Every finding on record at Green Hills Hospice LLC

Based on interview and record review the hospice failed to maintain compliance with this Condition of Participation – IDG, Care Planning, Coordination of Services, in that: Refer to L0557Based on record review and interview the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services for 1 of 14 patients reviewed (Patient #4).The Clinical Supervisor failed to report to the IDG team and LVN D Patient #1’s skin redness on the left side of the vaginal area and vaginal wound, failed to notify the MD of the wound and failed to obtain wound care orders.HA F did not report to the Clinical Supervisor Patient #1 had a wound to her left thigh.This failure could result in poor wound healing outcomes and places all patients at risk of a decline in health statusRefer to L0543Based on observation, record review and interview the agency failed to furnish hospice care and services as written on a plan of care established by the IDG to 1 of 14 patients reviewed. (Patient #4)The Clinical Supervisor did not assess Patient #4’s skin to her buttocks, vaginal area or upper thighs during a nursing visit on 5/28/25.This failure caused the Clinical Supervisor to not be aware of Patient #4’s wound to the left thigh and could cause a decline in the wound. Refer to L539Based on record review and interview the hospice IDG failed to work together to meet the physical needs of 1 of 14 patients reviewed. (Patient #4)The IDG did not include interventions in the care plan based on skin assessment findings that included a wound and excoriation in the vaginal area documented by the Clinical Supervisor during the initial comprehensive assessment. The failure caused Patient #4 to have unmet care needs and caused LVN D to not be aware of Patient #4’s wound to vaginal area.

Based on record review and interview the hospice IDG failed to work together to meet the physical needs of 1 of 14 patients reviewed. (Patient #4)The IDG did not include interventions in the care plan based on skin assessment findings that included a wound and excoriation in the vaginal area documented by the Clinical Supervisor during the initial comprehensive assessment. The failure caused Patient #4 to have unmet care needs and possible further decline in Patient #4’s wound to vaginal area. --- Findings included: Review of a care plan dated 4/4/25 to 7/2/25 indicated Patient #4 was admitted to hospice services on 4/4/25. Terminal diagnosis was congestive heart failure (when the heart cannot pump blood efficiently to give the body a normal supply) with related conditions of dementia (a brain disease that affects memory, problem-solving, language and behavior) and asthma(lung disease that causes inflammation and narrowing of the airways in the lungs). Interventions included skilled nursing services two days weekly and home health aide five days weekly. The care plan included interventions to assess skin and provide interventions for skin breakdown and prevention and to assess and provide interventions for wound care. The care plan did not include interventions for providing wound care and did not identify location of the wound that was documented during the initial assessment on 4/4/25. The care plan indicated the Clinical Supervisor prepared the care plan.Review of the hospice initial comprehensive  assessment dated 4/4/25 indicated the Clinical Supervisor documented Patient #4 had redness on the left side of the vaginal area with slight opening and slightly red on the right side of the vaginal area, and  Patient #4 said “Ouch when the redness was touched and cleaned.”Review of the hospice initial comprehensive  assessment dated 4/4/25 indicated the Clinical Supervisor documented Patient #4 had redness on the left side of the vaginal area with slight opening and slightly red on the right side of the vaginal area, and  Patient #4 said “Ouch when the redness was touched and cleaned.”Review of the clinical record revealed there were no coordination notes documented to indicate coordination of care had occurred between the Clinical Supervisor and MD, LVN D, HA F  or other members of the IDG regarding Patient #4’s vaginal area wound and redness that was documented on the admission assessment on 4/4/25.Review of the clinical record revealed there were no orders documented within the clinical record for wound care for the vaginal area wound and redness that was document on the admission assessment on 4/4/25. Review of nursing notes dated 4/8/25 and after indicated there was no documented evidence that Patient #4’s vaginal wound and redness had resolved. Review of the documented IDG/IDT Meeting Minutes dated 4/15/25 indicated the only topic documented pertaining to Patient #4 was her admission. The minutes indicated Client #4’s vaginal redness and wound was not addressed during IDG/IDT.Review of IDG/IDT Plan of care dated 4/15/25 to 7/2/25 indicated Patient #4 was a high risk for skin breakdown, interventions included monitor and teach measure to prevent skin breakdown. The check box labeled wound location was not marked and the box for wound care interventions was marked but contained no written wound care interventions.  