Every finding on record at Cura-Hpc, LLC

Based on record review and interview, the hospice failed to ensure development of a community-based risk assessment (All Hazards Risk Assessment) for 106 patients and all employees. --- A review of administrative records showed no community-based risk assessment which addressed the agency and the patient population. On 02/05/25 at 2:50 pm, Staff C stated there was no documentation of an all-hazards risk assessment.

Based on record review and interview, the hospice failed to ensure an individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for ten (Patients #1, 2, 3, 4, 5, 6, 8, 13, 14 and 18) of 19 patients reviewed. --- Patient #1 A plan of care dated 12/20/24 to 03/19/25 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #2 A review of the plan of care dated 11/28/24 to 01/26/25 documented a primary diagnosis of multiple sclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #3 A plan of care dated 10/07/24 to 01/04/25 documented a primary diagnosis of generalized atherosclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 12/19/24 to 03/18/25 documented a primary diagnosis of generalized atherosclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #5 A plan of care dated 10/09/24 to 01/06/25 documented a primary diagnosis of congestive heart failure and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #6 A plan of care dated 03/26/24 to 06/23/24 documented a primary diagnosis of Alzheimer's disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #8 A plan of care dated 12/01/24 to 01/29/25 documented a primary diagnosis of generalized atherosclerosis and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #13 A plan of care dated 11/06/24 to 01/04/25 documented a primary diagnosis of chronic obstructive pulmonary disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #14 A plan of care dated 10/14/24 to 12/12/24 documented a primary diagnosis of Alzheimer's disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #18 A plan of care dated 09/16/24 to 11/14/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 02/05/25 at 2:45 pm, Staff B stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 8, 13, 14 and 18 failed to include patient specific services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure the plan of care was revised to reflect increased hospice aide services for one (Patient #1) of 13 patients. Findings: Patient #1 A review of the plan of care dated 03/24/22 to 06/21/22 and plan of care updates dated 03/25/22, 04/08/22, 04/22/21 and 05/06/22 showed orders for a hospice aide frequency of one visit per week. A review of the clinical record showed: hospice aide visits dated 04/05/22 and 04/07/22 during the week of 04/03/22 to 04/09/22 (two completed visits); hospice aide visits dated 04/12/22 and 04/14/22 during the week of 04/10/22 to 04/16/22 (two completed visits); hospice aide visits dated 04/19/22 and 04/21/22 during the week of 04/17/22 to 04/23/22 (two completed visits); hospice aide visits dated 04/26/22 and 04/28/22 during the week of 04/24/22 to 04/30/22 (two completed visits); and hospice aide visits dated 05/03/22 and 05/05/22 during the week of 05/01/22 to 05/07/22 (two completed visits). Updates to the plan of care showed no coordination by the interdisciplinary group or updates to services provided to the patient to reflect patient needs based on increased hospice aide services. On 05/11/22 at 12:05 pm, Staff D stated the plan of care should have been updated to reflect the hospice aide services provided for Patient #1.

Based on record review and interview, the hospice failed to ensure evaluation and measurable progress of their PIP for 99 current patients and all employees. Findings: A review of QAPI records showed a PIP initiated in 2020 and 2021. Documentation showed no measurable progress of the PIP. On 05/11/22 at 1:00 pm, Staff C stated the PIP did not show the data being tracked to determine measurable progress.