Every finding on record at Elements of Elder Care

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 14 (14%) clinical records reviewed revealed the patient's individual written plan of care (POC) lacked specific interventions based on problems identified in the initial and updated comprehensive assessments. Document 1: Policy #9-017, "The Plan of Care (Dated: 4/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group . . . This plan will focus on identified problems, goals, and interventions." Clinical Record 8: The patient elected the hospice benefit on 7/24/23. The certificate of terminal illness (CTI) for certification period 7/24/23 - 9/21/23 stated the patient had an ileostomy. The POC dated 7/24/23 lacked evidence of interventions for the Ileostomy (stoma). There was a goal that stated, ".... will maintain stoma integrity and function for as long as possible." The specific interventions stated, "instruct patient/family in proper skin care surrounding stoma." The intervention lacked detail of specific instruction as to specific cleansing order. Clinical Record 11: The patient elected the hospice benefit on 4/3/23. The CTI stated the patient had oxygen and had a wound. The POC dated 8/28/23 had evidence of goals for respiratory and integumentary. The record lacked evidence of specific interventions for the oxygen (missing Oxygen L/min and via cannula), and the record lacked evidence of specific interventions for the wound care ordered. Upon interview on 9/1/2023, the Chief Executive Officer and the Administrator/Director of Clinical Services reviewed and agreed the POCs above lacked the specific interventions for the treatment(s) being provided.