During a home visit interview on 5/28/25 at 11:30 am Family Member #15 said agency nurses came to the home twice a week and the hospice aide came Monday to Friday, 5 days a week. Family Member #15 further stated that the only agency staff that looked at Patient #4’s bottom was HA F. Family Member #15 said Patient #4 had redness and a wound to back of her left thigh and showed surveyor a bottle of Nystatin Powder (powder used to treat yeast infections on the skin)100000 units per gram with no prescription label on it. During an interview on 5/28/25 at approximately 12:10 pm the Clinical Supervisor said she was the nurse who admitted Patient #4. The Clinical Supervisor said she would assess Patient’s skin on admission and if there was a concern or the aide told her there was an issue then she would assess the skin. The Clinical Supervisor said Patient #4 currently had had no issue with her skin on her bottom. The Clinical Supervisor said she should not have assessed Patient #4’s skin today because Patient #4 does not like for them to look at her butt, she had asked the patient  earlier when she was there, and Patient #1 said “No” and Family Member #15 sees her bottom too. The Clinical Supervisor said the agency had a policy to assess Patient’s skin weekly. The Clinical Supervisor said HA F was Patient #4’s aide, would see HA F every once in a while. The Clinical Supervisor said she thought the aides communicated more to the office, aides would let the Administrator know if there was an issue and then the office would let her know. The Clinical Supervisor said LVN D would let her know if there were any problems. During an interview on 5/29/25 at 11:15 a.m., the Administrator said there were no coordination notes written by the Clinical Supervisor regarding the redness and vaginal wound she had documented in Patient #4’s initial comprehensive assessment the Administrator said she would expect a skilled nurse to perform a skin assessment if the patient had a history of skin issues or fragile skin. The Administrator said Patient #4 was admitted to the hospice on 4/4/25 by the Clinical Supervisor. The Administrator said the Clinical Supervisor did not do a proper assessment of the Patient #4’s skin on admission and did not follow up to see if it was improving. The Administrator said there should have been documentation that the skilled nurse was checking Patient #4’s skin each visit to see if the issue was getting better or if further intervention was needed. The Administrator said the care plan should have specified where the wound was located. The Administrator said Patient #4’s care plan did not indicate what the hospice was doing to prevent skin breakdown. The Administrator said a sore behind the left thigh would be a change in condition and the physician should have been notified. The Administrator said a possible consequence of not providing treatment for the wound could be a lack of care for the wound and a possible worsening of her condition. During a telephone interview on 5/30/35 at 10:25 am LVN D said he saw Patient #4 on 4/8/2025 and the Clinical Supervisor had never reported to him Patient #4 had excoriation in the vaginal area or a wound to her left thigh. LVN D said if skin issues had been identified during the initial assessment it should have been included on the care plan and he could not remember specifically what had been discussed in the IDG meeting about it. LVN D said he had seen Patient #4 several times, his skin assessments of her would consist of standing her up to visualize the buttocks area. LVN D said he usually did not take the brief off to look at her vaginal area.During a telephone interview on 5/30/25 at 11:10 am the Clinical Supervisor said she performed Patient #4’s initial assessment, could not remember if she had identified any skin issues during the assessment. The Clinical Supervisor said the wound and redness should have been put on the care plan and she should have notified the doctor, if she did not it was an oversight on her part. The Clinical Supervisor said the care plan development was a team effort and could not remember if she typed up Patient #4’s care plan. The Clinical Supervisor said she had looked at the care plan from 4/4/25 and the integumentary (skin) wound section she did not put anything there, and it was probably meant for the vaginal area wound to be documented, it should have been on the care plan and was an oversight. The Clinical Supervisor said the skin issue should have been discussed in the IDG meeting, she had not told LVN D and thought she did tell MD. The Clinical Supervisor said the Administrator and Alternate Administrator perform quality assurance and read her notes but could not remember if they asked her about the skin issues found during the initial assessment. Review of an agency policy with a reviewed date on 9/1/24 titled Interdisciplinary Group Roles and Responsibilities indicated:-The IDG/IDT responsibilities include participation in the establishment of the plan of care.-The IDG/IDT, in collaboration with the attending physician (if any), will prepare a written plan of care for each patient specifying the care and services necessary to meet the patient’s specific needs identified in the comprehensive assessment.

