Every finding on record at Cfhc No24 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. In 3 of 5 (60%) clinical records reviewed, the agency did not ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 07/07/2023, with a terminal diagnosis of Renal Cancer. The Registered Nurse documented in the comprehensive assessment dated 07/07/2023 that the patient was prescribed insulin and monitored blood glucose values daily through fingerstick testing for symptoms of hypo/hyperglycemia. The Hospice Plan of Care (POC) dated 07/07/2023 included medications prescribed to control Diabetes Mellitus (DM). The Hospice POC orders included, Novolog 100u/ml 22U SQ TID (three times a day) and Basaglar Kwik pen 100u/ml 50U sq QHS (at bedtime). The Hospice POC did not include planned interventions related to DM assessment and management based on the problems identified in the initial comprehensive assessment dated 07/07/2023. Clinical Record 2: The patient elected the hospice benefit on 07/07/2023, with a terminal diagnosis of Renal Cancer. The Registered Nurse documented in the comprehensive assessment dated 07/07/2023 that the patient was prescribed insulin and monitored blood glucose values daily through fingerstick testing for symptoms of hypo/hyperglycemia. The Hospice POC dated 07/07/2023 included medications prescribed to control DM. The Hospice POC orders included, Novolog 100u/ml 22U SQ TID and Trulicity Kwik pen 1.5mg/.5ml 1.5mg sq q (every) week. The Hospice POC did not include planned interventions related to DM assessment and management based on the problems identified in the initial comprehensive assessment dated 07/07/2023. Clinical Record 4: The patient elected the hospice benefit on 07/18/2023, with a terminal diagnosis of Hepatic Encephalopathy. The Registered Nurse documented in the comprehensive assessment dated 07/18/2023 that the patient had a “16Fr 10cc foley catheter inserted on 07/04/2023 in place” and the comprehensive assessment included a planned interventions that read “foley catheter change q (every) month and prn (as needed) for dislodgement.” The Hospice POC dated 07/18/2023 did not include interventions regarding the assessment and management of the patient’s foley catheter. During an interview dated 08/16/2023, the Administrator reviewed the associated records and stated interventions had since been added to the plans of care.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service. Clinical Record 3: The patient elected the hospice benefit on 07/11/2023, with a terminal diagnosis of Alzheimer’s Disease. The initial psychosocial assessment dated 07/14/2023 was completed by the Medical Social Worker in the EMR (Electronic Medical Record). The initial psychosocial assessment was not signed or dated by the MSW. Review of Hospice Aide visit notes dated 07/11/2023 through 08/05/2023 revealed the visit notes had been completed in the EMR but were not signed and dated by the clinician that completed the visit notes. During an interview dated 08/16/2023, the Administrator reviewed the associated record and stated the assessment/visit notes had since been sent back to the clinicians and were now signed and dated.