Every finding on record at Legacy Hospice of Colorado Springs, LLC

Upon patient record review, 1 of 19 records (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: A coordination note dated 8/20/23 indicated that the patient had visited a pulmonologist on 8/4/23 and nasal spray was ordered. There was not evidence that this was on the medication profile.

Upon patient record review, 3 of 19 records (Patient #8,#10,#11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #8: The patient was admitted on 5/18/23. The record indicated that the bereavement assessment was completed on 7/27/23. Patient #10: The patient was admitted on 4/22/23. The record indicated that the bereavement assessment was completed on 5/19/23. Patient #11: The patient was admitted on 7/20/23. The record indicated that the bereavement assessment was completed on 7/27/23.

Upon patient record review, 1 of 19 records (Patient #12) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #12: The record indicated that the last assessment and RN visit was on 8/7/23 which is greater than the 15 day requirement.

Upon patient record review, 1 of 19 records (Patient #1) 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: The record indicated that the patient was a Full Code and did not have any funeral arrangements in place. The documentation dated 7/5/23 during the evaluation revealed that the patient did not want to discuss funeral arrangements at this time and the social worker would follow up. There was not evidence that the plan of care reflected goals and interventions based on preparing end of life planning and decisions.

Upon patient record review, 1 of 19 records (Patient #1) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: A coordination note dated 8/20/23 indicated that the patient had visited a pulmonologist on 8/4/23 and an x-ray and nasal spray were ordered. There was not evidence of an order.

Upon client record review, 4 of 19 records (Patient #2,#6,#9,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record contained volunteer documentation of a visit dated 6/19/23. The order for the volunteer visit frequency was on 6/29/23 to be effective 6/26/23 for 1 time/week for respite, companionship and music. The volunteer visit frequency was discontinued on 7/28/23. There was not evidence of visits by the volunteer between 6/26/23 and 7/28/23. Patient #6: The visit frequency for the skilled nurse was 2x/week. For the week of 7/9/23-7/15/23, the record indicated only 1 visit. Patient #9: The volunteer visit frequency was 1x/week to start the week of 8/1/23. The record indicated that there were 2 visits the week of 8/13/23 (8/14/23 and 8/15/23), and 2 visits the week of 8/20/23 (8/21/23 and 8/22/23). Patient #12: The visit frequency for the nurse was 2x/week. For the weeks of 8/13/23-8/19/23 and 8/20/23-8/26/23, the record indicated only 1 visit each of these weeks.

Upon observation and home visit, there was not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #7, RN: The staff member was observed placing a BP cuff into a container, and a stethoscope into the nursing bag without cleaning the equipment either before or after usage.

Upon personnel record review, 1 of 13 records (Personnel #11) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #11: The initial competency did not contain evidence of the validation method for all tasks. It was not documented as to how the validation was performed (verbal or return demonstration during direct patient care). There was not evidence that any of the above listed tasks were observed while providing direct patient care.

Upon patient record review, 2 of 19 records (Patient #1,#2) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide that 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 specifically 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 #1: The record indicated an order dated 7/20/23 that only 1 aide will provide personal care (decreased from 2 aides). There was not evidence that the aide plan of care was revised to reflect the change to 1 aide, but still required 2 aides for the tasks of bath, toileting, stand-by assists and alerts. Corrected on site. Patient #2: The aide visit frequency was 3x/week (1 Aide). The aide plan of care indicated 2 aides for the tasks of bathing and incontinence care. (The patient resides in her own home with no outside agency help). Corrected on site.

Upon patient record review 4 of 19 records (Patient #1,#2,#4,#5) 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 Patient #1: The visit frequency for the aide was 2 aides/2 times/week. The record indicated documentation by 3 aides on 7/6/23, documentation only by 1 aide 7/10/23, 7/11/23, 7/14/23, 7/17/23, and 7/18/23. On 7/20/23, the visit frequency was revised to only 1 aide to perform personal care. For the dates of 8/3/23, 8/8/23, 8/15/23, and 8/22/23, the record indicated documentation by 2 aides. Patient #2: The aide plan of care indicated to provide a bed bath every other visit and a shower every other visit. Also, to shampoo weekly. From 7/17/23 to current, the record did not indicate the bathing types were provided at every other visit but showers were done 2 visits in a row and other days both a bed bath and a shower was done. In addition, shampoo was provided at most all visits. (Aide visit frequency was 3x/week). Patient #4: The aide plan of care indicated to shower the first visit of the week, and to shave the patient weekly. (Aide visit frequency was 2x/week). From 8/1/23 to current, the record indicated that a shower and a shave were performed at all visits. Patient #5: The aide visit frequency, effective 6/30/23 was 3x/week. For the weeks beginning7/2/23, 7/9/23, 7/16/23, 8/6/23 and 8/13/23, the record indicated only 2 visits each of these weeks. For the week of 7/24/23, the record indicated 4 visits

