24/7 Team Care Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The initial nursing assessment dated 06/02/2024 stated the patient had shortness of breath (SOB) and was on oxygen 2 liter per minute via nasal canula, as needed. The POC dated 06/02/2024 had a goal for SOB but lacked intervention(s) for oxygen. Clinical Record 3: The initial social worker assessment dated 04/07/2023 stated the social worker frequency ordered was one time per month. The POCs dated from 04/07/2023 thru 06/12/2024 lacked goal(s) and intervention(s) the social worker was addressing every month. The Administrator/Chief Executive Officer/Licensed Vocational Nurse and the Director of Patient Care Services/Alternate Administrator stated in an interview while performing joint clinical record review on 06/19/2024 that the agency did not ensure the plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed for patients that revoked the hospice benefit revealed the agency did not ensure a copy of the discharge summary was forwarded to the patient’s attending physician. Clinical Record 7: The patient revoked hospice on 01/25/2024 to pursue aggressive treatment with the patient’s primary care provider (PCP). The record lacked evidence of the discharge summary being forwarded to the patient’s PCP. Clinical Record 8: The patient revoked hospice on 01/25/2024 to pursue aggressive treatment with the patient’s PCP. The record lacked evidence of the discharge summary being forwarded to the patient’s PCP. Clinical Record 9: The patient revoked hospice on 11/07/2023 to pursue aggressive treatment with the patient’s PCP. The record lacked evidence of the discharge summary being forwarded to the patient’s PCP. Clinical Record 10: The patient revoked hospice on 09/23/2023 to pursue aggressive treatment with the patient’s PCP. The record lacked evidence of the discharge summary being forwarded to the patient’s PCP. Clinical Record 11: The patient’s family revoked hospice on 08/02/2023 and transferred patient via 911 to the hospital to pursue aggressive treatment. The record lacked evidence of the discharge summary being forwarded to the patient’s PCP. The Administrator/Chief Executive Officer/Licensed Vocational Nurse and the Director of Patient Care Services/Alternate Administrator stated in an interview while performing joint clinical record review on 06/19/2024 that the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician.”