer Analysis” report, provided by the facility, dated from 07/01/24 to 06/30/25 revealed, “Total Volunteer Hours at 103 hours with an hourly rate at $34.79…” The report documented the “Volunteer Time Percentage” at 4.12%.During an interview on 07/11/25 at 1:00 PM, the Administrator confirmed the volunteer time percentage was below the required 5%. The Administrator stated the agency was active with recruiting events.Review of the policy titled, “Hospice Volunteer Services”, dated July 2025, revealed, “. . . Purpose: to document cost-savings attributable to volunteer services as part of the organizational fiscal stewardship . . . Calculate cost savings using standardized volunteer hourly wages . . .””

“Based on staff interview and document review, it was determined the hospice failed to ensure each patient’s plan of care included an accurate medication profile in two (2) of seven (7) medical records reviewed in the survey sample. Medical record #’s 3 and 7. Seven (7) medical records were reviewed 01/02/24 - 01/03/24. The medical record for patient #3 contained documentation that the nurse applied triple antibiotic ointment to the patient’s wound on 04/03/23. The patient’s medication profile did not contain triple antibiotic ointment. The medical record for patient #7 contained documentation that the nurse applied triple antibiotic ointment to the patient’s peg tube site on 12/24/23. The patient’s medication profile failed to contain triple antibiotic ointment. Staff member #1 confirmed on 01/03/24 that all medications should be listed on the patient’s medication profile.”

“Based on staff interview and clinical record review, it was determined the hospice failed to ensure each patient received care in accordance with the written plan of care established by the interdisciplinary group in four (4) of seven (7) clinical records reviewed in the survey sample. Clinical record #3, 4, 7, 9. Seven (7) medical records were reviewed 01/02/24 - 01/03-24. 1. The medical record for patient #3 contained documentation that nurses provided wound care to the patient’s sacral wound from 03/28/23 - 04/06/23 with no orders for wound care documented in the patient’s plan of care. Orders were documented in the record on 04/06/23 as follows: Right foot heel blister/left foot heel observation. May apply transparent film dressing if needed to keep skin intact. Decubitus/pressure ulcer stage II/inner buttocks gluteal fold. Using aseptic technique, cleanse wound with normal saline or dermal wound cleanser and pat dry with non-sterile gauze. Apply very thin layer of antibiotic ointment. Cover with foam bandage. Wound care to be completed 3 times weekly by skilled nurse and as needed by family for loose or soiled dressings. Prior to 04/06/23 the patient’s record contained no documentation of orders for wound care to either the patient’s heels or the patient’s inner buttocks/sacral wound. The medical record contained documentation that on 04/10/23 the nurse utilized zeroform (a dressing containing 3% Bismuth Tribromophenate in a special petrolatum blend on fine mesh gauze, https://www.cardinalhealth.com/en/product-solutions/medical/skin-and-wound-management/traditional-wound-care/non-adherent-moist-gauze-dressings/xeroform-occlusive-dressing.html) for the patient’s wound. Patient #3’s care plan contained no documented order for a xeroform dressing. 2. The medical record for patient #4 contained documentation that the nurse made an as needed visit on 11/25/23 to troubleshoot problems with the patient’s Foley catheter. The patient’s plan of care failed to contain orders for the catheter. 3. The medical record for patient #9 contained documentation that the nurse drained and provided site care to the patient’s peg tube on 12/28/23. The patient’s plan of care failed to contain orders for site care or draining. 4. The medical record contained documentation that patient #9 had wounds to the shoulder and sacrum. The record contained documentation that the nurse changed the dressings to these wounds on 12/27/23. The patient’s plan of care failed to contain documentation of written orders for the wound care. An interview was conducted with staff member #6 on 01/03/24 who confirmed all orders four wound care and catheter care should appear on the patient’s plan of care. Seven (7) medical records were reviewed 01/02/24 - 01/03-24. 1. The medical record for patient #3 contained documentation that nurses provided wound care to the patient’s sacral wound from 03/28/23 - 04/06/23 with no orders for wound care documented in the patient’s plan of care. Orders were documented in the record on 04/06/23 as follows: Right foot heel blister/left foot heel observation. May apply transparent film dressing if needed to keep skin intact. Decubitus/pressure ulcer stage II/inner buttocks gluteal fold. Using aseptic technique, cleanse wound with normal saline or dermal wound cleanser and pat dry with non-sterile gauze. Apply very thin layer of antibiotic ointment. Cover with foam bandage. Wound care to be completed 3 times weekly by skilled nurse and as needed by family for loose or soiled dressings. Prior to 04/06/23 the patient’s record contained no documentation of orders for wound care to either the patient’s heels or the patient’s inner buttocks/sacral wound. The medical record contained documentation that on 04/10/23 the nurse utilized zeroform (a dressing containing 3% Bismuth Tribromophenate in a special petrolatum blend on fine mesh gauze, https://www.cardinalhealth.com/en/product-solutions/medical/skin-and-wound-management/traditional-wound-care/non-adherent-moist-gauze-dressings/xeroform-occlusive-dressing.html) for the patient’s wound. Patient #3’s care plan contained no documented order for a xeroform dressing. 2. The medical record for patient #4 contained documentation that the nurse made an as needed visit on 11/25/23 to troubleshoot problems with the patient’s Foley catheter. The patient’s plan of care failed to contain orders for the catheter. 3. The medical record for patient #7 contained documentation that the nurse drained and provided site care to the patient’s peg tube on 12/28/23. The patient’s plan of care failed to contain orders for site care or draining. 4. The medical record contained documentation that patient #9 had wounds to the shoulder and sacrum. The record contained documentation that the nurse changed the dressings to these wounds on 12/27/23. The patient’s plan of care failed to contain documentation of written orders for the wound care. An interview was conducted with staff member #6 on 01/03/24 who confirmed all orders four wound care and catheter care should appear on the patient’s plan of care.”

