Every finding on record at Careline Hin100 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 14 (7%) clinical records reviewed, it was revealed that the agency did not ensure that the plans of care included all interventions based on the needs of the patient identified in the comprehensive assessments. CLINICAL RECORD 5: The hospice benefit of the election was 11/26/2024 with a primary diagnosis of Alzheimer's disease with secondary diagnoses of stage 3 pressure ulcer, and urinary and fecal incontinence. Wound care was managed by the facility staff. The nursing comprehensive assessment was documented on 02/10/2025 and included wound care change orders and documented that the patient was using Prostat (a nutrition drink) 3 times a day and the patient occasionally refused this. The updated plans of care on 02/18/2025, 03/04/2025, and 03/18/2025 noted slow healing wounds and decreasing oral intake but were not updated (as of the record review on 03/26/2025) to include interventions for the supplement or any other interventions specific to the nutritional concerns documented. During interview with the Administrator who reviewed the record and confirmed that the Prostat that the patient was using was not documented on the plan of care nor was the plan of care updated with interventions specific to the decline in nutrition noted in the assessments.

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 clinical record review and interview. In 1 of 12 (8%) clinical records reviewed, in which a hospice aide services were accepted, the agency did not ensure that the hospice aide followed all assigned tasks on the interdisciplinary ordered plan of care. CLINICAL RECORD 1: The hospice aide plans of care with effective dates of 11/07/2024 and 01/17/2025 both included the task “obtain weight on the first visit of each month.” The following dates were for the first aide visits of the month 12/02/2024, and 01/03/2025; they lacked documented evidence that a weight was obtained. The vital sign flow sheet, located in the clinical record, included a documented weight on 02/05/2025 and 02/13/2025 of 143 pounds, it is unclear who documented this weight. The record was jointly reviewed with the Administrator, on 03/26/2025, and during the interview they confirmed that the monthly weights were not obtained and documented by the aide per the care plan orders.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescriptions and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review and interview. 1 of 9 (11%) records revealed that the agency did not ensure the patient’s oxygen was included on the medication profile. Record #98378: The medication profile initiated on 4/8/2022 and reviewed on 4/20/2022, 5/4/2022, 5/18/2022 and 6/1/2022, per IDG notes, did not include documentation of the oxygen used by the patient. Nursing documentation on notes dated 04/08/2022, 4/11/2022, 4/21/200, 4/28/2022 and 5/26/2022 revealed that patient was utilizing oxygen. Interview with the Chief Clinical Officer on 6/7/2022 confirmed that the medication profile in the clinical record did not include oxygen.

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, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation and interview. 1 of 9 (11%) records reviewed revealed the agency did not ensure that oxygen, related to the palliation and management of the terminal illness, was identified in the plan of care. Record #98378 - The Plan of Care written 4/07/2022 revealed interventions for oxygen safety with no orders for oxygen. No physician orders for oxygen were present in the patient record, including no record of amount, frequency or duration that oxygen was to be utilized. Nursing documentation on notes dated 04/08/2022, 4/11/2022, 4/21/200, 4/28/2022 and 5/26/2022 revealed the patient was utilizing oxygen. During a home visit observation completed on 6/7/2022, the patient was observed wearing a nasal cannula and utilizing oxygen. Interview with the Chief Clinical Officer on 6/7/2022 confirmed that the clinical record did not include orders for the use oxygen on the plan of care.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by personnel record review, observation, policy review and interview. 1 of 9 (11%) personnel records revealed the agency did not ensure documented evidence of the vaccination status of each employee prior to providing care and services to patients and families. Personnel Record #16493 - The employee was hired on 5/25/2022 and the record did not contain evidence of vaccination status or request for exemption. During a home visit observation on 6/7/2022, the clinician was observed providing patient care in the patient's home in an assisted living facility. Prior to the end of the site visit review, an exemption request was initiated. Agency policy, "No. 4-005, Covid-19 Vaccination Response and Management", stated in part: “Upon hire, all eligible employees will be required to submit applicable vaccination documents or exemption forms to Human Resources department for review and approval.” Interview with the Chief Clinical Officer on 6/8/2022 confirmed the personnel file did not include vaccination status or request for exemption until 06/07/2022. Chief Clinical Officer reported that Human Resources reported on 6/8/2022 that they had not received any documents related to vaccination status or exemptions as of 6/8/2022.