Every finding on record at Hill Country Hospice, LLC

Based on record review and interview the agency failed to update the comprehensive assessment with changes agreed upon by the interdisciplinary team for 3 of 19 patients for which records were reviewed (Patient #12, #18 and #19) in that hospice aide (HHA) services for Patient #12 and volunteer services for Patients #18 and #19 were not added to plan of care. Failure to ensure that patients plan of care was updated per the hospice interdisciplinary group (IDG) orders had the potential to affect these 3 patients due to a need to change the care plan and could prevent the provision and supervision of necessary services. --- Findings include: Review of the clinical record for Patient #12 revealed a start of care date of 08/22/2023. Review of the POC for the certification period 07/08/2020 – 08/28/2020 revealed orders: SN 2wk X 13wk (2 times per week) +15 prn, SW 1mo X 3mo + 8 prn and Chaplain 2mo X 3mo + 10 prn. Review of the record revealed HHA services were provided 3 times per week from 08/28/2023 – 10/20/2023. Review of the POC revealed the POC was not updated to reflect HHA services were added. An Interview was conducted on 12/12/2023 at 12:00 p.m. with the Administrator. The clinical record for Patient #12 was reviewed. Surveyor requested documentation that the patients POC had been updated per the IDG meeting notes. The Administrator acknowledged the POC had not been updated to reflect the addition of HHA services. Surveyor asked what may have caused the failure. Administrator stated there had been several staffing changes since the change in ownership of the agency. Review of the clinical record for Patient #18 revealed a start of care date of 06/27/2023. Review of the POC for the certification period 09/25/2023-11/25/2023 revealed orders: SN 2wk X 13wk + 15 prn, HHA 3wk X 13wk, Chaplain 1mo X 3mo + 10 prn and SW 1mo X 2mo + 8 prn. Review of the clinical revealed volunteer services were provided on 10/09/2023, 10/16/2023, 10/26/2023 and 11/14/2023. Review of the POC revealed the agency failed to update the patients POC to reflect the addition of volunteer services. Review of the clinical record for Patient #19 revealed a start of care date of 09/02/2023. Review of the POC for the certification period 09/02/2023 – 10/28/2023 revealed orders: SN 2wk X 13wk + 15 prn, HHA 3wk X 13wk, 2wk X 1wk, Chaplain 2m X 3m + 10 prn and SW 1m X 3m + 8 prn. Review of the clinical record revealed volunteer services were provided on 10/07/2023 and 10/25/2023. Review of the POC revealed the agency failed to update the patients POC to reflect the addition of volunteer services. Surveyor conducted an interview on 12/14/2023 at 11:40 a.m. with the Volunteer Coordinator. Surveyor reviewed the clinical records for Patient #18 and #19 with the Volunteer Coordinator. Volunteer Coordinator confirmed volunteer services were provided. Surveyor asked if volunteer services were added to the patients POC. Volunteer Coordinator stated, ";No. I should have done that. I didnt think about it. Ive only been the Volunteer Coordinator for 3 months." Review of the agencys policy and procedure manual revealed a policy entitled ";Plan of Care Process, PC.30, Rvd:102022", which read in part ";The POC includes, but is not limited to: Designation of discipline(s) responsible for providing specific services. A revised POC will include information from the patients updated comprehensive assessment and will note the patients progress toward outcomes and goals specified in the plan of care."