Every finding on record at Covenant Hospice & Palliative Care LLC

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 the following: measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #C_09A, "Plan of Care" (revised 01/20/2020), stated in part, "Measurable outcomes have data attached to them." In 10 of 14 (71%) clinical records reviewed, the hospice did not ensure that the plan of care included documentation of patient and family goals with defined and measurable outcomes. Clinical Record 1: The patient elected hospice care on 01/23/2023 with the diagnosis of senile degeneration of brain. The initial comprehensive assessment documented the problem of "alteration in comfort." The POC documented the goal: "Pt/caregiver understand the cause of pain." The goal statement did not define how the desired outcome of "understanding the cause of pain" would be specifically measured. Clinical Record 2: The patient elected hospice care on 03/03/2022 with the diagnosis of chronic obstructive pulmonary disease (COPD). The initial comprehensive assessment documented the problem of "difficulty breathing." The POC documented the goal: "Respiratory changes will be identified promptly and intervention initiated promptly." The goal statement did not define how the desired outcome of "will be identified promptly and intervention initiated promptly" would be specifically measured. Clinical Record 3: The patient elected hospice care on 02/10/2023 with the diagnosis of senile degeneration of brain. The initial comprehensive assessment documented the problem of "altered sensory neurological status." The POC documented the goal: "Patient/caregiver understands neurological problems." The goal statement did not define how the desired outcome of "understanding neurological status" would be specifically measured. Clinical Record 4: The patient elected hospice care on 04/10/2023 with malignant neoplasm upper lobe left bronchus. The initial comprehensive assessment documented the problem of "alteration in comfort." The POC documented the goal: "Pt/caregiver understand the cause of pain." The goal statement did not define how the desired outcome of "understanding the cause of pain" would be specifically measured. Clinical Record 6: The patient elected hospice care on 07/11/2023 with the diagnosis of atherosclerotic native arteries of extremities. The initial assessment documented the problem of "alteration in skin integrity." The POC documented the goal: "Patient/caregiver demonstrates proper wound care." The goal statement did not define how the desired outcome of "demonstrates proper wound care" would be specifically measured. Clinical Record 7: The patient elected hospice care on 03/14/2023 with the diagnosis of Alzheimer's. The initial comprehensive assessment documented the problem of "alteration in comfort." The POC documented the goal: "Pt/caregiver understand the cause of pain." The goal statement did not define how the desired outcome of "understanding the cause of pain" would be specifically measured. Clinical Record 8: The patient elected hospice care on 02/10/2023 with the diagnosis of alcoholic hepatitis with ascites. The initial comprehensive assessment documented the problem of "alteration in respiratory." The POC documented the goal: "Patient will have minimal problems with respiratory comfort." The goal statement did not define how the desired outcome of "minimal problems" would be specifically measured. Clinical Record 9: The patient elected hospice care on 01/12/2023 with the diagnosis of neurocognitive disorder with Lewy bodies. The initial comprehensive assessment documented the problem of "alteration in comfort." The POC documented the goal: "Pt/caregiver understand the cause of pain." The goal statement did not define how the desired outcome of "understanding the cause of pain" would be specifically measured. Clinical Record 10: The patient elected hospice care on 03/14/2023 with the diagnosis of COPD. The initial comprehensive assessment documented the problem of "alteration in respiratory." The POC documented the goal: "Patient will have minimal problems with respiratory comfort." The goal statement did not define how the desired outcome of "minimal problems" would be specifically measured. Clinical Record 14: The patient elected hospice care on 04/15/2022 with the diagnosis of protein-calorie malnutrition. The initial assessment documented the problem of "alteration in nutrition." The POC documented the goal: "Patient will have minimal problems with nutrition." The goal statement did not define how the desired outcome of "minimal problems with nutrition" would be specifically measured. During an interview on 08/16/23, the Director of Quality Outcomes confirmed the finding and stated they were working on a performance improvement plan with these identified documentation issues.