A Care Hospice Inc.

“Upon patient record review, 1 of 14(Patient #5) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 5: The medical record contained RN visits 9/2/23, 10/9/23, and 11/4/23. There was no evidence of continuous oversight and assessment by the RN.”

“Upon patient record review, 1 of 14 (Patients #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 4: The medical record contained documentation identifying an order for nystatin oral medication was received 2/12/22 upon request from the patient’s daughter. There was no evidence of an assessment by the RN and no assessment for effectiveness of the medication. The record also contained documentation of IV fluid administration 2/6/22 and 2/7/22. There was no evidence of an assessment by the RN to examine the IV site and patient tolerance of the fluids, and no documentation of IV removal.”

“Upon patient record review, 5 of 14 (Patients #1,#2,#8,#9,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contained nursing documentation 11/5/23 identifying patient requires thickened liquids for aspiration precautions and the patient also was receiving spiritual care visits by the chaplain. There was no evidence of problems, goals, and interventions related to risk for aspiration and spiritual care. Corrected on site. Patient 2: The patient was receiving spiritual care visits. There was no evidence of problems, goals, and interventions related to spiritual care. Corrected Patient 8: The patient was receiving social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care. Patient 9: The patient was receiving social work visits. There was no evidence of problems, goals, and interventions related to psychosocial care. Patient 10: The patient was receiving social work and spiritual care visits. There was no evidence of problems, goals, and interventions related to psychosocial and spiritual care.”

“Upon patient record review, 3 of 14 (Patients #1,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained orders for A&D and Calmoseptine topical ointments with no area defined for administration, and an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 3: The medical record contained an order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medical record contained an order for oxygen with no delivery method.”

“Upon client record review, 5 of 14 (Patients #2,#3,#4,#5,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an ordered social work visit frequency of one visit every recert. There was no evidence of social work visits since 3/31/23. Patient 3: The medical record contained an ordered spiritual care visit frequency of one visit every recert. There was no evidence of a spiritual care visit during benefit period 3. Patient 4: The medical record contained an ordered nursing frequency of once weekly. There were 2 visits completed the weeks of 1/15/22, 1/29/22, and 2/5/22. There was no evidence of an ordered spiritual care frequency. There was one spiritual care visit completed 2/18/23. Patient 5: The medical record contained an ordered spiritual care visit frequency of one visit every recert. There was no evidence of a spiritual care visit between 3.13.23 and 10.11.23 Patient 6: The medical record contained an ordered nursing frequency of once weekly. There were 2 visits completed each week of October 2023.”