Every finding on record at Angelic Hospice, LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments and includes intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed it was revealed that the agency did not ensure that the individualized written plan of care included planned interventions based on problems identified in the updated comprehensive assessment. Clinical Record 6: The patient elected the hospice benefit on 3/1/23. The second benefit period #2 (BP#2), dated 5/30/23 to 8/27/23 was reviewed. During an Interdisciplinary Team (IDT) meeting held on 6/29/23 it was documented by the registered nurse (RN), “New purple pressure spot to R heel, facility staff, hospice staff and medical director made aware." On 7/7/23 an RN conducted a routine nursing visit and documented; “Patricia has a reddish-brown spot on her heel. Doctor aware. Antibiotic Pill and ointment delivered and started today. Educated caregiver on warm compress throughout the day and care regimen for the heel.” The plan of care (POC) for BP#2, dated 5/30/23 to 8/27/23 included physician orders dated 7/7/23, Keflex 500mg every 8 hours, oral, for 10 days, Bactroban 2% ointment apply to right ankle bid. The POC for BP#2 lacked evidence of problems, goals, or interventions to address the patient's wound or skin integrity. In an interview conducted with the Administrator/Clinical Director on 8/2/23 they did confirm that the plan of care was not updated following the new wound identified on 6/29/23 and that the care plan should have included problems, goals, or interventions related to skin integrity and wound care.