Every finding on record at Clm Enterprises Inc.

It is required that each patient’s individualized written plan of care reflects patient and family goals and 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. Agency policy “Interdisciplinary Group (IDG) Plan of Care” (review date 2024) stated in part, “The IDG plan of care reflects patient/family goals and interventions based on the findings of the initial and updated comprehensive assessments.” In 2 of 6 (33%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) reflected patient and family goals and identified planned interventions based on problems identified in the initial comprehensive assessments. Clinical Record 1: The patient elected hospice care on 02/23/2024. The plan of care dated 02/23/2024 documented chronic systolic (congestive) heart failure as the terminal diagnosis. The initial nursing assessment dated 02/23/2024 documented, “New York Heart Association Class IV with signs of persistent fluid overload including non-pitting bilateral lower extremity edema as well as crackles to bilateral lower lobes.” The plans of care effective 02/23/2024 and 02/28/2024 documented goals and interventions for anticipatory grief, impaired skin integrity, the risk of COVID-19, pain, falls, and spiritual needs. The plans of care did not include documentation of goals or identified planned interventions related to the patient’s fluid overload, edema, and crackles to bilateral lower lobes. Clinical Record 2: The patient elected hospice care on 08/13/2024. The plan of care dated 08/13/2024 documented heart failure, unspecified as the terminal diagnosis. The initial nursing assessment dated 08/13/2024 documented, “Patient shortness of breath with moderate exertion at times. Staff reports that the patient is short of breath at times during conversations. Non-pitting edema to bilateral lower extremities.” The plans of care effective 08/13/2024 and 08/28/2024 documented goals and interventions for anticipatory grief, chronic pain, impaired skin integrity, the risk of airborne infection, falls, and spiritual needs. The plans of care did not include documentation of goals or identified planned interventions related to the patient’s shortness of breath and edema. The Alternate Director of Health Care Services confirmed the findings in a joint record review and interview on 09/04/2024.