Every finding on record at Care Alternatives of Puerto Rico, 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. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) records reviewed it was revealed that the agency did not ensure the plan of care included specific interventions based on the problems identified within the comprehensive assessments. Clinical Record 13: The initial comprehensive nursing assessment, dated 03/09/2024, documented the patient had a tracheostomy in place. The plan of care, effective 03/09/2024, did not include any problems, goals, or interventions related to the tracheostomy. Personnel Record 1: During a joint record review, conducted on 04/26/2024, the regional director of operations and the director of clinical services (personnel record 3) agreed that the plan of care did not include any interventions related to the tracheostomy.

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 2 of 9 (22%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the RN provided the aide with specific written care instructions for the aide to follow. Clinical Record 1: The patient elected the hospice benefit on 02/02/2024 with a diagnosis of senile degeneration of the brain. The hospice aide visits were documented as completed on 02/06/2024 and 02/08/2024, however, the hospice aide care plan (assignment) had an effective date of 02/13/2024. A joint record review was completed with the regional director of operations (personnel record 1) and the director of clinical services (personnel record 3), on 04/25/2024, who confirmed the record did not include any evidence the RN provided written care instructions for the aide visits that were made on 02/06/2024 or 02/08/2024. Clinical Record 13: The patient elected the hospice benefit on 03/09/2024 with a diagnosis of anoxic brain damage. The initial RN assessment dated 03/09/2024 documented the patient was receiving continuous oxygen via a mask over the tracheostomy. The hospice aide care plan (assignment), effective as of 4/9/2024, listed the relevant tasks of "bed bath" and "dressing patient", the care plan did not alert the aide that the patient had a tracheostomy with oxygen administered via a mask or provide any guidance on if the oxygen could or could not be removed during care. In a joint record review, conducted on 04/26/2024, the regional director of operations (personnel record 1) and the director of clinical services (personnel record 3) agreed that the assignment should have included guidance on the tracheostomy, what to do if the dressing was wet or dislodged, and if the oxygen could or could not be removed.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) records reviewed it was revealed that the agency did not ensure the signed copy of the election of benefit statement was completed in accordance with the code of federal regulations (CFR) 418.24. Document 1: Code of Federal Regulations (CFR) 418.24 stated in relevant parts: "(b) Content of election statement. The election statement must include the following: (4) The effective date of the election, which may be the first day of hospice care or a later date, but may be no earlier than the date of the election statement." Clinical Record 3: Record review revealed the patient is a Medicare recipient. The "Declaration of Election of Hospice" form was signed by the patient/representative on 01/11/2024. The section of the form which stated, "I recognize and understand all the aforementioned, and authorize the hospice services from Medicare will be provided by (agency name) beginning on..." the date section was left blank. Clinical Record 4: Record review revealed the patient is a Medicare recipient. The "Declaration of Election of Hospice" form was signed by the patient/representative on 02/13/2024. The section of the form which stated, "I recognize and understand all the aforementioned, and authorize the hospice services from Medicare will be provided by (agency name) beginning on..." the date section was left blank. Personnel Record 1: During the joint record reviews, conducted on 04/25/2024, the regional director of operations confirmed that the records did not include any additional documentation signed by the patient/representative to acknowledge when they had elected the Medicare hospice benefit and stated, "we are having them sign attestation statements today."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 19 (16%) records reviewed it was revealed that the agency did not ensure the clinical record included complete physician orders which were written in accordance with the agency policy and procedure. Document 2: Medications-Orders, Policy Number: PC.M55 (no date). Stated in relevant part, "1. Both telephone and written orders for medications are documented in the patient's clinical record and include: d. purpose (if PRN and/or antibiotics)." Clinical Record 4: The physician order, with an effective date of 02/13/2024, stated, "Oxygen at 2 liters PRN (as needed)". The order did not include a purpose for when the oxygen should be administered. Clinical Record 8: The physician order, with an effective date of 01/20/2024, stated, "Oxygen at 2.5 liters continuous during the night and 2.5 liters PRN during the day". The order did not include a purpose for when the oxygen should be administered. Clinical Record 14: The physician order, with an effective date of 10/23/2023, stated, "Oxygen at 2 liters PRN." the order did not include a purpose for when the oxygen should be administered. Personnel Record 1: During an interview on 04/26/2024 the regional director of operations confirmed that all PRN medication orders needed to have the purpose included and reported the director of clinical services was "Already obtaining clarification orders to fix these."