Bayada Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals, including all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is by the hospice’s policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 19 of 19 (100%), clinical records reviewed revealed the agency did not ensure that the plan of care included individualized plans of care to include measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: The patient elected hospice on 10/18/2023. A review of the plan of care (POC) on 06/03/2024 noted “pain.” The goal...Patient /Caregiver will verbalize understanding of administration and side effects of pain medication. The plan of care did not include a measurable goal. Clinical Record 2: The patient elected hospice on 04/17/2023. A review of the plan of care (POC) on 06/03/2024.noted “knowledge deficit related to medication management.” The goal...Patient /Caregiver will verbalize understanding of administration and side effects of medications. The plan of care did not include a measurable goal. Clinical Record 3: The patient elected hospice on 04/03/2023. A review of the plan of care (POC) on 06/03/2024 noted a “fall risk.” The goal...Patient Caregiver will verbalize safety precautions. The plan of care did not include a measurable goal. Clinical Record 4: The patient elected hospice on 04/22/2024. A review of the plan of care (POC) on 06/03/2024 noted a “fall risk.” The goal...Patient Caregiver will verbalize safety precautions. The plan of care did not include a measurable goal. Clinical Record 17: The patient elected hospice on 10/09/2023. A review of the plan of care (POC) on 06/03/2024 noted a “fall risk.” The goal...Patient Caregiver will verbalize safety precautions. The plan of care did not include a measurable goal. Clinical Record 5: The patient elected hospice on 11/17/2023. A review of the plan of care (POC) on 06/04/2024 noted “edema.” The goal...The patient’s edema will decrease. The plan of care did not include a measurable goal. Clinical Record 6: The patient elected hospice on 02/28/2024. A review of the plan of care (POC) on 06/04/2024 noted “abdominal pain.” The goal...the patient will have decreased abdominal pain. The plan of care did not include a measurable goal. Clinical Record 18: The patient elected hospice on 02/04/2023. A review of the plan of care (POC) on 06/04/2024 noted “difficulty breathing.” The goal...the patient will have less difficulty breathing. The plan of care did not include a measurable goal. Clinical Record 7: The patient elected hospice on 05/23/2024. A review of the plan of care (POC) on 06/05/2024 noted an “alteration in circulatory.” The goal...Patient Caregiver will verbalize understanding of measures to manage cardiac symptoms. The plan of care did not include a measurable goal. Clinical Record 8: The patient elected hospice on 04/02/2024. A review of the plan of care (POC) on 06/05/2024 noted “fall risk.” The goal is for fall risk to be promptly identified so the intervention can be implemented quickly. The plan of care did not include a measurable goal. Clinical Record 9: The patient elected hospice on 05/23/2024. A review of the plan of care (POC) on 06/05/2024 noted an “alteration in comfort pain.” The goal...Patient Caregiver will verbalize understanding of the pain scale and how to manage and report pain. The plan of care did not include a measurable goal. Clinical Record 10: The patient elected hospice on 03/06/2024. A review of the plan of care (POC) on 06/05/2024 noted “bowel Incontinence.” The goal...the patient will have an effective bowel regimen. The plan of care did not include a measurable goal. Clinical Record 11: The patient elected hospice on 12/02/2023. A review of the plan of care (POC) on 06/05/2024 noted “alteration in comfort pain.” The goal...Patient/ Caregiver will verbalize understanding of measures to manage pain. The plan of care did not include a measurable goal. Clinical Record 12: The patient elected hospice on 03/26/2024. A review of the plan of care (POC) on 06/05/2024 noted “alteration in circulatory.” The goal...Patient Caregiver will verbalize understanding of measures to manage cardiac symptoms. The plan of care did not include a measurable goal. Clinical Record 13: The patient elected hospice on 02/20/2024. A review of the plan of care (POC) on 06/05/2024 noted “funeral arrangements.” The goal...the patient’s funeral arrangements will be completed. The plan of care did not include a measurable goal. Clinical Record 14: The patient elected hospice on 02/21/2024.A review of the plan of care (POC) on 06/05/2024 noted “grieving.” The goal...Patient Caregiver will have grief issues identified and supported. The plan of care did not include a measurable goal. Clinical Record 15: The patient elected hospice on 06/07/2023. A review of the plan of care (POC) on 06/05/2024 noted an “alteration in comfort pain.” The goal...Patient Caregiver will verbalize understanding of measures to manage pain. The plan of care did not include a measurable goal. Clinical Record 16: The patient elected hospice on 12/21/2023. A review of the plan of care (POC) on 06/05/2024 noted “safety.” The goal...Patient Caregiver will verbalize understanding of safety measures. The plan of care did not include a measurable goal. Clinical Record 19: The patient elected hospice on 08/04/2023. A review of the plan of care (POC) on 06/04/2024 noted “saturation.” The goal...Patient/ Caregiver will verbalize understanding of the indications of oxygen use. The plan of care did not include a measurable goal. An interview with the Director of Nursing and the Division Director on 06/03/2024 included a discussion regarding the current process for updating the electronic medical record (EMR) documentation and individualizing the patient plan of care with measurable goals. The Director of Nursing and the Division Director confirmed the findings. No further information was provided.”