Every finding on record at Adams and Gray, Inc

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 clinical record review, document review and interview. In 1 of 12 (8%) clinical records reviewed revealed the patient's individual written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. Document 2: Policy #9.12, "IDG Care Planning Process (Revised: 2/2022)", stated in part, "Procedure: 8. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments." Clinical Record 1: The patient elected the hospice benefit on 8/16/23. The physician order dated 8/19/23 stated to start oxygen 1-5 liters/minute via nasal cannula. The interdisciplinary group (IDG) POC dated 8/22/23 had a goal for dyspnea but lacked an intervention for oxygen with the specifics of the order. Upon interview on 9/12/23, the Administrator and the Director of Clinical Services reviewed and agreed the POC included a goal but did not ensure planned intervention(s) to meet the stated goal.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group (IDG). This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 10 (20%) clinical records reviewed for patients that received hospice aide services revealed the agency did not ensure the aide provided services ordered by the interdisciplinary group. Document 2: Policy 9.12, "IDG Care Planning Process (Revised: 2/2022)", stated in part, "Policy: The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs." Clinical Record 4: The patient elected the hospice benefit on 8/25/23. The aide POC dated 8/29/23 had interventions ordered to shower and shampoo/style hair weekly. The aide frequency was 1x/week. The aide completed visits on 9/8/23 and 9/11/23. Neither of the aide visit notes demonstrated that the aide completed the shower and shampoo/style hair. Clinical Record 1: The patient elected the hospice benefit on 8/17/23. The Aide plan of care (POC) dated 8/21/23 ordered an aide visit frequency of 1x/week. The record lacked evidence of an aide visit the week of 8/21/23 and the week of 8/28/23. There was evidence of an aide visit completed on 9/4/23. Upon interview on 9/12/23, the Administrator and the Director of Clinical Services reviewed and agreed the agency did not ensure the hospice aide provided services as ordered by the IDG.

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 clinical record review, document review and interview. In 2 of 10 (20%) clinical records reviewed for patients that received hospice aide services revealed the agency did not ensure that the aide reported changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse (RN) as the changes related to the plan of care (POC) and any quality assessment and improvement activities. Document 3: Policy #11.3, "Hospice Aide Documentation (Revised: 6/2019)", stated in part, Procedure: 2. The Hospice Aide will be responsible for reporting any changes in the patient's condition and/or other pertinent observations to the supervising RN." Clinical Record 1: The patient elected the hospice benefit on 8/17/23. The aide POC dated 8/21/23 had interventions ordered to shower and clean fingernails weekly. For the week of 9/3/23, the aide completed two visits, 9/4/23 and 9/8/23. Neither of the aide visit notes that week demonstrated that the aide completed the shower and/or cleaning the fingernails. The record lacked evidence that the aide reported not completing the shower and/or cleaning the fingernails to the hospice RN. Clinical Record 4: The patient elected the hospice benefit on 8/25/23. The aide POC dated 8/29/23 had interventions ordered to shower and shampoo/style hair weekly. The aide frequency was 1x/week. The aide completed visits on 9/8/23 and 9/11/23. Neither of the aide visit notes demonstrated that the aide completed the shower and shampoo/style hair. The record lacked evidence that the aide reported not completing the shower and shampoo/style hair to the hospice RN. Upon interview on 9/13/23, the Administrator and the Director of Clinical Services reviewed and agreed that the agency did not ensure the hospice aide reported interventions not completed as per the plan of care to the RN case manager.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: The hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the hospice election statement had been completed according to the agency Consent for Election of Medicare Hospice Benefit policy. Document 1: Policy #12.2, "Election of Hospice Care Policy/Designation of Attending Physician/Election Statement Addendum (Revised: 2/2022)", stated in part, "Procedure: 2. The election statement must include the following: The effective date of the election, which may be the first day of Hospice care or a later date, but may be no earlier than the date of the election statement." Clinical Record 1: The patient elected the hospice benefit on 8/16/23. The Consent for Election of Medicare/Medicaid Hospice Benefit was signed by a family member on 8/16/23. "The acknowledgment/understanding the above, I choose to elect the Medicare/Medicaid hospice benefit and receive services from agency to begin on" was blank. Upon interview on 9/12/23, the Administrator and the Director of Clinical Services reviewed and agreed the agency did not ensure the effective date of the election was missing.