Acg Hospice

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 12 of 19 (63%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected hospice care on 03/06/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD). On admission the nursing comprehensive assessment documented “altered cardiopulmonary status.” The POC documented the patient’s goal “Patient exhibits reduction/relief of any cardiopulmonary symptoms.” This goal did not document a measurable outcome. Clinical Record 2: The patient elected hospice care on 06/11/2024 with a primary diagnosis of diffuse traumatic brain injury (TBI) with (W) loss of consciousness (LOC) of unspecified (UNSP) duration sequela. On admission the nursing comprehensive assessment documented “Safety Needs.” The POC documented the patient’s goal “Pt/cg will verbalize, demonstrates understanding of proper safety measures.” This goal did not document a measurable outcome. Clinical Record 3: The patient elected hospice care on 09/20/2023 with the diagnosis of encephalopathy Unspecified. On admission the nursing comprehensive assessment identified the patient’s goal “a need for safety measures.” The POC documented the patient’s goal “Pt/cg verbalizes, demonstrates understanding of proper safety measures.” This goal did not document a measurable outcome. Clinical Record 4: The patient elected hospice care on 03/07/2024 with the diagnosis of Alzheimer’s Disease. On admission the nursing comprehensive assessment documented “Altered Nutrition/Hydration.” The POC documented the patient’s goal “Caregiver (Cg) verbalizes, understanding of need for adequate nutrition/hydration as tolerated.” This goal did not document a measurable outcome. Clinical Record 5: The patient elected hospice care on 02/23/2024 with the diagnosis of unspecified cirrhosis of liver. On admission the nursing comprehensive assessment documented “Alteration in comfort pain.” The POC documented the patient’s goal “Pt/cg will verbalize, satisfaction with level of pain management.” This goal did not document a measurable outcome. Clinical Record 6: The patient elected hospice care on 05/31/2024 with a diagnosis of heart failure. On admission the nursing comprehensive assessment identified the patient’s goal “a need for safety measures.” The POC documented the patient’s goal “Pt/cg verbalizes, demonstrates understanding of proper safety measures.” This goal did not document a measurable outcome. Clinical Record 14: The patient elected hospice care on 03/07/2024 with a diagnosis of cerebral atherosclerosis. On admission the nursing comprehensive assessment identified the patient’s goal “a need for safety measures.” The POC documented the patient’s goal “Pt/cg verbalizes, demonstrates understanding of proper safety measures.” This goal did not document a measurable outcome. Clinical Record 15: The patient elected hospice care on 03/07/2024 the diagnosis of malignant neoplasm of unspecified part of right bronchus or lung. On admission the nursing comprehensive assessment documented “Alteration in comfort pain.” The POC documented the patient’s goal “Pt/cg will verbalize, satisfaction with level of pain management.” This goal did not document a measurable outcome. Clinical Record 16: The patient elected hospice care on 05/10/2023 with the diagnosis of cerebral atherosclerosis. On admission the nursing comprehensive assessment documented “Need for skilled teaching related to preservation of skin integrity.” The POC documented the patient’s goal “Pt/cg will verbalize/demonstrate what to look for in routine skin inspection.” This goal did not document a measurable outcome. Clinical Record 17: The patient elected hospice care on 01/26/2024 with the diagnosis of Non-Hodgkin’s Lymphoma. On admission the nursing comprehensive assessment documented “Alteration in comfort pain.” The POC documented the patient’s goal “Pt/cg will verbalize, satisfaction with level of pain management.” This goal did not document a measurable outcome. Clinical Record 18: The patient elected hospice care on 12/21/2023 with the diagnosis of malignant neoplasm bronchus or lung. On admission the nursing comprehensive assessment documented “Alteration in comfort pain.” The POC documented the patient’s goal “Pt/cg will verbalize, satisfaction with level of pain management.” This goal did not document a measurable outcome. Clinical Record 19: The patient elected hospice care on 03/07/2024 with a diagnosis of Alzheimer’s Disease. On admission the nursing comprehensive assessment identified the patient’s goal “a need for safety measures.” The POC documented the patient’s goal “Pt/cg verbalizes, demonstrates understanding of proper safety measures.” This goal did not document a measurable outcome. During an interview and joint review of clinical records on 7/9/2024 and 7/10/2024, the Director of Operations confirmed that these records did not include measurable goals. There was no additional information or documentation provided.”