Based on observation, record review and interview the agency failed to furnish hospice care and services as written on a plan of care established by the IDG to 1 of 14 patients reviewed. (Patient #4)The Clinical Supervisor did not assess Patient #4’s skin to her buttocks, vaginal area or upper thighs during a nursing visit on 5/28/25.This failure caused the Clinical Supervisor to not be aware of Patient #4’s wound to the left thigh and could cause a decline in the wound. --- Findings included:Review of a care plan dated 4/4/25 to 7/2/25 indicated Patient #4 was admitted to hospice services on 4/4/25. Terminal diagnosis was congestive heart failure (when the heart cannot pump blood efficiently to give the body a normal supply) with related conditions of dementia (a brain disease that affects memory, problem-solving, language and behavior) and asthma(lung disease that causes inflammation and narrowing of the airways in the lungs). Interventions included skilled nursing services two days weekly and home health aide five days weekly. The care plan included interventions to assess skin and provide interventions for skin breakdown and prevention and to assess and provide interventions for wound care. The care plan did not include interventions for providing wound care and did not identify location of the wound that was documented during the initial assessment on 4/4/25. The care plan indicated the Clinical Supervisor prepared the care plan.Review of a medication profiled dated 4/4/25 to 7/2/25 indicated Patient #4 had been prescribed Nystatin Powder 100,000 units per gram to be applied three times daily to the reddened skin area. Nystatin is used for fungal infections on the skin..Review of an IDG/IDT Meeting Minutes note dated 5/14/25 indicated Patient #4’s plan of care change included cellulitis (skin infection)  but the location was not documented. Review of an IDG/IDT Plan of care dated 5/14/25 indicated Patient #4’s functional disability included the patient was at high risk for skin breakdown, wounds to both legs with intact blisters, interventions included to monitor and teach measures to prevent skin breakdown. Review of hospice aide visit notes dated 5/20/25 to 5/27/25 indicated HA documented in her caregiver notes Patient #4 had a sore behind the left thigh and on the 5/28/25 at 9:30 am note documented a sore behind the left thigh and the Case Manager notified was the Clinical Supervisor.  During an interview on 5/29/25 at 11:15 a.m., the Administrator said there were no coordination notes written by the Clinical Supervisor regarding the redness and vaginal wound she had documented in Patient #4’s initial comprehensive assessment the Administrator said she would expect a skilled nurse to perform a skin assessment if the patient had a history of skin issues or fragile skin. The Administrator said Patient #4 was admitted to the hospice on 4/4/25 by the Clinical Supervisor. The Administrator said the Clinical Supervisor did not do a proper assessment of the Patient #4’s skin on admission and did not follow up to see if it was improving. The Administrator said there should have been documentation that the skilled nurse was checking Patient #4’s skin each visit to see if the issue was getting better or if further intervention was needed. The Administrator said the care plan should have specified where the wound was located. The Administrator said Patient #4’s care plan did not indicate what the hospice was doing to prevent skin breakdown. The Administrator said a sore behind the left thigh would be a change in condition and the physician should have been notified. The Administrator said a possible consequence of not providing treatment for the wound could be a lack of care for the wound and a possible worsening of her condition. During an observation on 5/28/25 at 11:30 am at Patient #4’s home the Clinical Supervisor assessed the patient’s right and left lower legs below the knees and feet but she did not assess any other skin on the patient to monitor for skin breakdown and she did not ask Family Member #15 if Patient #4 had any wounds, skin breakdown and or rashes.  