Commonheart Hospice

“Based on record review and interview, the agency failed to develop a POC (plan of care) to meet the individualized needs of the patient with discipline specific assessments, interventions, and measurable goals in 1 of 15 active patient records reviewed (Patient #2) in a total of 19 records reviewed. Findings include: Review of agency “ALL STAFF Guidelines/Expectations: Hospice Care planning” (not dated) revealed “Regulations require that hospice conducts assessments and that the findings of those assessments are used to develop specific care plans that have measurable, individualized and time specific goals. The interventions also need to be individualized and specific. 418.56 Content of Plan of Care: Hospice must develop an INDIVIDUALIZED written POC for each patient. The POC must reflect the patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. 4. Standardized care plans to be used: b. Discipline specific. A. Pain/Comfort as well as any other untoward symptoms should always be addressed in the care plan.” Record review of Patient #2’s POC dated 02/14/2025 to 05/14/2025 revealed Patient #2 was admitted to hospice with primary diagnosis of “Unspecified severe protein-calorie malnutrition” and secondary diagnoses of “Dysphagia unspecified and Adult Failure to Thrive.” The POC revealed in part, “Skilled nursing to assess and evaluate 02/14/2025 through 02/19/2025, skilled nursing 1 time per week for 13 weeks. 02/14/2025: Brief narrative statement: Unfortunately continues to decline now and has lost 25 pounds since January of 2025 and 10 pounds since discharge from the hospital just on 01/21/2025. This is despite high protein meals, supplements and eating majority of his meals. (Patient #2) is reported to have muscle wasting and appear cachectic. His diet has been advanced despite evidence of aspiration on swallow evaluation.” Record review of Patient #2’s POC dated 02/14/2025 to 05/14/2025 revealed the POC did not identify nursing discipline specific or IDT (Interdisciplinary team) assessments, interventions or goals related to nutrition to meet the individualized needs of Patient #2. Record review of Patient #2’s IDT note dated 02/27/2025 revealed in part, “Discipline: RN (Registered Nurse). Patient eating double portions. Wanting to get better so (Patient #2) can go home. Patient focused on getting better.” During an interview with Director A on 03/04/2025 at 2:00 PM, when asked about Patient #2’s POC not being individualized and lacking nursing assessments, interventions or goals pertaining to Patient #2’s nutrition diagnoses, Director A replied, “The nurse talked in IDT that that needs to be added to the care plan.””

“Based on record review and interview, the agency failed to develop plans of care that outlined the specific responsibilities of hospice and facility staff for the care and services of patients receiving care in a SNF (Skilled Nursing Facility) or ALF (Assisted Living Facility) setting in 7 of 10 patients that resided in a facility (Patient #2, #5, #6, #7, #10, #13, #14) in a total of 19 records reviewed. Record review of Patient #5’s Plan of Care dated 02/11/2025 to 05/11/2025 revealed Patient #5 was admitted to hospice with primary diagnosis of unspecified Hydrocephalus and resided in an ALF. Review of Patient #5’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. Record review of Patient #6’s Plan of Care dated 02/12/2025 to 05/12/2025 revealed Patient #6 was admitted to hospice with primary diagnosis of Acute on Chronic Respiratory Failure and resided in an ALF. Review of Patient #6’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. Record review of Patient #7’s Plan of Care dated 03/01/2025 to 04/29/2025 revealed Patient #7 was admitted to hospice with primary diagnosis of Human Immunodeficiency Virus with recurrent severe infections and resided in an SNF. Review of Patient #7’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. Record review of Patient #10’s Plan of Care dated 02/12/2025 to 05/12/2025 revealed Patient #10 was admitted to hospice with primary diagnosis of Pneumonitis and resided in an SNF. Review of Patient #10’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. Record review of Patient #13’s Plan of Care dated 01/17/2025 to 03/17/2025 revealed Patient #13 was admitted to hospice with primary diagnosis of Huntington’s Disease and resided in an SNF. Review of Patient #13’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. Record review of Patient #14’s Plan of Care dated 03/01/2025 to 04/29/2025 revealed Patient #14 was admitted to hospice with primary diagnosis of Renal and Perinephric Abscess and resided in an SNF. Review of Patient #14’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided. During an interview with Director A on 03/04/2025 at 11:24 AM, when asked what the expectation is regarding delineation of services in the patients POC, Director A stated, “ We expect that our Hospice nurses are delineating services when creating the plan of care for our patients residing in facilities.” Findings include: Review of agency “All Staff Guidelines/Expectations: Hospice Careplanning” document (not dated) revealed “Careplan guidelines: 3. Careplan Interventions: Facility/Discipline Specific: i. When a patient is a resident of a facility, Hospice MUST outline what interventions hospice does and what ones the facility does. ii. Collaborate with the facility to identify what the facility will do and what the hospice will do. Remember to include tasks/activities that the facility is doing that may impact hospice goals.” Record review of Patient #2’s Plan of Care dated 02/14/2025 to 05/14/2025 revealed Patient #2 was admitted to hospice with primary diagnosis of Unspecified severe protein-calorie malnutrition and resided in an ALF. Review of Patient #2’s plan of care revealed no delineation to outline which provider was responsible for care and interventions to be provided.”