St Claire Hospice/Palliative Care

“Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included outcome measures for specific care activities. For example, during a review of the medical record for HosRRHV#1, the following was identified: 1) The plan of care included the following goal statement: “Patient will achieve and maintain regular bowel elimination and skin integrity”. The goal statement did not include a method to measure the effectiveness of problem interventions. 2) The falls risk assessment indicated the patient was at risk for falls. During an interview, the patient’s caregiver stated the patient had experienced a fall during week 1 of the 2nd benefit period. The plan of care was not updated with a goal statement to evaluate the response to care, treatment and services related to fall prevention interventions. 3) During week 3 of the 1st benefit period, an updated comprehensive assessment documented the presence of moderate pain at the buttocks. The plan of care did not include a goal statement to evaluate the response to care, treatment, and services related to pain management. Example #2: During a review of the medical record for HosRRHV#2, it was noted that the patient’s primary diagnosis was Idiopathic normal pressure hydrocephalus. The plan of care did not include outcome measures related to the care, treatment, and services of the patient’s primary diagnosis disease process. Example #3: During a review of the medical record for HosRRHV#3, it was noted that the patient’s primary diagnosis was Protein Calorie Malnutrition. The plan of care did not include outcome measures related to the care, treatment, and services of the patient’s primary diagnosis disease process. Example #4: During a review of the medical record for HosRRNHV#5, an updated comprehensive assessment documented the presence of pain at the stomach area. The plan of care did not include outcome measures related to pain management. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice and the Director of Home Health and Hospice.”

“Observed in Record Review. In 4 of 14 patient records reviewed, it was noted that the organization did not ensure the plan of care was revised when the patient’s condition changed. For example, a review of the medical record for HosRRHV#1, revealed that the falls risk assessment indicated the patient was at risk for falls. During an interview, the patient’s caregiver stated the patient had experienced a fall during week 1 of the 2nd benefit period. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. In addition, during week 3 of services an updated comprehensive assessment documented the presence of moderate pain at the buttocks. The plan of care did not include interventions related to pain management. 

Example #2: In 1 of 14 patient records reviewed, it was noted that the plan of care did not include interventions based on problems identified in the comprehensive assessment. For example, during a review of the medical record for HosRRHV#2, it was noted that the patient’s primary diagnosis was Idiopathic normal pressure hydrocephalus. The plan of care did not include interventions related to the care, treatment, and services of the patient’s primary diagnosis disease process. 

Example #3: During a review of the medical record for HosRRHV#3, it was noted that the patient’s primary diagnosis was Protein Calorie Malnutrition. The plan of care did not include interventions related to the care, treatment, and services of patient’s primary diagnosis disease process. 

Example #4: During a review of the medical record for HosRRNHV#5, an updated comprehensive assessment documented the presence of pain at the stomach area. The plan of care did not include interventions related to pain management. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice and the Director of Home Health and Hospice.


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“Observed in Record Review. In 1 of 5 patient records reviewed, for patient’s receiving Hospice Aide services, it was noted that the organization did not ensure the plan of care included orders for Hospice Aide services. For example, a review of the medical record for HosRRHV#2, revealed that the Hospice Aide was visiting the patient two times per week, starting week 1 of hospice services. The plan of care did not include a description of visit frequency for hospice aide services. This observation was reviewed with the Assistant Director of Hospice/Quality and Compliance Hospice.”

“Observed in Record Review. In 1 of 5 patient records reviewed, for patients receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide supervision was effective. For example, during the review of the medical record for HosRRHV#2, it was noted that a Hospice Aide supervision visit was not documented by the Registered Nurse every 14 days during the first benefit period. The first supervision visit was documented during week 6 of hospice services. This observation was reviewed with the Director of Home Health and Hospice. 

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“Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not ensure that the requirement for a written Certification of Terminal Illness statement was implemented. For example, a review of the medical record for HosRRHV#1, revealed that a CTI statement for benefit period #2 was not present in the medical record. The 2nd benefit period of hospice services started 12 days before the start of survey activities. Documentation to support the medical prognosis and recertification of hospice services was not present in the medical record. This observation was reviewed with the Director of Home Health and Hospice.”