During an interview on 5/28/25 at approximately 12:10 pm the Clinical Supervisor said she was the nurse who admitted Patient #4. The Clinical Supervisor said she would assess Patient’s skin on admission and if there was a concern or the aide told her there was an issue then she would assess the skin. The Clinical Supervisor said Patient #4 currently had had no issue with her skin on her bottom. The Clinical Supervisor said she should not have assessed Patient #4’s skin today because Patient #4 does not like for them to look at her butt, she had asked the patient  earlier when she was there, and Patient #1 said “No” and Family Member #15 sees her bottom too. The Clinical Supervisor said the agency had a policy to assess Patient’s skin weekly. The Clinical Supervisor said HA F was Patient #4’s aide, would see HA F every once in a while. The Clinical Supervisor said she thought the aides communicated more to the office, aides would let the Administrator know if there was an issue and then the office would let her know. The Clinical Supervisor said LVN D would let her know if there were any problems. During an interview on 5/29/25 at 2:10 pm the Administrator said nurses should assess the skin every visit and it should be a head-to-toe (complete) skin assessment.During a telephone interview on 5/29/25 at 2:50 pm HA F said she had been seeing Patient #4 five days a week Monday thru Friday. HA F said she provides personal care, daily showers, dressing, and applies lotion to Patient #4. HA F said in the beginning her skin to the breast and vaginal area was very red but had improved. HA F said she documented issues found in the caregiver notes and thought the Clinical Supervisor reviewed the notes and how she was being notified of issues during visits. Review of a hospice nursing clinical noted dated 5/29/25 indicated LVN D documented Patient #4 had a wound to the left thigh measuring 0.7cmx0.5cmx0.10cm. This visit with a skin assessment was conducted after the surveyors prompted the agency a new assessment was needed based off of HA F’s aide visit note documentation the existence of a wound but the day before (5/28/25) the Clinical Supervisor documented Patient #4 had no wounds During a telephone interview on 5/30/35 at 10:25 am LVN D said he saw Patient #4 on 5/29/25, did a full body assessment on her and visualized her skin. LVN D said Patient #4 had under the left breast had redness and maybe a little excoriated on the edges. LVN D said he identified a stage 2 pressure ulcer (shallow open ulcer, a blister , or an open/ruptured blister) on the back of the upper left thigh.  LVN D said Family Member #15 changed the patient’s brief. LVN D said the wound could be a shear, but he thought it was more pressure because she sits for long periods of time. LVN D said he had seen Patient #4 several times, his skin assessments of her would consist of standing her up to visualize the buttocks area. LVN D said he usually did not take the brief off to look at her vaginal area. LVN D said he has only spoken to HA F maybe once. LVN D said HA F usually communicated in meetings about problems, HA F sees Patient #4 Monday though Friday. LVN D said HA F should call the nurse directly and report to the Clinical Supervisor.  During a telephone interview on 5/30/25 at 10:55 am MD said, it had been mentioned in the IDG meetings Patient #4 had some rash in her groin and was on nystatin. MD did not provide dates of the IDG meetings when it was discussed. MD said the Administrator gave home an updated on 5/29/25, it was not a surprise Patient #4 had a pressure ulcer. It was mentioned in the meetings she had some  rash in her groin and was on nystatin. Thigh it was mentioned in the IDG. Treatment was skin barrier cream or just monitor.   It was not a surprise she had pressure ulcer. The Admin gave me an update yesterday. Described it was described as a shear type of injury. Keep it clean and dry, barrier cream and avoid any further injury.During a telephone interview on 5/30/25 at 11:10 am the Clinical Supervisor said she performed Patient #4’s initial assessment, could not remember if she had identified any skin issues during the assessment. The Clinical Supervisor said the wound and redness should have been put on the care plan and she should have notified the doctor, if she did not it was an oversight on her part. The Clinical Supervisor said the care plan development was a team effort and could not remember if she typed up Patient #4’s care plan. The Clinical Supervisor said she had looked at the care plan from 4/4/25 and the integumentary (skin) wound section she did not put anything there, and it was probably meant for the vaginal area wound to be documented, it should have been on the care plan and was an oversight. The Clinical Supervisor said the skin issue should have been discussed in the IDG meeting, she had not told LVN D and thought she did tell MD. The Clinical Supervisor said the Administrator and Alternate Administrator perform quality assurance and read her notes but could not remember if they asked her about the skin issues found during the initial assessment.

