Every finding on record at Coastal Home Health & Hospice, Inc.

Based on interview and medical record review, it was determined the agency failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 17 of 19 patient care plans reviewed (Patients #1 - #5, #7, and #9 - #19). --- Review of the medical record of Patient #1 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Pain, Respiratory, Anxiety and Psychological." A patient problem of "Safety" with a patient goal of "Patient's risk of injury will be minimized while on hospice" was listed. The care plan lacked information that would individualize this problem for this patient and how "minimized" would be measured. Review of the medical record of Patient #2 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Pain, Respiratory, Anxiety and Psychological." A patient problem of "Safety" with a patient goal of "Patient's risk of injury will be minimized while on hospice" was listed. The care plan lacked information that would individualize this problem for this patient and how "minimized" would be measured. Similar findings were identified in the records of patients #3 - #5, #7, #9 - #13, and #15 - #19. Review of the medical record of Patient #16 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Pain, Nutrition, Dementia and Respiratory." A patient problem of "Skin" with a patient goal of "Patient's skin integrity will remain intact within limits of disease process while on hospice" was listed. The care plan lacked information that would individualize this problem for this patient and how "within limits of disease process" would be measured. Review of the medical record of Patient #19 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Pain, Nutrition, Dementia and Respiratory." A patient problem of "Skin" with a patient goal of "Patient's skin integrity will remain intact within limits of disease process while on hospice" was listed. The care plan lacked information that would individualize this problem for this patient and how "within limits of disease process" would be measured. Review of the medical record of Patient #1 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Respiratory, Anxiety, Neurological and Psychological." A patient problem of "Pain" was listed with a patient goal of "Patient will achieve desired pain level throughout hospice care." The care plan lacked information that would individualize this problem and how "desired pain level" would be measured. Review of the medical record of Patient #2 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Respiratory, Anxiety, Neurological and Psychological." A patient problem of "Pain" was listed with a patient goal of "Patient will achieve desired pain level throughout hospice care." The care plan lacked information that would individualize this problem and how "desired pain level" would be measured. Similar findings were identified in the record of patient #3 - #4, #10, #11, #13 - #16 and #19. Review of the medical record of Patient #4 revealed a document titled "Plan of Care - Problems." Listed in this document were several patient care problems such as, but not limited to, "Respiratory, Anxiety, Nutrtition [sic] and Psychological." A patient problem of "increasing weakness" with a patient goal of "increasing weakness, safety for falls, bed bound" was listed. The care plan lacked information that would individualize this problem for the patient and how the goal would be measured. During interview and review of documentation on 5/15/2023 at 11:00 AM, Employee #13 confirmed that the care plans did not have individualized measurable goals.