Springhill Home Health and Hospice

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. Agency policy #9-017.1 “Plan of Care.” (reviewed 05/15/2020) stated in part, “The written plan of care will contain, but not limited to, measurable outcomes anticipated from implementing and coordinating the plan of care.” In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that the patient’s individualized plan of care (POC) included measurable outcomes from implementing and coordinating the plan of care (POC). Clinical Record 1: The patient elected the hospice benefit on 06/22/2024 with a diagnosis of senile degeneration of the brain. The initial comprehensive assessment documented the problem of “alteration in comfort.” The POC dated 06/22/2024 documented the patient’s goal: “Patient (Pt)/caregiver (cg) understand the cause of pain.” The goal statement did not include a measurable outcome. Clinical Record 2: The patient elected the hospice benefit on 01/05/2024 with a diagnosis of congestive heart failure (CHF). The initial comprehensive assessment identified the problem of “altered respiratory status.” The POC dated 01/05/2024 documented the patient’s goal: “Respiratory status will be stabilized.” The goal statement did not include a measurable outcome. Clinical Record 3: The patient elected the hospice benefit on 02/27/2024 with a diagnosis of chronic pulmonary disease (COPD). The initial comprehensive assessment documented the problem of “altered respiratory status.” The POC dated 02/27/2024 documented the patient’s goal: “Respiratory status will be stabilized.” The goal statement did not include a measurable outcome. Clinical Record 4: The patient elected the hospice benefit on 11/29/2023 with a diagnosis of atherosclerosis of coronary artery bypass and graft without angina pectoris. The initial comprehensive assessment documented the problem of “alteration in comfort.” The POC dated 11/29/2023 documented the patient’s goal: “Patient will have minimal problems with respiratory comfort.” The goal statement did not include a measurable outcome. Clinical Record 6: The patient elected the hospice benefit on 08/15/2023 with a diagnosis of atherosclerosis heart disease. The initial comprehensive assessment documented the problem of an “altered circulatory system.” The POC dated 08/15/2023 documented the patient’s goal: “Cardiac exacerbation is identified and minimized.” The goal statement did not include a measurable outcome. Clinical Record 9: The patient elected the hospice benefit on 04/11/2024 with a diagnosis of liver cell carcinoma.” The initial comprehensive assessment documented the problem “need for decubitus care.” The POC dated 04/11/2024 documented the patient’s goal: “Pt/cg verbalizes tolerance to decubitus care.” The goal statement did not include a measurable outcome. Clinical Record 16: The patient elected the hospice benefit on 07/14/2022 with a diagnosis of COPD. The initial comprehensive assessment documented the problem of “altered respiratory status.” The POC dated 07/14/2022 documented the patient’s goal: “Respiratory status will be stabilized.” The goal statement did not include a measurable outcome. Clinical Record 17: The patient elected the hospice benefit on 08/11/2023 with a diagnosis of Parkinson’s disease. The initial comprehensive assessment documented the problem “need for observation and assessment of altered comfort.” The POC dated 08/11/2023 documented the patient’s goal: “Pt/cg understand the pain scale and report changes to hospice.” The goal statement did not include a measurable outcome. During interviews and joint record reviews on 08/21/2024 and 08/22/2024, the Director of Clinical Operations confirmed the patients’ plans of care did not include goals with measurable outcomes.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. Agency policy # 9-020.2, “Plan of Care” (revised 01/2020), stated in part, “Hospice aide must report changes in the patient’s medical, nursing, rehabilitative, and or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities.” In 2 of 9 (22%) clinical records reviewed of patients that received Hospice Aide services, that agency did not ensure that the Hospice Aide reported changes related to the plan of care to the Registered Nurse (RN). Clinical Record 1: The patient elected hospice care on 06/22/2024. The HA care plan dated 06/22/2024 assigned the HA the relevant tasks to shave the patient and provide oral care every visit. The HA documented that the caregiver completed the tasks in the HA visit notes dated 06/22/2024 and 06/25/2024. There was no documented communication with the RN regarding the changes related to the HA care plan. Clinical Record 3: The patient elected hospice care on 02/27/2024. The HA care plan dated 02/27/2024 assigned the HA the relevant tasks to shower and shampoo the patient’s hair every visit. The HA documented that the caregiver completed the tasks in the HA visit notes dated 02/29/2024 and 05/05/2024, the HA documented that the caregiver completed the tasks. There was no documented communication with the RN regarding the changes related to the HA care plan. During an interview and a joint clinical record review on 08/21/2022, the Director of Clinical Operations confirmed that the HA did not inform the RN about changes to the HA care plan for the visits.”