Choice Hospice

“Upon patient record review, 5 of 14 (Patient #1,2,4,5,7) 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: There is evidence in the medical record on the initial nursing comprehensive assessment, the patient has a small open ulcer on the RLE. No care plan with problem/interventions/goals was opened for wound. Patient #2: There is evidence in the medical record on the initial nursing comprehensive assessment, the patient has stage 1 pressure ulcer on coccyx. No care plan with problem/interventions/goals was opened for skin integrity. (Corrected on site by adding skin integrity to the Plan of Care.) Patient #4: There is evidence in the medical record on the initial nursing comprehensive assessment identified patient with a “couple of falls prior to admission with most recent last week with cut over left eye brow”. No care plan with problem/interventions/goals was opened for fall risk. (Corrected on site by adding fall risk to the Plan of Care.) Patient #5: There is evidence in the medical record on the initial nursing comprehensive assessment stating the patient had “no desire to eat”, and primary diagnosis protein calorie malnutrition. No care plan with problem/interventions/goals was opened for nutrition. (Corrected on site by adding nutrition to the Plan of Care.) Patient #7: There is evidence in the medical record on the Medical Director certification of terminal illness stating the patient had “20 lb. weight loss in the past several months, patient eats 25% of meals”. No care plan with problem/interventions/goals was opened for nutrition. (Corrected on site by adding nutrition to the Plan of Care.)”

“Upon patient record review, 2 of 14 (Patient #1,9) 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: There is evidence on the medical record initial nursing comprehensive assessment, the patient had a wound on RLE with a description of the treatment being provided prior to admission, to clean wound with cleanser, apply Medi honey and foam dressing. There was not an order for the wound treatment. Patient #9: There is evidence in the medical record on 3/13/25 an order “clean wound with wound cleanser and apply bandage”. The order did not contain wound location, what bandage, frequency or who would change the bandage.”

“Upon patient record review, 3 of 14 (Patient #4,8,9) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #4: There is evidence in the medical record of a nursing recertification note stating “weight loss since admission” and physician recertification of terminal illness indicates MAC decrease 27 cm to 26 cm. There is no Problem/Interventions/Goals added for nutrition. (Corrected on site by adding nutrition to the plan of care.) Patient #8: There is evidence in the medical record of nursing assessment for recertification identifying “weight loss in past month”, also diet changed to pureed with difficulty chewing. There is no problem/interventions/goals added for nutrition. (Corrected on site by adding nutrition to the plan of care.) Patient #9: There is evidence in the medical record of a new wound identified on 3/13/25 with no problem/interventions/goals added for the wound.”

“Upon patient record review, 2 of 14 (Patient #4,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: There is evidence in the medical of an order 2/27/25 for MSW frequency 1XM and 1 PRN for emotional support. In the month of March MSW visited 1X (3/14/25) and 2 PRN (3/21/25 and 3/27/25). Patient #10: There is evidence in the medical of an order 4/21/25 for MSW frequency 1XM and 1 PRN for emotional support. In the month of May MSW visited 1X (5/21/25) and 2 PRN (5/19/25 and 5/27/25).”

“Upon patient record review, 2 of 14 (Patient #3,7) 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 #3: There is evidence on the aide POC of the task “partial bath/shower” every visit. The aide POC must specify one task for the aide. Patient #7: There is evidence in the medical record the patients diagnosis “convulsions unspecified”. Seizure precautions was not on the aide POC. (Corrected on site by adding seizure precautions to Aide POC.)”

“Upon patient record review 1 of 14 (Patient #8) 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 #8: There is evidence in the medical record of an order 3/17/25, aide 3Xwk. During the week of 4/13/25 the aide visited 4X week and the week of 4/21/24 the aide visited 5X week.”

“Upon patient record review, 2 of 14 (Patient #1,2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: There is evidence in the medical record the election statement did not have a legible, appropriately authenticated nurse’s signature. Patient #2: There is evidence in the medical record the election statement did not have a legible, appropriately authenticated nurse’s signature.”