Every finding on record at Aiden Healthcare 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 19 (5%) clinical records reviewed, the agency did not ensure the individualized plan of care included patient, and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/10/2025. The Registered Nurse documented on the nursing visit note dated 01/14/2025 that the daughter requested music therapy. The interdisciplinary group meeting dated 01/15/2025 included documentation that the team discussed and ordered music therapy for a frequency of one time every two weeks. The clinical record included documentation of two music therapy visits dated 01/21/2025 and 02/04/2025. The plan of care dated 01/15/2025 did not include goals and interventions for music therapy. During an interview on 04/28/2025 with the Senior Executive Director, the Director of Patient Care Services (DPCS), and the Business Office Manager, the DPCS stated that the music therapy goals and interventions missing from the plan of care had been identified by the agency earlier in April 2025, and a performance improvement plan was recently implemented.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records. 2 of 11 (18%) records reviewed revealed the agency did not ensure the drug profile contained all of the patient's current medications. Record #6 was reviewed and identified that the patient elected hospice care on 7/20/2022. A review of the record revealed a documented physician order for Oxygen at 2-4 liters per minute per nasal cannula for shortness of breath. The medication profile did not contain the medication Oxygen. The Administrator confirmed during an interview and a joint review of the clinical record on 7/28/2022, the oxygen was not listed on the medication profile Record #5 was reviewed and identified the patient elected hospice care on 6/30/2022. The plan of care dated 7/18/2022 documented, "Acetaminophen Oral Tablet 325mg, 2 tabs 4 times a day for pain... Crestor Oral Tablet 10mg, 1 tablet at bedtime...Warfarin sodium tablet by mouth 1.25mg at bedtime on M-W-F...Fleet Enema, 1 enema per day... Bisacodyl Rectal Suppository 10mg, 1 per day for constipation prn." During the home visit conducted on 7/27/2022, a review of the patient's medication profile revealed the medications Acetaminophen and Crestor were discontinued on 7/12/2022. In addition, the medication "Keppra Solution 100mg/ml give 5 ml by mouth every morning and at bedtime," was ordered on 6/27/2022. The patient's medication profile was not updated to include the patient's current medications.. The Administrator confirmed during an interview and a joint review of the clinical record on 7/28/2022, the medication reconciliation did not occur. See description below

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 and related conditions, including planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interview. 1 of 11 (9%) records reviewed revealed the agency did not ensure the plan of care included planned interventions based on problems identified in the initial comprehensive assessment. Record #8 was reviewed and identified the patient elected hospice care on 7/18/2022. The initial comprehensive assessment completed by the Registered Nurse (RN) documented, "open stage 3 right heel wound: length 1.3cm by width 1.27." The plan of care (POC) dated 7/18/2022 did not include interventions to address the patient's wound. The Administrator confirmed during an interview and a joint review of the record on 7/28/2022, the wound care order was not documented in the clinical record. See description below

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and Included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 8 of 11 (73%) records reviewed revealed the agency did not ensure Hospice Aide services followed the plan of care. Record #8 was reviewed and identified that the patient elected hospice care on 7/18/2022. The plan of care dated 7/18/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 7/18/2022. The aide did not follow the plan of care visit frequency. Record #4 was reviewed and identified that the patient elected hospice care on 6/14/2022. The plan of care dated 6/14/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 6/14/2022. The aide did not follow the plan of care visit frequency. Record #9 was reviewed and identified that the plan of care dated 7/22/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 7/26/2022. The aide did not follow the plan of care visit frequency. Record #3 was reviewed and identified that the patient elected hospice care on 6/1/2022. The plan of care dated 6/1/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 6/1/2022. The aide did not follow the plan of care visit frequency. Record #6 was reviewed and identified that the patient elected hospice care on 7/20/2022. The plan of care dated 7/20/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 7/20/2022. The aide did not follow the plan of care visit frequency. Record #5 was reviewed and identified that the patient elected hospice care on 6/30/2022. The plan of care dated 6/30/2022, documented the Aide visit frequency as 2 times per week. The record revealed one completed Aide visit documented for the week of 7/6/2022. The Aide did not follow the plan of care visit frequency. Record #7 was reviewed and identified that the patient elected hospice care on 6/16/2022. The plan of care dated 6/16/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 6/16/2022. The aide did not follow the plan of care visit frequency. Record #10 was reviewed and identified that the patient elected hospice care on 7/8/2022. The plan of care dated 7/8/2022, documented the aide visit frequency as 2 times per week. The record revealed one aide visit documented as completed for the week of 7/8/2022. The aide did not follow the plan of care visit frequency. The Administrator confirmed during a joint review of the records and an interview on 7/28/2022, the visit frequency was not followed. See description below