Acara

“It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 7 of 15 (47%) clinical records reviewed the agency did not ensure that plans of care included individualized interventions based on problems identified in the initial or updated comprehensive assessments. CLINICAL RECORD 1: The hospice benefit election date was 10/23/2023 with a primary diagnosis of Alzheimer’s Disease. A documented physician order was written 06/30/2025, “May check capillary blood glucose as needed for signs and symptoms of hyper/hypoglycemia.” The interdisciplinary plan, updated 07/09/2025 and updated every two weeks, did not document interventions for endocrine or blood sugar management. CLINICAL RECORD 7: The hospice benefit election date was 06/20/2024 with a primary diagnosis of Chronic Lymphocytic Leukemia. A physician order was written 06/25/2024 for oxygen via nasal cannula as needed. No oxygen was used by the patient until the nursing assessment documented on 02/21/2025 when it was used PRN (as needed). On the nursing assessment documented 02/24/2025 the oxygen was used at 2 liters prn and then documented as continuous on the 03/07/2025 assessment. On the nursing assessment documented on 03/08/2025, the oxygen was at 4.5 liters per nasal cannula. The IDG (interdisciplinary group) updated plans of care dated 02/20/2025 and 03/06/2025 following IDG meetings did not include interventions for oxygen. CLINICAL RECORD 8: The hospice benefit election date was 09/29/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A physician order was written 10/07/2024 for a foley catheter, 16 French, to be changed monthly using sterile technique. There were no interventions documented. During record review the Case Manager noted that the patient had been admitted with the Foley catheter in place and wrote the order for this mode of elimination. There were no updated interventions documented on the plan of care updated every two weeks until the patient’s date of death 01/22/2025. CLINICAL RECORD 10: The hospice benefit election date was 10/19/2024 with a primary diagnosis of Lung Cancer. The interventions written for respiratory status were not individualized for this patient. The initial nursing comprehensive assessment documented on 10/19/2024 that the patient was using oxygen at 3 liters per nasal cannula and increased to 4 liters on 11/04/2024. The plan of care intervention was “Review oxygen and morphine for shortness of breath with caregivers” but was non-specific for assessment regarding safety related to the oxygen use. The orders were specific for the oxygen flow rate and use per nasal cannula. CLINICAL RECORD 12: The hospice benefit election date was 11/22/2024 with a primary diagnosis of Diabetes and secondary diagnosis of Atherosclerosis. A documented physician order on 11/22/2024 was for a Foley catheter to dependent drainage, change every 30 days. The plan of care was not updated with interventions for the Foley catheter, up to the patient’s death on 11/30/2025. CLINICAL RECORD 14: The hospice benefit election date was 12/10/2024 with a primary diagnosis of Alzheimer’s Disease and comorbidity of Congestive Heart Failure. Physician orders documented on 12/10/2024 were for albuterol 0.083% every 6 hours for shortness of breath or congestion, morphine sulfate oral concentrate 20mg/milliliter take 0.25 milliliter to 1 milliliter by mouth as needed for shortness of breath, and oxygen one to 4 liters per nasal cannula for shortness of breath. The initial plan of care dated 12/10/2024 and updated every two weeks did not document respiratory interventions for oxygen or shortness of breath. The patient was using the morphine and oxygen during care received. CLINICAL RECORD 15: The hospice benefit election date was 02/07/2025 with a primary diagnosis of Hepatic Bile Duct Cancer. The physician ordered on 02/07/2025, for a Foley catheter, 16 French to be changed as needed using sterile technique, a Denver drain to be emptied up to 1000ml every day and the dressing changed every day or as needed. The initial plan of care and every two week updated plans of care did not include interventions for the Foley catheter or the Denver drain up to the patient’s death on 2/27/2025. During interview with the Case Manager (PERSONNEL RECORD 4) on 11/05/2025 she stated that she created interventions during the visit but if the family understood she ended them. If the family needed more education, it was reinforced later. She stated that leaving the interventions for problems that were current did make sense and would be done in the future. She stated that documentation of interventions in some of the records was not in the note like it should have been.”

“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 the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed, the agency did not ensure that measurable, individualized goals were documented. CLINICAL RECORD 10: The hospice benefit election date was 10/19/2024 with a primary diagnosis of Lung Cancer. The patient was using oxygen per nasal cannula. The respiratory goal on the initial plan of care and the plans of care updated every two weeks was, “Shortness of breath will be managed by 11/13/2024.” This was not measurable as it was not clear what “managed shortness of breath” would be for this patient. CLINICAL RECORD 15: The hospice benefit election date was 02/07/2025 with a primary diagnosis of Hepatic Bile Duct Cancer. The respiratory goal that was written on the initial and every two week updated plans of care was, “Patient will have optimum level of oxygenation.” This was not measurable as to what “optimum” would be for this patient. During interview with the Case Manager (PERSONNEL RECORD 4) she stated that the goals were not measurable.”

“It is required that each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record where the patient requested evaluation with therapists, the agency did not ensure that documentation of the therapy evaluations or updates were documented in the clinical record. CLINICAL RECORD 8: The hospice benefit date of election was 09/29/2024 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A physician order was written on 10/03/2024 for physical therapy and occupational therapy to evaluate for transfer and home safety. As of the date of record review on 11/05/2025 there was no documentation of the therapy evaluations or updates of the status of the therapy evaluations in the record. The patient died on 01/22/2025. During interview with the case manager (PERSONNEL RECORD 4) she stated that the family declined the therapy evaluations, and she had thought that (the declination) was documented in the record but was unable to find the documentation of this. She stated that the patient was declining, and the son no longer wanted the service.”