Upon patient record review 1 of 19 records (Patient #12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #12: The record indicated a supervisory visit on 8/4/23. There was not evidence of a supervisory visit since this date which is greater than the 14 day requirement.

Upon patient client record review, 4 of 19 records (Patient #5,#10,#11,#13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #5,#10,#11,#13: The benefit election statement that was signed on admission indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished.

Upon patient client record review, 1 of 19 records (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1: A notation by the social worker, dated 8/7/23 indicated that an OOHDNR was completed. There was not evidence of this document on the record. Corrected on site.

Upon patient client record review, 1 of 19 records (Patient #15) did not evidence that each patient record contains physician orders. Patient #15: The patient was discharged from hospice due to improved condition and no longer meeting criteria. There was not evidence of a discharge order from the medical director.

Upon patient client record review, 3 of 19 records (Patient #1,#2,#12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1:The initial plan of care and the updates to the plan of care (Dates of 7/21/23, 8/3/23, 8/17/23) indicated that the patient was a full code. The documentation in narrative section by the social worker indicated that the patient was not a full code. There was conflicting documentation in the record. Patient #2: A nurse note, documented on paper, was dated 4/19/23. The nurse visit document did not have evidence that the nurse signed , dated or used credentials on this document. Patient #12: The record contained a missed visit note that was entered on 8/21/23 by the RN but was for a missed visit for the aide. There was not evidence of the day that the visit was missed, and the aide had completed all visits for the week of 8/20/23-8/26/23.

Upon client record review, 1 of 19 records (Patient #16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #16: The patient revoked hospice on 7/13/23. There was not evidence that a copy of the discharge summary was sent to the attending physician.

Upon client record review, 1 of 19 records (Patient #16) did not have evidence that the discharge summary includes all required information. Patient #16: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management.

