Every finding on record at Health at Home Central, LLC

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. Agency policy # 0-4556 “Care Plan” (revised 06/03/2024) read in part, “The comprehensive plan of care reflects client/family goals based upon problems identified in the initial/updated assessments and includes all services necessary for palliation and management of the terminal illness and related conditions.” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included services necessary to manage problems identified in the initial and updated comprehensive assessments. Clinical Record 7: The patient elected the hospice benefit on 10/05/2023. The initial assessment completed by the Registered Nurse (RN) dated 10/05/2023 documented the patient had bilateral edema. The initial plan of care did not include documentation of interventions and goals related to managing the patient’s edema. Clinical Record 11: The patient elected the hospice benefit on 11/22/2024. The initial assessment completed by the RN dated 11/22/2024 documented the patient had bilateral edema. The initial plan of care did not include documentation of interventions and goals related to managing the patient’s edema. In an interview on 02/04/2025, the Clinical Manager confirmed the patient’s edema should have been identified in the plan of care problems with interventions and goals.