Every finding on record at Affinity Care of Nj LLC

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 and interview. In 1 of 5 (20%) clinical records reviewed of patients with a wound, the hospice did not ensure the plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. Clinical Record 5: The patient elected hospice care on 03/13/2023 with the diagnoses of peripheral vascular disease, dementia and wounds. The initial comprehensive assessment dated 03/13/2023 identified the patient had wounds to both lower extremities. The plan of care did not document a problem with goals for the wounds. The patient expired on 03/20/2023 During an interview on 01/10/2024, the Clinical Director confirmed the finding and stated the complete treatment orders were inadvertently omitted from the plan of care.

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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed of patients with a wound, the hospice did not ensure the plan of care included the wound care necessary to meet the needs of the patient. Clinical Record 5: The patient elected hospice care on 03/13/2023 with the diagnoses of peripheral vascular disease, dementia and wounds. The initial comprehensive assessment dated 03/13/2023 identified the patient had wounds to both lower extremities. The plan of care did not include documentation of treatment orders for the wounds. The patient expired on 03/20/2023 During an interview on 01/10/2024, the Clinical Director confirmed the finding and stated the missing wound care measurements and complete treatment orders were inadvertently omitted from the plan of care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 20 (15%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide received specific care instructions for the assigned patients. Clinical Record 4: The patient elected the hospice benefit on 01/05/2023 with the diagnosis of senile degeneration of brain. The patient resided in a skilled nursing facility (SNF) locked Memory Care unit. The Aide Care Plan dated 01/05/2023 assigned the Hospice Aide the tasks "dressing as needed, transfer as tolerated, and ADL services as requested." The assigned tasks did not include a specific frequency or day to be completed. Due to the decreased cognitive function of the patient, the patient was unable to determine what interventions were required for care. The patient resided in a facility and not in a home where the patient's family members could participate in determining care needs. Clinical Record 5: The patient elected the hospice benefit on 03/13/2023 with the diagnosis of peripheral vascular disease (PVD) dementia and wounds. The patient resided in a SNF. The Aide Care Plan dated 03/13/2023 assigned the Hospice Aide the tasks "bathing bed bath every visit, and bathing shower 2x/week Tuesdays and Fridays." The assigned tasks did not include the specific days for the bed bath, allowing the Hospice Aide to make decisions outside their scope of practice. Due to the decreased cognitive function of the patient, the patient was unable to determine which interventions were required for care. The patient resided in a facility and not in a home where the patient's family members could participate in determining care needs. Clinical Record 11: The patient elected the hospice benefit on 03/21/2023 with the diagnosis of end-stage renal disease. The patient resided in a SNF. The Aide Care Plan dated 03/21/2023 assigned the Hospice Aide the tasks "bathing bed bath every visit, and bathing shower 2x/week Tuesdays and Fridays." The assigned tasks did not include the specific days for the bed bath allowing the Hospice Aide to make decisions outside their scope of practice. During an interview on 01/10/2024, the Director of Clinical Services confirmed that the care plans in records 4, 5, and 11, created by the RN included multiple bath options for the patients bath and did not give specific instructions for the aide to perform tasks.