Every finding on record at Covenant Homecare

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 interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical record reviewed revealed the agency did not ensure that the individualized care plan included all of the services necessary for management of the terminal illness. Clinical Record 1: Patient admitted to hospice services on 12/21/2021 with a diagnosis of COPD. Face to face documentation dated 3/10/2023 completed by the Nurse Practitioner revealed the patient utilized a BiPap machine at night in addition to continuous oxygen during the day. The POC dated 3/22/2023 for certification period 4/6/23 to 6/4/2023, and POC dated 5/21/2023 for certification period 6/5/23 to 8/3/23 did not include documentation of interventions related to the administration and management of oxygen or BiPap. In an interview on 7/12/2023, the Director of Nursing verified that the plans of care cited in the findings did not include necessary interventions related to the management of oxygen and BiPap. 1 of 23 (4%) of clinical records reviewed revealed that the agency did not ensure that the individualized care plan included all of the services necessary for management of the terminal illness.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 1 (100%) clinical record reviewed involving a patient residing in a SNF revealed that the agency did not ensure that the plan of care specified which provider is responsible for performing the functions included in the plan of care (POC). Clinical Record 3: Patient with SOC 6/20/2023. Plan of care dated 6/20/2023 included an order that stated in part, "Hospice nurse to perform wound care to pressure ulcer on L sacral. ...Change every other day and PRN for dislodgement." SN visit frequency orders read, SN 2 WK 13. The POC did not identify the responsibility of the facility related to wound care. In interview on 7/12/2023, Director of Nursing stated, "The nurse should have documented the hospice nurse or the facility nurse. We will do further education." 1 of 1 (100%) of clinical records reviewed involving a patient residing in a SNF revealed that the agency did not ensure that the plan of care specified which provider is responsible for performing the functions included in the plan of care.