Based on record review and interview the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services for 1 of 14 patients reviewed (Patient #4).The Clinical Supervisor failed to report to the IDG team and LVN D Patient #1’s skin redness on the left side of the vaginal area and vaginal wound, failed to notify the MD of the wound and failed to obtain wound care orders.HA F did not report to the Clinical Supervisor Patient #1 had a wound to her left thigh.This failure could result in poor wound healing outcomes and places all patients at risk of a decline in health status. --- Findings included:Review of a care plan dated 4/4/25 to 7/2/25 indicated Patient #4 was admitted to hospice services on 4/4/25. Terminal diagnosis was congestive heart failure (when the heart cannot pump blood efficiently to give the body a normal supply) with related conditions of dementia (a brain disease that affects memory, problem-solving, language and behavior) and asthma(lung disease that causes inflammation and narrowing of the airways in the lungs). Interventions included skilled nursing services two days weekly and home health aide five days weekly. The care plan included interventions to assess skin and provide interventions for skin breakdown and prevention and to assess and provide interventions for wound care. The care plan did not include interventions for providing wound care and did not identify location of the wound that was documented during the initial assessment on 4/4/25. The care plan indicated the Clinical Supervisor prepared the care plan.Review of a medication profiled dated 4/4/25 to 7/2/25 indicated Patient #4 had been prescribed Nystatin Powder 100,000 units per gram to be applied three times daily to the reddened skin area. Nystatin is used for fungal infections on the skin..Review of the hospice initial comprehensive  assessment dated 4/4/25 indicated the Clinical Supervisor documented Patient #4 had redness on the left side of the vaginal area with slight opening and slightly red on the right side of the vaginal area, and  Patient #4 said “Ouch when the redness was touched and cleaned.”Review of the clinical record revealed there were no coordination notes documented to indicate coordination of care had occurred between the Clinical Supervisor and MD, LVN D, HA F  or other members of the IDG regarding Patient #4’s vaginal area wound and redness that was documented on the admission assessment on 4/4/25.Review of the clinical record revealed there were no orders documented within the clinical record for wound care for the vaginal area wound and redness that was document on the admission assessment on 4/4/25. Review of nursing notes dated 4/8/25 and after indicated there was no documented evidence that Patient #4’s vaginal wound and redness had resolved. Review of the documented IDG/IDT Meeting Minutes dated 4/15/25 indicated the only topic documented pertaining to Patient #4 was her admission. The minutes indicated Client #4’s vaginal redness and wound was not addressed during IDG/IDT.Review of hospice aide visit notes dated 5/20/25 to 5/28/25 indicated HA F documented Patient #4 had a sore behind the left thigh.Review of hospice nursing clinical notes dated 5/20/25, 5/23/25, 5/27/25 indicated LVN D documented Patient #4 had no wounds. There was no documented evidence that LVN D coordinated care concerning the sore behind Patient #4’s left thigh. Review of a hospice nursing clinical note dated 5/28/25 indicated the Clinical Supervisor documented Patient #4 had no wounds. Review of a hospice nursing clinical noted dated 5/29/25 indicated LVN D documented Patient #4 had a wound to the left thigh measuring 0.7cmx0.5cmx0.10cm. This visit with a skin assessment was conducted after the surveyors prompted the agency a new assessment was needed based off of HA F’s aide visit note documentation the existence of a wound but the day before (5/28/25) the Clinical Supervisor documented Patient #4 had no wounds Review of a hospice nursing clinical noted dated 5/30/25 indicated the Clinical Supervisor documented Patient #4 had a wound to the left thigh measuring 0.7cmx0.5cmx0.10cm.Review of IDG/IDT Plan of care dated 4/15/25 to 7/2/25 indicated Patient #4 was a high risk for skin breakdown, interventions included monitor and teach measures to prevent skin breakdown. The check box labeled wound location was not marked and there were interventions for wound care present. During a home visit observation with Patient #4 on 5/28/25 at 11:30 am the Clinical Supervisor only assessed the lower legs and feet of Patient #4. The Clinical Supervisor made no attempt to further assess Patient #4’s skin vaginal area, buttocks nor the patient’s upper thighs. The Clinical Supervisor made no attempt to ask Patient #4’s primary caregiver Family Member # 15 if Patient #4 had any wounds, skin breakdown or if Patient #4 complained of any pain to her bottom or vaginal area to suggest possible skin breakdown or wounds.During a home visit interview on 5/28/25 at 11:30 am Family Member #15 said agency nurses came to the home twice a week and the hospice aide came Monday to Friday, 5 days a week. Family Member #15 further stated that the only agency staff that looked at Patient #4’s bottom was HA F. Family Member #15 said Patient #4 had redness and a wound to back of her left thigh and showed surveyor a bottle of Nystatin Powder (powder used to treat yeast infections on the skin)100000 units per gram with no prescription label on