Oasis Healthcare - Moody

“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. In 8 of 19 (42%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 10: The patient elected the hospice benefit on 12/07/2023 with a terminal diagnosis of cerebral vascular accident (CVA). The plan of care (POC) dated 12/07/2023 identified the patient’s problem: “Altered comfort.” The POC documented the patient’s goal: “(Patient/Caregiver) Pt/Cg understands the pain scale, how to manage pain, and report changes to hospice.” The goal did not include a measurable outcome for managing and reporting the patient’s pain. Clinical Record 11: The patient elected the hospice benefit on 9/09/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The POC dated 09/09/20/23 identified the patient’s problem: “Altered Respiratory Status.” The POC documented the patient’s goal: “(Patient’s) Pt’s respiratory symptoms will be managed.” The goal did not include a measurable outcome for managing the patient’s respiratory symptoms. Clinical Record 12: The patient elected the hospice benefit on 09/29/2023 with a terminal diagnosis of amyotrophic lateral sclerosis (ALS). The POC dated 09/29/2023 identified the patient’s problem: “Altered Respiratory Status.” The POC documented the patient’s goal: “Pt’s respiratory symptoms [sic] is stabilized.” The goal did not include a measurable outcome for stabilizing the patient’s respiratory symptoms. Clinical Record 13: The patient elected the hospice benefit on 02/27/2024 with a terminal diagnosis of hypertensive chronic kidney disease. The POC dated 02/27/2023 identified the patient’s problem: “Altered Genitourinary Status.” The POC documented the patient’s goal: “Pt’s genitourinary symptoms will be managed.” The goal did not include a measurable outcome for managing the patient’s genitourinary symptoms. Clinical Record 14: The patient elected the hospice benefit on 03/01/2023 with a terminal diagnosis of acute respiratory failure. The POC dated 03/01/2023 identified the patient’s problem: “Altered Respiratory Status.” The POC documented the patient’s goal: “Pt’s respiratory symptoms [sic] is stabilized.” The goal did not include a measurable outcome for stabilizing the patient’s respiratory symptoms. Clinical Record 17: The patient elected the hospice benefit on 02/06/2023 with a terminal diagnosis of Parkinson’s Disease. The POC dated 02/06/2023 identified the patient’s problem: “Alteration Respiratory Status.” The POC documented the patient’s goal: “Pt’s respiratory symptoms will be managed.” The goal did not include a measurable outcome for managing the patient’s respiratory symptoms. Clinical Record 18: The patient elected the hospice benefit on 07/31/2023 with a terminal diagnosis of Alzheimer’s Disease. The POC dated 07/31/2023 identified the patient’s problem: “Alteration in comfort pain.” The POC documented the patient’s goal: “Pt’s pain will be managed.” The goal did not include a measurable outcome for managing the patient’s pain. Clinical Record 19: The patient elected the hospice benefit on 02/19/2024 with a terminal diagnosis of COPD. The POC dated 02/19/2024 identified the patient’s problem: “Alteration Respiratory Status.” The POC documented the patient’s goal: “Pt’s respiratory symptoms will be managed.” The goal did not include a measurable outcome for managing the patient’s respiratory symptoms. During a joint record review and interviews on 09/10/2024, the Executive Director confirmed that the written plans of care were not individualized to include measurable outcomes.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed with Hospice Aide (HA) services provided, the agency did not ensure the HA provided services included in the care plan. Clinical Record 1: The patient elected the hospice benefit on 11/29/2022. The HA care plan dated 09/01/2024 assigned the HA the relevant task of shampooing the patient’s hair weekly. The HA visit notes dated 09/04/2024 and 09/06/2024 documented that the HA shampooed the patient’s hair. There was no evidence that the HA care plan was changed. During a joint record review and interview on 09/10/2024, the Executive Director confirmed that the HA did not follow the care plan.”

“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. In 3 of 17 (18%) clinical records reviewed with Hospice Aide (HA) services provided, the agency did not ensure the Hospice Aide reported changes in the patient’s care needs to the Registered Nurse (RN). Clinical Record 1: The patient elected the hospice benefit on 11/29/2022. The HA care plan dated 09/01/2024 assigned the HA to shampoo the patient’s hair weekly. The HA visit notes dated 09/04/2024 and 09/06/2024 documented that the HA shampooed the patient’s hair. A clinical record review revealed no evidence that the HA notified the Registered Nurse (RN) of the change in the patient’s needs related to the HA care plan. Clinical Record 2: The patient elected the hospice benefit on 08/30/2024. The HA care plan dated 09/01/2024 assigned the HA the relevant tasks: bed bath, hair care, skin care, and oral care. On 09/4/2024, the HA visit note documented that no tasks were completed. A clinical record review revealed no evidence that the HA notified the RN of the change in the patient’s needs related to the HA care plan. Clinical Record 3: The patient elected the hospice benefit on 08/1/2024. The HA care plan dated 08/01/2024 assigned the HA the relevant tasks: tub bath, shampoo, skincare, and perineal care every visit. On 08/4/2024, the HA visit note documented that the patient refused care. A clinical record review revealed no evidence that the HA notified the RN of the change in the patient’s needs related to the HA care plan. During a joint clinical record review and interview on 09/10/2024, the Executive Director confirmed the Hospice Aide did not report changes in the patient’s care needs to the RN.”