Every finding on record at Compassioncare Hospice Las Vegas LLC

Based on medical record review, interview, and policy review, the hospice agency failed to ensure that the patient, caregiver, and family goals outlined in the plan of care for 19 of 19 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19) were individualized based on information obtained in the comprehensive assessment which is completed within the first five days and the updated comprehensive assessment completed at least every 15 days. The failure to identify individualized patient and caregiver goals could result in the patient and caregiver needs to not be met. Findings include: --- Review of the 19 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19) Hospice Certification and Plan of Care documents revealed they all contained the following goals for patients, caregivers, and families. "A nursing plan of care will be established that meets the patient's needs." "A medical social worker plan of care will be established that meets the patient's needs. The plan of care will be reviewed/updated with IDG (Interdisciplinary Group) at a minimum of every 15 days throughout the hospice benefit." "A chaplain plan of care will be established that meets the patient's needs. The plan of care will be reviewed/updated with IDG (Interdisciplinary Group) at a minimum of every 15 days throughout the hospice benefit." "Patient/caregiver will actively participate in the plan of care as evidenced by voicing understanding of current plan of care throughout the hospice benefit." "Patient, family, caregivers are knowledgeable and involved in hospice plan of care for patient throughout the hospice benefit." "Patient/Caregiver will administer medications as prescribed as evidenced by no adverse effects from medication error throughout the hospice benefit." "Patient's respiratory status will be stabilized to comfort as possible throughout the hospice benefit." "Patient will be free of signs/symptoms of discomfort related to genitourinary system throughout the hospice benefit." "Skin breakdown will be identified and measures to resolve breakdown implemented promptly throughout the hospice benefit." "Patient will have an effective bowel program as evidenced by effortless bowel movements according to their normal bowel pattern or caregiver calling hospice 25/7 for no bowel movement in three days throughout the hospice benefit." "Patient will receive personal care and hygiene, including other activities of daily living to their optimal level throughout the hospice benefit." "Caregivers verbalize understanding of anorexia and/or dehydration in the dying patient and demonstrate comfort with plan of care throughout the hospice benefit." "Patient/caregiver understand the risks and benefits of side rail use throughout the hospice benefit." "Signs and symptoms of infection will be identified and physician notified for prompt intervention to minimize associated risks throughout episode throughout the hospice benefit." "General hospice comfort kit will be provided to the patient throughout the hospice benefit." During an interview on 03/02/23 at 1:00 PM, the Administrator stated the nurse picks patient goals, in addition to staff goals, by clicking on choices available in the Electronic Medical Record (EMR). The Administrator also confirmed that the software program in the EMR automatically generates additional goals at each staff visit based on problems identified during the assessment. During an interview on 03/03/23 at 2:45 PM, the Senior Regional Compliance Director stated the agency is aware that goals on the plan of care are not individualized and may not reflect the comprehensive assessment. The Compliance Director stated the company currently had a project group working on this because they identified it as an issue. The Compliance Director confirmed the goals in the reviewed 19 patient plans of care did not reflect an individual assessment or patient and caregiver collaboration in the treatment planning process. Review of an agency policy titled, "The Plan of Care-Nevada," dated 05/11/20, revealed, "A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program ...The plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care."

Based on medical record review, interview, and policy review, the hospice agency failed to ensure the goals in the patient plan of care included measurable data elements for 19 of 19 patients (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19). The failure to utilize data elements as a part of the plan of care could result in the agency not recognizing avoidable negative patient outcomes and potential harm to the patient. Findings include: --- Review of 19 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, and P19) Hospice Certification and Plan of Care documents revealed the following goals which did not include data elements to measure patient outcomes as a part of the plan of care. "Patient, family, caregivers are knowledgeable and involved in hospice plan of care for patient throughout the hospice benefit." "Patient's respiratory status will be stabilized to comfort as possible throughout the hospice benefit." "Patient will maintain optimal cardiac function within the constraints of disease throughout the hospice benefit." "Patients personal care needs will be met throughout the hospice benefit." "Patient will be free of signs/symptoms of discomfort related to genitourinary system throughout the hospice benefit." "Caregivers are knowledgeable of care and need to report changes of LOC [level of consciousness]" "Patient/Caregiver will understand the pain scale. How to manage pain and report changes to hospice" During an interview on 03/02/23 at 1:00 PM, the Administrator stated the nurse picks patient goals by clicking on choices available in the Electronic Medical Record (EMR). The Administrator confirmed that the reviewed patient plans of care did not include data elements that would demonstrate if patient outcomes were being achieved. During an interview on 03/03/23 at 2:45 PM, the Senior Regional Compliance Director stated the agency is aware of deficits in the plan of care generated by the specific software utilized and have a project group working on this concern. The Compliance Director confirmed the lack of data elements as a measurable component of the goals in the plan of care. Review of an agency policy titled, "The Plan of Care-Nevada," dated 05/11/20, revealed, "Each patient will be monitored for his/her response to care, or services provided against established patient goals and patient outcomes to evaluate progress toward goals. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes ... The written plan of care will contain, but will not be limited to, the following: ... Statement of treatment goals and documentation of progress of outcomes ... measurable outcomes anticipated from implementing and coordinating the plan of care." The policy did not specify outcomes should include measurable data elements.