Moments Hospice of Chicago North LLC

“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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care identified interventions based on problems identified in the updated comprehensive assessments. Clinical Record 13: The patient elected hospice care on 05/22/2023 with a diagnosis of cerebral infarction. The patient resided in a SNF. The RN comprehensive assessment completed by the Registered Nurse (RN) dated 06/22/2024 documented a coccyx wound, stage IV, with a wound onset date of 10/18/2023. The physician’s narrative for the recertification period 11/18/2023 to 01/16/2024 documented “new decubitus ulceration.” Physician orders for wound care were initiated on 10/18/2023 for “Medihoney” three (3) times per week. MetroCream 0.75% topical cream three times per week was added on 11/18/2023 and cleansing with Dakin solution was added on 01/24/2024. Weekly wound assessments had been documented since 10/18/2023, with a decrease in the wound size. The plans of care, effective 10/18/2023 to current, included documentation of the medication/wound treatment orders. The plans of care did not include documentation of problems, goals, or non-pharmacological interventions related to skin breakdown or wounds. During an interview and a joint record review on 06/27/2024, the Clinical Manager and the Vice President of Clinical/Quality confirmed that the wound care had been documented, but “the wound problem was not added to the care plan.””

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received specific patient care instructions from the Registered Nurse (RN). Clinical Record 3/Home Visit 3: The patient elected hospice on 11/26/2022 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). For the current benefit period, dated 05/19/2024 to 07/17/2024, the HA care plan assigned the HA the relevant task to transfer the patient “with one assist.” During the home visit on 06/26/2024, the HA stated that the patient was transferred using a mechanical Hoyer lift. The RN narrative note dated 05/22/2024 documented that the patient was to be transferred to bed with a Hoyer lift. The HA care plan did not assign the HA to utilize the mechanical lift. The HA stated they had used the mechanical Hoyer lift to transfer the patient during personal care. Clinical Record 11: The patient elected hospice care on 03/27/2024 with a diagnosis of anoxic brain damage. The patient resided in a SNF. On 04/26/2024, the physician ordered, “Insert Foley catheter to help reduce skin breakdown.” The HA care plan had noted revisions documented on 05/01/2024 and 06/21/2024 that assigned the HA the relevant tasks to perform bed baths and peri-care with each visit. The HA care plan did not address the Foley catheter or if the HA was to perform catheter care. On 06/25/2024, the HA care plan was revised to include catheter care as a task for the HA to complete at each visit. During an interview and a joint record review on 06/26/2024, the Clinical Manager and the Vice President of Clinical/Quality agreed the aide care plans should have included the Hoyer lift and the catheter care. They reported that the RN had updated them now.”

“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, interview, and observation. In 1 of 19 (5%) clinical records reviewed of patients receiving Hospice Aide (HA)services, the agency did not ensure that the Hospice Aides provided services included in the plan of care. Clinical Record 3/Home Visit 3: The patient elected hospice on 11/26/2022 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). For the current benefit period, dated 05/19/2024 to 07/17/2024, the HA care plan assigned the HA the relevant task to transfer the patient “with one assist.” During the home visit on 06/26/2024, the HA stated that the patient was transferred using a mechanical Hoyer lift. The Registered Nurse (RN) narrative note dated 05/22/2024 documented that the patient was to be transferred to bed with a Hoyer lift. The HA stated they had used the Hoyer lift to transfer the patient. The HA care plan did not assign the HA to utilize the mechanical Hoyer lift. During an interview and a joint record review on 06/26/2024, the Clinical Manager and the Vice President of Clinical/Quality (VP) agreed that the record contained multiple entries by the RN that reported the Hoyer lift was used for transfers and agreed the aide had been performing this task without it being included in the plan of care. The RN updated the HA care plan to use the lift for transfers.”