Gentle Care Hospice

“Upon patient record review, 5 of 6 (Patient #1,#2,#3,#4,#6) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/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. Patient #1: The record indicates patient has a diagnoses of Congestive heart failure with pulmonary hypertension and requires use of oxygen. There was not evidence that the plan of care reflected patient goals and interventions based on cardiovascular problems and oxygen use. Patient #2: The records indicates patient has a diagnosis of Alzheimer’s dementia and dysphagia. There was not evidence that the plan of care reflected patient goals and interventions based on Alzheimer’s/dementia or for issues related to dysphagia. Corrected on site. Patient #3: The record indicates patient required oxygen 2 LPM via NC, puree diet with nectar thick liquids, had difficulty swallowing , and incontinence. There was not evidence that the plan of care reflected the patients goals and interventions related to oxygen use, dietary needs, difficulty swallowing, or incontinence. Patient #4: The record indicates that on 6/14, 6/18, and 7/5 the aide documented behavioral issues with patient during care which she reported to the Admin and owners. There was not evidence of the plan of care reflecting the patients goals and interventions related to behavioral changes in patient. Corrected on site Patient #6: The record indicates on the RN initial assessment that patient has high risk skin breakdown and incontinence. There was not evidence that the plan of care reflected goals and interventions related to high risk of skin breakdown and incontinence. Corrected on site.”

“Upon patient record review, 3 of 6 (Patient #2,4,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated the 4/17 order for nurse frequency at 1 time per week and 2 PRN. The week of 4/17/24 there was documentation of 2 scheduled visits on 4/17 and 4/19. Corrected on site. Patient #4: The record indicated the 6/13 order for nurse frequency at 1 time per week and 2 prn. The week of 6/16 two nurse visits were documented on 6/19 and 6/21 and were documented as scheduled visits. The record indicated the 6/13 order for MSW frequency was 1 time per week and 1 prn. The only MSW visits were documented as being once a month on 6/17 and 7/22. The record indicated the 6/13 order for spiritual visits at 1 time per week and 1 prn. Spiritual visit was only made on 6/14 and 7/23. Corrected on site. Patient #5: The record indicated the 4/2 order for MSW frequency was 1 time per week. The only MSW visit was documented on 4/6. Corrected on site.”

“Upon patient record review 3 of 6 (Patient #1,#4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The record indicates Aide visit frequency at 2 time per week. The week of 4/14 pt was seen on 4/15, 4/17, and 4/18. Corrected on Site Patient #4: The record indicates order for aide visit frequency is 2 times per week. The week of 6/13 only one visit was documented on 6/14. Corrected on site. Patient #5: The record indicates order for aide visit frequency is 2 times per week. The week of 4/14 only one aide visit was made on 4/14. On the week of 4/28 only one aide visit was documented on 4/29. Corrected on site.”

“Upon patient record review, 2 of 6 (Patient #1,#4) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient #1: The record indicates on RN visit for 4/12 the nurse documented patient complaining of generalized body pain at 2 out of 10 on the numerical pain scale. The patient was given Tylenol per POC. There is no evidence of follow-up on response to medication or if pain improved. The record indicates on RN visit for 6/7 patient reported pain a 5 out of 10 on numerical pain scale to left hand with swelling. The nurse documented advising patient to take IBU 800 and to elevate hand/arm. There is no evidence on follow-up if symptom management was effective. The record indicates on RN visit for 5/31 The patient reported leg pain at a 4 out of 10 on the numerical pain scale. The pain assessment indicates patient having pain “all the time”. There is documentation that the nurse educated on management and treatment of peripheral edema. There is no evidence of any follow-up with or response to symptom management. Patient #4: The record indicates during RN visit for 6/19 the patient was anxious and agitated. The RN ordered lorazepam 0.5 take 1 every 8 hours as needed for anxiety and quetiapine 25 take one daily for agitation. There is no evidence of follow-up on effectiveness or response to treatment.”