Every finding on record at Castle Senior Living, Inc.

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, document review and interview. In 1 of 4 (25%) clinical records reviewed in which complementary therapy services were accepted, it was revealed that the agency did not ensure the updated plan of care documented interventions for the therapy. Agency policy 829, Plan of Care - Revised, stated in part, "Revised plan of care must include information from the patient updated comprehensive assessment and must note the patient progress toward outcomes and the patient's goals as specified in the plan of care. The plan of care includes services necessary for the palliation and management of the terminal illness and related conditions and includes the identification of problems or needs and the establishment of appropriate goals." Clinical Record 9: The hospice election of benefit was dated 07/02/2024. The benefit periods were dated 07/02/2024 - 09/29/2024 and 09/30/2024 - 11/28/2024. All plans of care were reviewed. The complementary therapy service began on 09/19/2024 at a frequency of one time a month, providing pet therapy. As of 11/21/2024, no goals or interventions were documented for complementary therapy. A frequency of one (1) time a month was ordered but no documented interventions or goals were on any of the updated care plans. During an interview, the Executive Director and Coordinator of Complimentary Therapy who reviewed the record, confirmed the finding and stated the interventions of comfort and coping were not documented on the plan of care.

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 13 (15%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure the registered nurse (RN) prepared a hospice aide plan of care (POC) that contained clear and specific instructions for the patient's required care. Clinical Record 2: The aide POC was updated on 10/04/2024 for a patient with a primary diagnosis of senile degeneration of the brain with the following assigned tasks: shower on Friday; and complete bed bath if the patient is exhibiting increased anxiety. As written, the assigned task allows the aide to decide which bath to provide and define the signs and symptoms of increased anxiety, which is outside of the scope of practice for an aide. The aide visits were reviewed from this time frame and the aide only completed the shower task. Clinical Record 7: The aide POC was dated 09/30/2024 with the assigned task to apply barrier cream to -_______ every visit. The aide documented that barrier cream was applied every visit but did not identify and document the location. During an interview on 11/22/2024, the aide stated the cream was applied to the coccyx area as discussed with the nurse. During an interview on 11/21/2024, the Executive Director confirmed the aide plans of care did not include specific patient care instructions.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed did not include documented evidence the skilled nurse followed the plan of care as ordered. Record #42716 was reviewed and identified the plan of care assigned a visit frequency for skilled nursing visit two times a week starting 9/19/2021. During the week of 9/19/2021-9/25/2021, there was one nurse visit. There was no documented evidence of a second nurse visit that week. The Executive Director was interviewed on 12/15/2021 and stated, the nurse was out on COVID precautions on this date. The Executive Director confirmed the visit was cancelled by the hospice agency.

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 the following: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 5 (60%) clinical records reviewed did not include documented evidence that the plan of care included measurable outcomes. Record #42716 was reviewed and identified a comprehensive assessment was completed on 9/8/2021. The documentation revealed: “area under right breast reddened as well as folds in groin. Current order for nystatin 2x daily, desitin (zinc oxide) 2 x daily and hibs cleanse 2 x weekly with showers.”. The plan of care dated 9/8/2021 identified a problem, “skin integrity”, with a goal that “patient will achieve and maintain optimal skin integrity as disease progresses.” The goal did not include a description of how the patient's progress toward the desired outcome would be measured. Record #87195 was reviewed and identified a comprehensive assessment was completed on 9/3/2021. The documentation revealed: “patient did report she experiences SOB at rest, rated it 3/10 which is tolerable. Patient has experienced SOB exacerbations in the past.”. The plan of care dated 9/3/2021 identified a problem “respiratory” with a goal “patient will achieve optimal breathing patterns, airway patency, and comfort.” The goal did not include a description of how the patient's progress toward the desired outcome would be measured. Record #49942 was reviewed and identified a comprehensive assessment was completed on 10/28/2021. The documentation revealed: “3+ edema to bilateral ankles and non-pitting edema to bilateral feet and lower legs. Discoloration also noted in BLE’s.” The plan of care dated 10/28/2021 identified a problem, “cardiovascular”, with a goal, “patient will maintain adequate cardiac/circulatory function and fluid volume as long as possible.” The goal did not include a description of how the patient's progress toward the desired outcome would be measured. The Director of Nursing was interviewed on 12/14/2021 and stated the goals did not contain statements to measure the outcome. The Executive Director confirmed this finding on 12/15/2021.

It is required that a hospice aide provides services are 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. 2 of 5 (40%) clinical records reviewed did not include documented evidence the hospice aide followed the plan of care as ordered. Record #42716 was reviewed and identified the plan of care assigned a visit frequency for the hospice aide four times a week starting 9/19/2021. During the week of 9/19/2021-9/25/2021, there were two hospice aide visits completed. There was no documented evidence of a third or fourth hospice aide visit that week. A documented missed visit by clinician stated, “COVID-19 precautions. Patient has reliable caregiver, RN to check in via phone as needed." Record #87195 was reviewed and identified the plan of care assigned a visit frequency for the hospice aide two times a week starting 9/19/2021. During the week of 9/19/2021-9/25/2021, there was one hospice aide visit. There was no documented evidence of a second hospice aide visit that week. The Executive Director was interviewed on 12/15/2021 and stated, the hospice staff assigned to the aide visits was out on COVID precautions on these dates. The Executive Director confirmed the visits were cancelled by the hospice agency.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. Review of 1 of 5 (20%) clinical records revealed the hospice plan of care did not specify which provider was responsible for performing a treatment included in the plan of care. Record #42716 was reviewed and identified a comprehensive assessment was completed on 9/8/2021. The documentation revealed “area under right breast reddened as well as folds in groin. Current order for nystatin 2x daily, desitin 2x daily, and hibs cleanse 2x weekly with showers.”. There was no documented evidence on the plan of care that described who was responsible for completing the ordered treatment. The Director of Nursing was interviewed on 12/14/2021 and stated there was no designation of responsibility for the treatment. It was stated that the facility administers the medications as ordered and the hospice nurse checks during her visits and provides the treatment if needed. The Executive Director confirmed this finding on 12/15/2021.