Based on interview and record review, the hospice failed to ensure the registered nurse (RN) case manager that was a member of the interdisciplinary group (IDG) provided coordination of care and ensured continuous assessment of the patient's needs and implemented the interdisciplinary plan of care for 1 of 1 patient records reviewed who had a Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine) (Patient #3). --- AGENCY POLICY According to the agency policy dated, 6/27/22 and titled, Hospice Nursing Care, (read in pertinent parts): "A hospice registered nurse will be assigned as the Case Manager for each patient and family/caregiver, and his/her duties will be enumerated in a job description. Duties will include the responsibility for coordination of care, fostering communication between the patient and the interdisciplinary group and participation in all interdisciplinary group meetings for his/her assigned patients. The Case Manager will assure that components of the plan of care are established and implemented by the interdisciplinary group. The Case Manager will determine the scope and frequency of services needed based on acuity and patient and family/caregiver needs." 1. The clinical record for Patient #3 was reviewed on 1/10/23. The patient was admitted for hospice care and services on 11/30/22 with a terminal diagnosis of senile degeneration of the brain. The plan of care for the certification period 11/30/22 through 2/27/23 included orders for skilled nursing (SN) services two times a week for thirteen weeks, one time a week for a week, and three as needed (PRN) visits for symptom management; and medical social worker and chaplain evaluations. At the time of Patient #3's admission he lived at home and on 12/10/22 he moved into an assisted living residence. Further review of plan of care for the certification period 11/30/22 through 2/27/23 revealed the SN was to provide instructions/reinforcement of care of Patient #3's indwelling catheter. The plan of care failed to show evidence of orders for what size catheter Patient #3 had, if the hospice was to irrigate Patient #3's catheter or when Patient #3's catheter was to be changed and by whom (Cross Reference L547) Review of the Hospice Plan of Care Report revealed RN #8, on 11/30/22, identified Patient #3 had the SN need for skilled teaching related to the care of an indwelling urinary catheter. RN #8 included the following SN interventions for the care of Patient #3's indwelling urinary catheter: instruct regarding signs and symptoms of urinary tract infection, instruct caregiver(s) on care of Foley catheter, instruct regarding record keeping (input/output), and instruct regarding perineal care. a) The hospice failed to ensure the RN case manager (RNCM) completely assessed Patient #3. Specifically, the RNCM failed to accurately assess what type of urinary catheter Patient #3 had and failed to identify the care needs for Patient #3's urinary catheter including the size of catheter, if the catheter needed to be irrigated, when the catheter was to be changed and by whom and the daily care needs of the urinary catheter. Review of the start of care comprehensive assessment for Patient #3, completed by RN #8 on 11/30/22, showed RN #8 identified in her genitourinary assessment that Patient #3 had incontinence and an indwelling/suprapubic catheter (a tube inserted into the bladder through a cut in the abdomen used to drain urine). RN #8 assessed the catheter to be size 16 (failed to provide a measurement descriptor with the number 16), the retention balloon had 10 ml of water, and the catheter was inserted on 11/3/22. RN #8 stated catheter irrigation was not ordered. In the narrative section of the comprehensive assessment, RN #8 stated Patient #3 had "a 16FR [French] (French size is the universal gauge system used to determine what size catheter a patient has and is based upon the measurement of the external diameter of the catheter tube) indwelling foley catheter inserted by the hospital." During an interview on 1/10/23, RN #9 confirmed she was the RN assigned to be Patient #3's RNCM. Review of visit notes revealed on 12/2/22, RN #9 completed her first visit with Patient #3. RN #9 documented she assessed Patient #3's genitourinary system and identified Patient #3 to have a suprapubic catheter. RN #9 documented she did not change the catheter and failed to document the size of the catheter. In the narrative section of her visit note, RN #9 stated Patient #3 had a suprapubic catheter that was producing clear yellow urine. RN #9 failed to assess that Patient #3 had a foley catheter and what size foley catheter Patient #3 had. However, in the intervention section of the the visit note, RN #9 stated she provided instruction to the patient/caregiver on