Every finding on record at Asante Rogue Regional Medical Center Hospice Services

Based on interview and medical record review, it was determined the hospice failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 9 of 16 patient care plans reviewed (Patients #1, #3, #4, #5, #6, #8, #14, #15, and #16). Findings: 1. Review of the medical record of Patient #1 and #5 revealed careplan information titled "Care Plan H360: Volunteer/Massage/Music Services Goals ... " and the statement "Patient demonstrates decreased symptoms." The care plans lacked individualized information regarding what "decreased symptoms" meant for each patient and how achieving decreased symptoms would be measured. 2. Review of the medical record of Patient #3 and #8 revealed careplan information titled "Care Plan H250: Skin/Wound Goals ... " and the statements "Patient's wound improves within limits of disease process" and "Patient's skin remains intact within limits of disease process." The care plan lacked individualized information regarding what "limits of disease process" meant for each patient who are diagnosed with different conditions and how achieving these goals would be measured. 3. Review of the medical record of Patients #3, #4, #5, #6, 14, #15, and #16 revealed careplan information titled "Care Plan H430: Grief/Sadness Goals ... " and the statement "Family emotionally supported during patient terminal illness." The care plan lacked individualized measurable outcomes for each patient who are diagnosed with different conditions and how achieving these goals would be measured. During the preliminary deficiencies review with the Agency Director, QAPI Coordinator, Clinical Supervisor, Business Manager, Medical Director, and Medical Provider on 11/12/2021 at 3:00 PM the above findings were presented and discussed. The Agency Director, QAPI Coordinator, and Clinical Supervisor acknowledged the goal statements sounded generic and that Massage Therapists and Spiritual Care Providers were not trained in writing careplans.