Canyon Home Care & Hospice

“It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the individualized plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy O-06 Plan of Care Content (Dated 1/11/23) stated in part, “To ensure appropriate and individualized care to patients that meet the patients’ needs. Goals will be discipline specific and include the physical, social, and spiritual support needed as assessed in the admission/initial/follow-up assessments. Planned Interventions, including what services are to be provided, by whom, with what frequency, and what actions are expected to take place.” Clinical Record 2: The patient elected the hospice benefit on 10/04/2023 with a terminal diagnosis of Parkinson’s disease. On the certification of terminal illness dated 10/04/2023 the physician documented the patient was bedbound. The plan of care contained no documented evidence of goal(s) and intervention(s) related to the patient’s bedbound status and skin integrity. Clinical Record 3: The patient elected the hospice benefit on 11/30/2023. The initial nursing assessment dated 11/30/2023 included documentation that the patient was on oxygen at 2 liters per minute via nasal canula, and the patient had shortness of breath rating of 3 out of 10 (10 being the worst). The physician documented on the initial certification of terminal illness dated 11/30/2023 that the patient’s cancer had spread to the right lung. The plan of care dated 11/30/2023 contained no documented evidence of goal(s) and intervention(s) related to the patient’s respiratory status, including the use of oxygen and shortness of breath. Clinical Record 11: The patient elected the hospice benefit on 08/18/2023. The physician documented on the certification of terminal illness dated 08/18/2023 the patient had five falls recently. The plan of care dated 08/18/2023 contained no documented evidence of goal(s) and intervention(s) for fall risk prevention related to the patient’s recent history of falls. The Alternate Administrator/Registered Nurse stated in an interview on 12/06/2023 that the plans of care lacked goal(s) and intervention(s) for patient problems identified in the initial and updated comprehensive assessments.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 12 (8%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide reported changes in the patient’s medical needs to the Registered Nurse (RN) as the changes related to the plan of care. Agency policy O-07 Changes in Plan of Care (Dated: 1/11/23) stated in part, “Any changes in a patient’s condition requiring a change in the plan of care, or preference by the patient and/or caregiver that are immediate in nature will be coordinated with the case manager or supervising clinician in person or by telephone. Notification will be given to the director or Hospice Director of Clinical Services and the IDT [interdisciplinary team] of any significant changes in the patient’s status that would facilitate a change in the patient’s plan of care.” Clinical Record 2: The patient elected the hospice benefit on 10/04/2023. The Hospice Aide plan of care dated 10/04/2023 assigned the aide “Hygiene: May file any long or uneven fingernails; May file any long or uneven toenails; and Oral care.” The Hospice Aide visit note dated 12/05/2023 stated, “Patient refused” for fingernail care, toenail care, and oral care. The clinical record contained no documented evidence that the aide notified the RN of changes in the patient’s medical needs. The Alternate Administrator/Registered Nurse stated in an interview on 12/06/2023 that the agency did not ensure the hospice aide reported changes in the patient’s medical needs to the RN as the changes related to the plan of care.”