Every finding on record at Healthy Lifestyle Hospice Care Inc

Upon patient record review, 2 of 14 (Patient #1,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, No evidence of plan of care for pain and symptom management; although there were orders for tramadol 50mg 1 tab 2x/day PRN for mod to severe pain and Acetaminophen 500mg every 6 hours PRN for mild pain. Patient #5, No evidence of an individualized care plan for seizure management; although there was an order for Keppra 250mg 1 tablet 1x/day.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #13, 14, Aide care plan documents to complete bed bath and shower with no evidence to identify if patient able to identify which one they want.

Upon patient record review 4 of 14 (Patient #6,7,13,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #6, Aide frequency 2x/week. The week of 4/28/24, 3 aide visits made. Patient #7, Care plan directs aide to complete assist OOB/transfer, up in chair. On 4/17/24, no evidence aide completed tasks, documentation in these areas state no, without documentation of aide reporting to RN the tasks that were not completed. Patient #13, Care plan directs aide to complete bed bath, foley care and transfer. On 4/11/23, no evidence aide completed tasks, documentation in these areas state no, without documentation of aide reporting to RN the tasks that were not completed. Patient #14, Care plan directs aide to complete bed bath, shave, transfer. On 12/8/23, no evidence aide completed tasks, documentation in these areas state no, without documentation of aide reporting to RN the tasks that were not completed.