Bellevue Hospice, LLC

“Based on record review and interview, the agency failed to include what services would be provided on the plan of care for 5 records (2, 3, 4, 5, 7) and failed to include the frequency and duration on the plan of care for 2 records (9, 11), from a total of 11 records reviewed, resulting in the potential for unmet care needs. Findings include: P-2: The start of care (SOC) was dated 12/31/24, with diagnoses that included dementia, and amputation. The plan of care (POC) documented a frequency of 1 visit/week, 1 visit/week, and 1 visit, with no services documented. There was no indication of what services corresponded with the visit frequencies.P-3: The SOC was dated 2/14/25, with diagnoses that included dementia, carpal tunnel, and hypertension. The POC documented a frequency of 1 visit/week, with no services documented. There was no indication of what service corresponded with the visit frequency.P-4: The SOC was dated 3/1/25, with diagnoses that included heart failure, atrial fibrillation, and chronic kidney disease. The POC documented a frequency of 1 visit/week, 1 visit/week, 1 visit/week, and 1 visit, with no services documented. There was no indication of what services corresponded with the visit frequencies.P-5: The SOC was dated 1/7/25, with a diagnosis of dementia. The POC documented a frequency of 1 visit/week, 1 visit/week, 1 visit/week, and 1 visit, with no services documented. There was no indication of what services corresponded with the visit frequencies.P-7: The SOC was dated 2/6/25, with diagnoses of dementia, and atrial fibrillation. The POC documented a frequency of 1 visit/week, 1 visit/day, 2 visits/week, and 1 visit, with no services documented. There was no indication of what services corresponded with the visit frequencies.P-9: The SOC was dated 2/6/25, with a diagnosis of dementia. The POC documented services to be provided were skilled nursing, medical social worker, and home health aide. There was no corresponding visit frequencies for each service documented on the POC.P-11: The SOC was dated 3/4/25, with diagnoses of heart failure, and failure to thrive. The POC documented services to be provided were skilled nursing, and medical social worker. There was no corresponding visit frequencies for each service documented on the POC.During an interview on 5/2/25 at 3:00 p.m., the administrator (Adm-1) acknowledged the above findings.”

“Based on record review and interview, the agency failed to include measurable goals on the plan of care for 11 records (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) from a total of 11 records reviewed, resulting in the potential for unmet care needs. Findings include: P-1: The start of care (SOC) was dated 2/18/25, with diagnoses that included surgical procedure, heart disease, and coronary angioplasty. The plan of care (POC) dated 2/18/25 and reviewed on 4/29/25, failed to include measurable goals. One goal stated, “Patient will have measures in place to manage risk factors for pressure ulcer/wound development within 1 week with ongoing evaluation of effectiveness..., another stated, patient’s pain will be evaluated at every visit to include evaluation of patient’s acceptable level of pain tolerance.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-2: The start of care (SOC) was dated 12/31/24, with diagnoses that included dementia, and amputation. The POC dated 12/31/24, and reviewed on 4/29/25, failed to include measurable goals. One goal stated, “Patient’s Cardiac symptoms of irregular heart rhythm will be managed to the patient’s indicated level of comfort throughout service period. Another stated, patient will have made decisions for the remainder of life completing self-determined life closure in anticipation of death.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-3: The SOC was dated 2/14/25, with diagnoses that included dementia, carpal tunnel, and hypertension. The POC dated 2/14/25, and reviewed on 4/30/25, failed to include measurable goals. One goal stated, “Patient will remain safe at home through-out service period. Another stated, patient’s pain will be evaluated at every visit to include evaluation of patient’s acceptable level of pain tolerance.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-4: The SOC was dated 3/1/25, with diagnoses that included heart failure, atrial fibrillation, and chronic kidney disease. The POC dated 3/1/25, and reviewed on 5/1/25, failed to include measurable goals. One goal stated, “Patient’s cardiac symptoms of shortness of breath will be managed to the patient indicated level of comfort through-out the service period. Another stated, patient’s dyspnea will be managed through non-pharmacological measures to maintain patient’s identified comfort level to allow patient to perform desired activities through-out service period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-5: The SOC was dated 1/7/25, with a diagnosis of dementia. The POC dated 1/7/25, and reviewed on 5/1/25, failed to include measurable goals. One goal stated, “Patient will remain free of or have early detection of infection through-out the service period. Another stated, patient will have measures in place to manage risk factors for pressure ulcer/wound development within 1 week with ongoing evaluation of effectiveness...” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-6: The SOC was dated 2/9/25, with diagnoses that included debility, and failure to thrive. The POC dated 2/9/25, and reviewed on 5/1/25, failed to include measurable goals. One goal stated, “Patient’s edema will be managed to the patient’s level of comfort through-out the service period. Another stated, patient will remain safe at home through-out the service period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-7: The SOC was dated 2/6/25, with diagnoses of dementia, and atrial fibrillation. The POC dated 2/6/25, and reviewed on 5/1/25, failed to include measurable goals. One goal stated, “Patient will remain safe at home through-out service period. Another stated, patient’s pain will be evaluated at every visit to include evaluation of patient’s acceptable level of pain tolerance.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-8: The SOC was dated 3/10/25, with diagnoses of neoplasm of lung and dementia. The POC dated 3/10/25, and reviewed on 5/2/25, failed to include measurable goals. One goal stated, “Patient’s Cardiac symptoms of palpitations will be managed to the patient’s indicated level of comfort throughout service period. Another stated, patient will remain safe at home through-out service period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-9: The SOC was dated 2/6/25, with a diagnosis of dementia. The POC dated 2/6/25, and reviewed on 5/2/25, failed to include measurable goals. One goal stated, “Patient’s pain will be evaluated at every visit to include evaluation of patient’s acceptable level of pain tolerance. Another stated, patient will remain safe at home through-out the service period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-10: The SOC was dated 1/20/25, with diagnosis of dementia. The POC dated 1/20/25, and reviewed on 5/2/25, failed to include measurable goals. One goal stated, “Patient will maintain bowel frequency identified at the comfort level for the patient through-out the service period. Another stated, patient’s pressure ulcer/wound will remain infection free and at identified comfort level through-out the service period.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.P-11: The SOC was dated 3/4/25, with diagnoses of heart failure, and failure to thrive. The POC dated 3/4/25, and reviewed on 5/2/25, failed to include measurable goals. One goal stated, “Patient will have made decisions for the remainder of life completing self-determined life closure in anticipation of death. Another stated, patient’s pain will be evaluated at every visit to include evaluation of patient’s acceptable level of pain tolerance.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals.During an interview on 5/2/25 at 3:00 p.m., the administrator (Adm-1) acknowledged the above findings.”