“Based on staff interview and document review, it was determined the hospice failed to ensure each patient’s plan of care included all services necessary for the management of the terminal illness and related conditions in five (5) of seven (7) medical records reviewed in the survey sample. Medical record #’s 2, 3, 4, 7, 9. Additionally, the hospice failed to ensure each patient’s plan of care was individualized in four (4) of seven (7) medical records reviewed. Medical record #’s 6 - 9. Seven (7) medical records were reviewed 01/02/24 - 01/03-24. The medical record for patient #2 contained documentation that the patient had foley and pleurx catheters. The plan of care failed to contain orders for the foley catheter to include the size of the catheter and care of the catheter. The medical record failed to contain documentation of orders for dressing changes or site care to the pleurx site. The medical record for patient #3 contained documentation that nurses provided wound care to the patient’s sacral wound from 03/28/23 - 04/06/23 with no orders for wound care documented in the patient’s plan of care. The medical record for patient #4 contained documentation that the nurse made an as needed visit on 11/25/23 to troubleshoot problems with the patient’s Foley catheter. The patient’s plan of care failed to contain orders for the catheter. Patient #6’s care plan contained a skilled nursing goal documented as follows: patient will remain comfortable. The plan of care was not individualized to contain a personalized pain goal or a description of the goal of “comfort.” The medical record for patient #7 contained documentation that the nurse drained and provided site care to the patient’s peg tube on 12/28/23. The patient’s plan of care failed to contain orders for site care or draining. Patient #7’s care plan reads in part: patient will be pain free or verbalize an acceptable pain level with current pain management regimen. The plan of care was not individualized to contain a patient stated pain goal or what level of pain would be considered “acceptable” to the patient. The medical record for patient #8 contained documentation that the patient was experiencing pain. The plan of care was not individualized to contain a patient stated pain goal or what level of pain would be considered acceptable to the patient. The medical record contained documentation that patient #9 had wounds to the shoulder and sacrum. The record contained documentation that the nurse changed the dressings to the wounds on 12/27/23. The patient’s plan of care failed to contain documentation of written orders for the wound care. Patient #9’s care plan contained a skilled nursing goal documented as follows: patient will remain comfortable. The plan of care was not individualized to contain a personalized pain goal or a description of the goal of “comfort.” An interview was conducted with staff member #1 on 01/03/24 who confirmed all orders and supplies should be listed on the plan of care.”

“Based on staff interview and document review, it was determined the hospice failed to ensure each patient’s plan of care failed to include measurable outcomes using data elements in seven (7) of seven (7) medical records reviewed in the survey sample. Medical record #’s 2, 3, 4, 6, 7, 8 and 9. Seven (7) medical records were reviewed in the agency 01/02/24-01/03/24. All of the clinical records reviewed failed to contain documentation of measurable outcomes anticipated from implementing the plan of care. Staff member #2 acknowledged the lack of measurable outcomes on the patients’ plans of care on 01/03/24.”

“Based on staff interview and document review, it was determined the hospice failed to ensure each patient’s plan of care was updated as frequently as the patient condition required in one (1) of seven (7) medical records reviewed in the survey sample. Medical record # 6. Seven (7) medical records were reviewed in the hospice 01/02/24-01/03/24. The medical record for patient #6 contained documentation that the patient had a prn visit by the nurse on 12/27/23 to address new onset dyspnea. The nurse notified the nurse practitioner who ordered oxygen via nasal canula at 2 L as needed for shortness of breath. The hospice’s interdisciplinary group meeting on 12/28/23 documented discussion regarding the patient’s dyspnea, however the patient’s plan of care was not updated with interventions for newly reported symptoms. Staff member #2 confirmed on 01/03/24 that patient #6 plan of care had not been updated when the patient’s condition changed.”