Ability Hospice

“Upon patient record review, 1 of 14 (Patient #6) 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#6: There is no evidence of an RN visit made between 09/23/24- 10/21/24.”

“Upon patient record review, 5 of 14 (Patient #1,#2,#3,#4,#7) 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 RN documents patient has ongoing issues with vascular dementia a co morbidity, is on oxygen and requires daily meds for constipation as well as take diarrhea medication twice a week. There is no evidence of problems with goals and interventions related to these issues. Corrected on site. Patient#2: The record indicates patient is receiving spiritual services. There are no problems, goals, or interventions on plan of care for these services. Corrected on site. Patient#3: The record indicates patient take Eliquis daily. There is no evidence of bleeding precaution on plan of care. Also, this patient is receiving spiritual and psychosocial services. There is no evidence of problems, goals, or interventions related to these services on plan of care. Corrected on site. Patient#4: The record indicates patient is receiving spiritual and psychosocial services. There is no evidence of problems, goals, or interventions related to these services on plan of care. Corrected on site. Patient#7: Documentation on IDG 12/17/24 states a glucometer, lancets, and strips were ordered for patient who is NIDDM. The same IDG note also states patient has an unstageable wound to right heel. There is no evidence of problems, goals, or interventions related to these issues on plan of care.”

“Upon patient record review, 2 of 14 (Patient #1,#5) 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 record indicates patients terminal diagnosis was changed to protein mal-nutrition on 3/18/25. There is no evidence of an order for change in diagnosis in record. Corrected on site. Patient#5: The record indicates that patient has an order for wound care. However, the order does not specify who is responsible for wound care. Patient resides in board and care home. Corrected on site.”

“Upon client record review, 2 of 14 (Patient #1,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1: The record indicates patient was out of town 04/11/25-04/14/25 on travel contract. There is no evidence of an order to discontinue visits this week. There is no documentation of any visit completed by this agency or travel agency for this week. Patient#9: The record indicates SN frequency is ordered at one time per week. There is no evidence of SN visit for week of 6/30, 7/14, and week of 7/27/24.”

“Upon patient record review, 1 of 14 (Patient #9) did not have evidence that Social work services are based on the patient’s psychosocial assessment and the patient/family’s needs and acceptance of these services. Patient#9: The RN documented on the initial IDG on 6/14/24 that she would refer to MSW for assistance with poor living conditions. She documents that the living environment smells like trash or vomit. There are small children in the home, with a young girl laying on the couch in the room with a bad, harsh, cough. There is no evidence of documentation of any follow up on the situation by MSW or other team member.”

“Upon patient record review, 2 of 14 (Patient #1,#3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: RN admit documentation indicates patient requires aspiration precautions, bleeding precautions, and is legally blind. There is no indication of aspiration precautions, bleeding precautions, or patient being legally blind on the aide plan of care. Corrected on site. Patient#3: The record indicates the patient takes Eliquis daily. There is no evidence of bleeding precautions on the aide plan of care. Corrected on site.”

“Upon patient record review 3 of 14 (Patient #1,#2,#4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The record indicates the aide frequency is ordered at 2 times per week. The week of 4/13/25 there is only one documented visit. There is no evidence of an order for missed visit or to reduce visit frequency for this week. Patient#2: The record indicates an order was entered on 4/24/25 to increase aide frequency to 3 times per week. However, the aide continued to be scheduled 2 times per week until 5/5/25. Patient#4: On the aide visit for 5/2/25 the aide documented completing task that are no assigned on the aide plan of care. Unassigned task completed include colostomy care, turn and position, toileting, catheter care, and measure urinary output. On aide visit 4/18/25 the aide documents not completing the following task that were assigned for every visit: fall precautions, peri care, encourage fluids, mental status, oxygen precautions, and housekeeping including change linens, tidy room empty trash.”