care of the Foley catheter. Review of visit notes revealed on 12/6/22, RN #9 documented she assessed Patient #3's genitourinary system and identified Patient #3 to have a Foley catheter. RN #9 documented she did not change the catheter and failed to document the size of the catheter. In the intervention section of the visit note, RN #9 stated she provided instruction to the patient/caregiver on care of the Foley catheter. Review of visit notes from 12/8/22 through 1/9/23 revealed the following: -on 18 visits (12/8/22, 12/12/22, 12/13/22, 12/15/22, two visits on 12/19/22, 12/21/22, 12/25/22, 12/27/22, 12/28/22, two visits on 12/30/22, two visits on 1/3/23, 1/4/23, 1/5/23, 1/6/23, and 1/9/23) RNs #9, #11, #13 and #14 and LPNs #7 and #12 documented they assessed Patient #3's genitourinary system and identified Patient #3 had a Foley catheter. -on four visits (12/11/22, 12/31/22, 1/1/23 and 1/8/23 RN #10 documented he assessed Patient #3's genitourinary system and identified Patient #3 had a suprapubic catheter. -on one visit (1/7/23) RN #10 documented he assessed Patient #3's genitourinary system and identified Patient #3 had no genitourinary deficits and did not have a catheter. During an interview on 1/10/23 at 4:23 p.m., the executive director stated the hospice expectation for the nurses when they completed a "head to toe assessment" was that the SN assessed the patient's general appearance and body systems. If the SN identified the patient had any external device, such as a urinary catheter, the expectation was the SN would specify the specific type of device the patient had. During an interview on 1/10/23 at 2:05 p.m., RN #8 stated she worked for the hospice as a PRN RN and she completed SN visits including admission visits as the hospice assigned her. RN #8 confirmed she completed the admission visit for Patient #3 and she assessed Patient #3 to have a Foley catheter. RN #8 stated on Patient #3's plan of care she identified Patient #3 had a Foley catheter and included the intervention that the SN was to provide teaching of how to care for the Foley catheter for the patient/caregiver, but she did not include orders about what size Foley catheter, if the Foley catheter was to be irrigated or when and by whom the Foley catheter was to be changed as that was the responsibility of the RNCM assigned to Patient #3. During an interview on 1/10/23 at 3:02 p.m., RN #11 stated Patient #3 had a Foley catheter and never had a suprapubic catheter. During an interview on 1/10/23 at 3:18 p.m., LPN #7 stated Patient #3 had a Foley catheter and never had a suprapubic catheter. During an interview on 1/10/23 at 2:45 p.m., RN #10 stated he was an on-call weekend RN for the hospice. He stated he provided care to patients based on calls the hospice received after-hours from patients/families/facilities requesting SN services. RN #10 stated he did not typically do a full head to toe assessment of each patient when he provided them care. Instead, he did a focused assessment of the patient based on the call that sent him out to provide care to the patient. RN #10 acknowledge he had provided care to Patient #3 and stated he had assessed Patient #3 to have a catheter. RN #10 stated he was 90% sure Patient #3 had a suprapubic catheter and not a Foley catheter. RN #10 stated on 1/7/23 when he documented Patient #3 did not have a catheter that he must of made a documentation error as Patient #3 had a catheter at this visit and RN #10 restated the catheter was a suprapubic catheter. During an interview on 1/10/23 at 2:12 p.m. RN #9 acknowledged she was Patient #3's RNCM. RN #9 stated her responsibilities as an RNCM included overseeing the care of the patients assigned to her. RN #9 stated as the RNCM it was her responsibility to identify a patient's care needs, ensure the hospice had the appropriate orders to meet the patient's needs and ensure care coordination occurred between patients/families/caregivers at home or at facilities. During continued interview, RN #9 stated on her initial visit with Patient #3 she documented patient #3 had a suprapubic catheter as she failed to do a physical assessment of Patient #3's genitourinary system as she did not want to make Patient #3 uncomfortable by examining his genital region. RN #9 stated, instead she asked Patient #3 what type of urinary catheter he had and he stated he had a suprapubic catheter. RN #9 stated in her subsequent visit she identified Patient #3 had a Foley catheter and not a suprapubic catheter. RN #9 acknowledged she failed to complete her responsibilities as RNCM to ensure Patient #3's plan of care included orders on what size Foley catheter Patient #3 had, if the Foley catheter needed to be irrigated, and when and by whom the Foley catheter needed to be changed.

