Every finding on record at Hearts Palliative & Hospice Care LLC

It is required that each patient’s individualized written plan of care 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 and interview. In 1 of 5 (20%) clinical records reviewed revealed the agency did not ensure that the plans of care included specific interventions based on problems identified in the comprehensive assessments. Clinical Record 3: The patient elected the hospice benefit on 10/19/2023. The Registered Nurse (RN) initial comprehensive assessment, dated 10/19/23, stated the patient had a terminal diagnosis of congestive heart failure and had two (2) plus pitting edema to bilateral lower extremities. The skilled nurse (SN) visit note dated 11/9/23, stated “SN (skilled nurse) assisted patient to elevate legs on center table with pillow. Patient was educated to keep legs elevated when sitting/lying down to decrease fluid retention.” The medication profile included furosemide 40 mg (milligrams) daily for fluid retention. The plan of care (POC), dated 10/19/23 included the problem titled, “cardio/respiratory” and revealed a checked box next to the intervention, “assess and instruct; edema, fluid retention, and dehydration.” Next to the intervention statement was a comment area that was left blank. There was no documented evidence for patient specific interventions for the cardio/respiratory system. During an interview, conducted on 11/21/2023, the Director of Nursing (Staff 2) reviewed the plan of care and agreed that the interventions should have included elevating the legs as per the specific instructions provided. It was further identified that the other problems / interventions on the patient's plan of care included the specific medications being administered for each problem and the DON confirmed that the Furosemide should have been listed as well.