“Based on record review and interview, the hospice failed to ensure the registered nurse prepared written patient care instructions for the aide that included safety precautions pertinent to the needs of the patient for 5 records (P-2, 6, 7, 8, 10) reviewed with aide services, from a total of 11 records reviewed, resulting in the potential for poor patient outcomes. Findings include: P-2: The start of care (SOC) was dated 12/31/24, with diagnoses that included dementia, and amputation. The POC dated 12/31/24, and reviewed on 4/29/25, had safety measures documented as follows, fall precautions/transfer safety, universal/infection precautions, anticoagulation precautions. During review of the aide care plan dated 1/8/25, it was discovered that the aide care plan had no safety precautions.P-6: The SOC was dated 2/9/25, with diagnoses that included debility, and failure to thrive. The POC dated 2/9/25, and reviewed on 5/1/25, had safety measures documented as follows, fall precautions/transfer safety, universal/infection precautions, keep pathways clear, and keep side rails up. During review of the aide care plan dated 2/10/25, it was discovered that the aide care plan had no safety precautions.P-7: The SOC was dated 2/6/25, with diagnoses of dementia, and atrial fibrillation. The POC dated 2/6/25, and reviewed on 5/1/25, had safety measures documented as follows, fall precautions/transfer safety, universal/infection precautions, keep pathways clear, aspiration precautions, proper use of assistive devices, and keep side rails up. During review of the aide care plan dated 2/13/25, it was discovered that the aide care plan had no safety precautions.P-8: The SOC was dated 3/10/25, with diagnoses of neoplasm of lung and dementia. The POC dated 3/10/25, and reviewed on 5/2/25, had safety measures documented as follows, fall precautions/transfer safety, universal/infection precautions, keep pathways clear, and proper use of assistive devices. During review of the aide care plan dated 3/25/25, it was discovered that the aide care plan had no safety precautions.P-10: The SOC was dated 1/20/25, with diagnosis of dementia. The POC dated 1/20/25, and reviewed on 5/2/25, had safety measures documented as follows, fall precautions/transfer safety, universal/infection precautions, anticoagulation precautions, oxygen usage precautions, proper use of assistive devices, aspiration precautions, and keep side rails up. During review of the aide care plan dated 1/21/25, it was discovered that the aide care plan had no safety precautions.During an interview on 5/2/25 at 3:00 p.m., the administrator (Adm-1) acknowledged the above findings.”