Every finding on record at Cfhc No21 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 and interview. 2 of 5 (40%) records reviewed revealed the hospice did not ensure the agency did not ensure the patient's individualized written plan of care (POC) identified goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: Benefit of Election on 08/01/2023 for congestive heart failure. The Pre-bereavement assessment was documented on 08/04/2023 with an identified risk level of medium and the daughter caring for her father (the patient) and her sister who was also declining in health and could die first. The IDG plan documented on 08/09/2023, 08/23/2023. and 09/06/2023 document a bereavement risk level of low. Clinical Record 4: Benefit of Election was 07/25/2023 for end stage liver disease. On Interdisciplinary group meeting 08/09/2023 the plan documented the hospice aide frequency of 3 times a week. The clinical record documented that on 07/28/2023 the aide was discontinued by the family. The plan of care documented 08/09/2023 was inaccurate. During an interview, the Administrator (Personnel Record 1) and Director of Nursing (Personnel Record 3) agreed that closer review of the plan of care was needed.

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, document review and interview. 4 of 5 (80%) records reviewed revealed the hospice did not ensure measurable outcomes that could be anticipated from the implementation and coordination of patient-specific, individualized goals of care. Document 4: PC.6 Plan of Care Process [reviewed 03/03/2022] stated in part,a "The Plan of Care includes, but is not limited to detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care. Measurable outcomes anticipated from implementing and coordinating the Plan of Care. Clinical Record 2: Benefit of election on 08/01/2023 with plan of care 08/01/2023 - 10/29/2023. a comprehensive assessment with identified problems and goals not exclusive of: Constipation - documented goal "Patient will have routine bowel movement and fewer episodes of constipation" (routine and the fewer episodes are not measurable). Edema - "Patient will have reduced and eliminated edema with increased level of comfort and relief from edema: (reduced and increased level of comfort are not measurable). Pain - "Assessment for pain will be done frequently and pain will be controlled or eliminated" (frequency assessment and controlled pain are not measurable, the assessment documented that the patient felt a pain level of 5 was tolerable. Clinical Record 3: Benefit of Election on 07/31/2023 with diagnosis of end stage heart disease. Plan of Care 07/31/2023 - 10/28/2023.With identified problems and not exclusive but unmeasurable goals. Edema - "Patient will have reduced and eliminated edema with increased level of comfort and relief from edema: (reduced edema and increased level of comfort are not measurable) Pain - "Assessment for pain will be done frequently and pain will be controlled or eliminated" (frequency assessment and controlled pain are not measurable, the assessment documented that the patient felt a pain level of 5 was tolerable. Shortness of Breath - "Patient will have increased level of respiratory comfort and decreased level of shortness of breath (increased and decreased levels are not defined) Skin - "Maintain good skin integrity by preventing skin breakdown" good skin integrity is not measurable.. Clinical Record 4: Benefit of Election 07/25/2023 - 10/22/2023 with Liver Disease. The Plan of Care identified problems not exclusive of but with unmeasurable goals: Weight Loss - "Assessment for weight loss done regularly, and patient caregivers are instructed on measures used to promote oral intake (regularly is not measurable). Nausea: "Patient is assessed frequently for s/s related to nausea and s/sx related to nausea will be eliminated or reduced. (assessed frequency was not measurable) Clinical Record 5: Benefit of Election on 08/03/2023 for hypertension. The Plan of Care 08/03/2023 - 10/31/2023 documented problems no exclusive but unmeasurable goals. . Pain - "Assessment for pain will be done frequently and pain will be controlled or eliminated" (frequency assessment and controlled pain are not measurable. During an interview, the administrator [Personnel Record1] and Director of Nursing [Personnel Record 3] stated that clearer nursing goals could been written.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by interview and observation. In 1 of 3 (33%) observed home visits revealed that the agency did not ensure the cleaning of equipment used standard precautions and safe handling of equipment during the home visit. Home Visit 1: Observed visit 09/13/2023 with nurse {Personnel Record 3) who during assessment measured the arm circumference with a retractable tape measure. The right arm was checked the tape measure retracted and the value written then the left arm was checked the tape measure retracted and the value written. As equipment was cleaned the tape measure was cleaned and retracted but had already been retracted into the holder and had contaminated the inside of the device. During an interview, the nurse who stated that no one had ever mentioned the tape measure, agreed it should be cleaned before retracted.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical records of a patient discharged to a hospital revealed the agency did not ensure the documentation of the summary sent to the facility was completed. Clinical Record 4: Hospice Benefit of Election 07/25/2023 for end stage Liver disease. Hospitalized on 08/19/2023. The discharge summary was written but lacked documented evidence that it was sent to the hospital where the patient was admitted. The summary was sent to the physician. The nurse did speak to the hospital to clarify admission, there was no documentation in the clinical record that the summary was sent. During an interview on 9/14/2023, the Director of Nursing (Clinical Record 3) stated that another nurse did this summary and documentation of it being sent to the hospital was not present.