Based on interview and record review, the agency failed to ensure the individualized written plan of care (POC) included all services necessary for the palliation and management of the terminal illness and related conditions; the agency failed to provide a detailed statement of the scope of services necessary to meet the specific needs of the patient. Specifically, the agency failed to provide orders for an indwelling catheter (Foley catheter), and skin tear, for one of one patients receiving indwelling catheter care (Patient #3). --- Findings include: AGENCY POLICY According to the agency policy titled, The Plan of Care dated 2/2020 (in pertinent parts): "The Case manager (or admitting nurse) will complete the Initial assessment and will initiate the development of the plan of care. The Case manager will then notify the attending physician of the findings, the identification of the patients' needs and then recommended services to meet those needs. The plan of care will be reviewed prior to care being delivered. The plan of care will identify the patients' needs and services to meet those needs, it must state in detail the scope and frequency of service needed to meet the patients' needs, goals and outcome achievements." According to agency policy titled, Wound Assessment, Documentation and clinical Oversight, dated 8/5/2022 (in pertinent parts): "Physician orders will be obtained for all wound treatments. wound care supplies are to be included in the patient's plan of care. Orders may not be obtained from the patient/caregiver. Documentation of the wound should be done with every dressing change and/or weekly." 1. The clinical record for Patient #3 was reviewed on 1/10/23. The patient was admitted for hospice care and services on 11/30/22 with a terminal diagnosis of senile degeneration of the brain. The POC for the certification period 11/30/22 through 2/27/23 included orders for skilled nursing (SN) services two times a week for thirteen weeks, one time a week for a week, and three as needed (PRN) visits for symptom management; medical social worker and chaplain evaluations. At the time of Patient #3's admission he lived at home and on 12/10/22 he moved into an assisted living residence. a) The hospice failed to ensure the POC included a detailed statement of the duration and frequency of services for an indwelling catheter. Review of the POC dated 11/30/22 and signed by the attending physician on 12/10/22 failed to reveal orders for an indwelling Foley catheter. Review of an initial comprehensive assessment completed on 11/30/22 by RN #8, under the genitourinary section, read; indwelling/suprapubic catheter, size 16 French, inserted 11/3/22, no irrigation orders, and balloon 10ml. During the same visit, within the narrative section of the note, RN #8 documented the patient had a 16 Fr indwelling Foley catheter inserted by the hospital. Review of a routine visit note signed and dated 12/2/22 by RN #9, revealed Patient #3 had a suprapubic catheter. Review of routine visit notes signed and dated 12/6/22, 12/8/22, 12/12/22, 12/15/22, 12/29/22, 12/21/22, 1/4/23, 1/5/23, and 1/6/23, by RN #9, revealed Patient #3 had a Foley catheter in place. Review of on call visit notes signed and dated 12/11/22, 12/31/22, 1/1/23, and 1/8/23, by RN #10, revealed Patient #3 had a suprapubic catheter. On 1/7/23 RN #10 documented Patient #3 did not have a catheter present. Further review of clinical notes dated; 12/13/22,12/27/22, 12/28/22, 12/30/22, 1/3/23, and 1/9/23 by various nursing staff revealed Patient #3 had a Foley catheter. Review of a physician order dated 12/9/22, revealed an order for catheter supplies but did not specify what supplies were needed, the catheter size, when to change the catheter, or how to care for the catheter, nor who was to do what or when. Review of the clinical record failed to reveal any orders for an indwelling catheter. During an interview on 1/10/23 at 2:05 p.m. RN #8, stated she was aware Patient #3 had a Foley catheter and the orders were to maintain it. She further stated that as the admission RN, she only documented if a patient had a Foley or not and the RN case manager should have followed up with the physician for the actual orders. During an interview on 1/10/23 at 2:12 p.m. RN #9, stated she originally asked Patient #3, what type of catheter he had in place and she denied actually observing the catheter. Patient #3 informed RN #9 it went into his bladder, so she documented it as a suprapubic catheter. RN #9 discovered at a later visit that it was a Foley catheter and corrected her documentation going forward. RN #9 further stated that she did not obtain an order for the Foley Catheter. During an interview on 1/10/23 at 2:45 p.m. RN #10, stated he was ninety percent certain Patient #3 had a suprapubic catheter in place. He further stated he never really looked at it. During an interview on 1/10/23 at 3:02 p.m. RN #11, stated she was one hundred percent sure Patient #3 had a Foley catheter in place. She further stated it was the hospice agency's responsibility to list on the POC who was doing what to care for the catheter. During an interview on 1/10/23 at 4:13 p.m., the administrator stated they did not have a policy for Foley catheter care. During the same interview Employee #3 stated, they should document orders for the Foley, including size, and how often to change it, as well as interventions and goals of care. b) The hospice failed to ensure the POC included a detailed statement of the duration and frequency of services for a wound, specifically a skin tear. Review of a triage note dated 12/24/22, revealed a facility caregiver called and stated Patient #3 had a fall and sustained a large skin tear to the left elbow. The caregiver requested a visit from hospice staff to assess the elbow and provide wound care. The triage nurse contacted the on-call RN and sent them to complete a visit. Review of a coordination of care note dated 12/24/22, RN #10 documented he dressed the wound. The note failed to reveal, where the wound was and if he obtained orders or not. Review of a clinical note dated 12/25/22 and signed by RN #11, stated skin assessment completed and a small area was noted on the sacrum. The note failed to reveal anything about the wound to the left elbow. Review of visits notes dated, 12/27/22, 12/28/22, 12/30/22, 12/31/22, 1/1/23, 1/3/23, 1/4/23, 1/5/23, 1/6/23, 1/7/23, 1/8/23, and 1/9/23 revealed integumentation to be normal for ethnicity. It failed to reveal further assessment of the left elbow skin tear/wound. Review of the clinical record failed to reveal any orders for wound care to the left elbow skin tear. During an interview on 1/10/23 at 2:45 p.m., RN #10 stated he completed a visit to Patient #3 on 12/24/22 to complete an assessment after a fall that resulted in a skin tear to the left elbow. He stated he dressed the wound with foam border gauze after rinsing it with saline. He further stated he made the decision on how to care for the wound and did not call a physician for orders. During an interview on 1/10/23 at 3:02 p.m., RN #9 stated she had not assessed the left elbow but should have called the physician for orders, since a dressing had been applied. During an interview on 1/10/23 at approximately 4:20 p.m., the administrator stated that the RN should call the physician to obtain orders for all new skin care issues and changes in patients care needs.