it. During an interview on 5/28/25 at approximately 12:10 pm the Clinical Supervisor said she was the nurse who admitted Patient #4. The Clinical Supervisor said she would assess Patient’s skin on admission and if there was a concern or the aide told her there was an issue then she would assess the skin. The Clinical Supervisor said Patient #4 currently had had no issue with her skin on her bottom. The Clinical Supervisor said she should not have assessed Patient #4’s skin today because Patient #4 does not like for them to look at her butt, she had asked the patient  earlier when she was there, and Patient #1 said “No” and Family Member #15 sees her bottom too. The Clinical Supervisor said the agency had a policy to assess Patient’s skin weekly. The Clinical Supervisor said HA F was Patient #4’s aide, would see HA F every once in a while. The Clinical Supervisor said she thought the aides communicated more to the office, aides would let the Administrator know if there was an issue and then the office would let her know. The Clinical Supervisor said LVN D would let her know if there were any problems. During an interview on 5/29/25 at 11:15 a.m., the Administrator said there were no coordination notes written by the Clinical Supervisor regarding the redness and vaginal wound she had documented in Patient #4’s initial comprehensive assessment the Administrator said she would expect a skilled nurse to perform a skin assessment if the patient had a history of skin issues or fragile skin. The Administrator said Patient #4 was admitted to the hospice on 4/4/25 by the Clinical Supervisor. The Administrator said the Clinical Supervisor did not do a proper assessment of the Patient #4’s skin on admission and did not follow up to see if it was improving. The Administrator said there should have been documentation that the skilled nurse was checking Patient #4’s skin each visit to see if the issue was getting better or if further intervention was needed. The Administrator said the care plan should have specified where the wound was located. The Administrator said Patient #4’s care plan did not indicate what the hospice was doing to prevent skin breakdown. The Administrator said a sore behind the left thigh would be a change in condition and the physician should have been notified. The Administrator said a possible consequence of not providing treatment for the wound could be a lack of care for the wound and a possible worsening of her condition. During a telephone interview on 5/29/25 at 2:50 pm HA F said she had been seeing Patient #4 five days a week Monday thru Friday. HA F said she provided personal care, daily showers, dressing, and applies lotion to Patient #4. HA F said in the beginning her skin to the breast and vaginal area was very red but had improved. Said she first documented the left thigh sore on 5/20/25 and did not know if the Clinical Supervisor knew. Said she documented the sore on the notes so the nurse would be aware. HA F said she had told the family she could not apply the Nystatin powder, they had to. During a telephone interview on 5/30/35 at 10:25 am LVN D said he saw Patient #4 on 4/8/2025 and the Clinical Supervisor had never reported to him Patient #4 had excoriation in the vaginal area or a wound to her left thigh. LVN D said if skin issues had been identified during the initial assessment it should have been included on the care plan and he could not remember specifically what had been discussed in the IDG meeting about it. During a telephone interview on 5/10/25 at 10:55 am MD said, it had been mentioned in the IDG meetings Patient #4 had some rash in her groin and was on nystatin. MD did not provide dates of the IDG meetings when it was discussed.During a telephone interview on 5/30/25 at 11:10 am the Clinical Supervisor said she performed Patient #4’s initial assessment, could not remember if she had identified any skin issues during the assessment. The Clinical Supervisor said the wound and redness should have been put on the care plan and she should have notified the doctor, if she did not it was an oversight on her part. The Clinical Supervisor said the care plan development was a team effort and could not remember if she typed up Patient #4’s care plan. The Clinical Supervisor said she had looked at the care plan from 4/4/25 and the integumentary wound section, she did not put anything there and it was probably meant for the vaginal area wound, it should have been on the care plan and was an oversight. The Clinical Supervisor said the skin issue should have been discussed in the IDG meeting, she had not told LVN D, and thought she did tell MD. The Clinical Supervisor said the Administrator and Alternate Administrator performed quality assurance and read her notes but could not remember if they asked her about the skin issues found during the initial assessment. Review of an agency administrative policy with a reviewed date of 9/1/24 titled Coordination of Care indicated: -Ensure the care and services provided are based on all assessments of the patient and family needs.-Provided for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.-The designated registered nurse will coordinate care with the IDG/IDT to ensure implementation of the POC meets the continuous assessed patient and family needs. -The IDG/IDT will ensure that the care and services provided are based on all assessments of the patient’s and family’s needs and are provided in accordance with the plan of care.