Hands and Hearts Hospice Corporation

“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, document review and interview. In 1 of 13 (8%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Document 1: Policy PC.P55 Plan of Care-content, dated 2023 stated in part, “The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and 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 including g. Measurable outcomes anticipated from implementing and coordinating the plan of care.” Clinical Record 7: The IDG Meeting Care Plan document dated 01/23/2024 included goals “Client will exhibit decreased episodes of anxiety and loneliness” and “Client will have no urinary tract infections.” The clinical record lacked evidence that the goals were measurable including the timeframe for achieving the stated goals. Personnel Record 2: In an interview and joint record review on 04/17/2024, the Director of Clinical Services confirmed the finding.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 13 (23%) clinical records reviewed it was revealed that the agency did not ensure that the aide services were provided as ordered by the interdisciplinary group (IDG) and included in the plan of care. Document 1: Policy PC.P40 Physician Orders, dated 2023 stated in part, “Some of the reasons orders are obtained from physicians include but are not limited to: b. Change in visit frequency if not within the range specified in the patient’s plan of care.” Clinical Record 1: A physician order was obtained on 03/04/2024 to change hospice aide frequency to five times per week. Two hospice aide visits were completed during the week of 03/04/2024, three hospice aide visits were completed during the weeks of 03/11/2024 and 03/18/2024, and four hospice aide visits were completed during the week of 03/31/2024. The clinical record lacked documentation of why the aide services were not provided as ordered or that the IDG was notified. Clinical Record 2: A physician order was obtained on 02/06/2024 for hospice aide visits two times per week beginning the week of 02/04/2024. No hospice aide visits were documented as completed the week of 02/04/2024. Hospice aide frequency increased on 02/11/2024 to three times per week. Only two visits were completed the week of 02/11/2024. Hospice aide visits were increased to four times a week on 02/18/2024, and only three visits were completed the week of 02/18/2024. Hospice aide frequency was increased to five times a week beginning the week of 03/03/2024, and only four visits were completed the week of 03/10/2024. There was no documentation of why the aide services were not provided as ordered or that the IDG was notified. Clinical Record 7: A physician order was received on 01/22/2024 for hospice aide visits three times per week beginning 01/28/2024. Five hospice aide visits were provided during the week of 02/19/2024 and four hospice aide visits were provided during the weeks of 03/17/2024 and 03/24/2024. The clinical record lacked documentation of why the aide services were not provided as ordered or that the IDG was notified. Personnel Record 2: In an interview and joint record review on 04/17/2024, the Director of Clinical Services confirmed the findings that the hospice aides did not follow the plan of care.”

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical record reviewed that a volunteer was requested it was revealed that the agency did not ensure that a volunteer was assigned to the patient as requested or in compliance with agency policy. Document 1: Policy PC.V10 Volunteers-Assignment dated 2023 stated in part “If the patient or caregiver is interested in having a direct service volunteer, the Volunteer Coordinator is notified. Volunteer assignments are made within three (3) working days after notification of the request. If this is not possible, there will be documentation regarding issues that are causing the delay and what is being done to meet the patient’s/caregiver’s needs. Clinical Record 1: The spiritual care coordinator’s clinical note dated 02/29/2024 stated in part “The patient would like a volunteer. Today, I collaborated with a member of the hospice team or IDG, (patient name) caregiver, or family member.” The clinical record lacked evidence that volunteer services were provided as requested or that additional collaboration occurred to coordinate volunteer services.” In an interview and joint record review on 04/17/2024, the Director of Clinical Services confirmed findings that volunteer services were not provided to the patient as requested and stated in part “I was not collaborated with on this request.””