Every finding on record at All Seasons Hospice

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure that the hospice aide reported changes in the patient's medical, nursing, and social needs as the changes related to the plan of care, to a registered nurse. Clinical Record 5: The patient elected the hospice benefit effective 10/11/2022. The primary hospice diagnosis was Alzheimer’s disease. The hospice aide plan of care effective 10/25/2022 ordered the aide to clean/file fingernails, and brush teeth/dentures. The hospice aide documentation on 2/28/2023 revealed the tasks of clean/file fingernails, and brush teeth/dentures as not completed due to “pt declined.” There was no documentation of notification to the RN. Clinical Record 6: The patient elected the hospice benefit effective 12/16/2022. The primary hospice diagnosis was Cerebrovascular disease. The hospice aide plan of care effective 12/23/2022 ordered the aide to brush teeth, and shampoo hair. The hospice aide documentation on 2/6/2023 revealed the tasks of brush teeth, and shampoo hair as not completed due to “pt declined.” There was no documentation of notification to the RN. Clinical Record 8: The patient elected the hospice benefit effective 3/4/2023. The primary hospice diagnosis was Chronic Respiratory Failure. The hospice aide plan of care effective 3/31/2023 ordered a shower. The hospice aide documentation on 4/10/2023 revealed the shower as not completed due to “patient not able to shower.” There was no documentation of notification to the RN. During an interview on 9/8/2023, the Director of Clinical Services agreed, there was no documented evidence that the hospice aide reported changes in the patient’s needs to a registered nurse as the changes related to the plan of care.