Every finding on record at Life Care Hospice, 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 and interview. In 5 of 6 (83%) clinical records reviewed revealed that that agency did not ensure the patient's individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial and comprehensive assessments. CLINICAL RECORD 1: The patient elected hospice care on 12/24/2024 with the diagnosis of chronic obstructive pulmonary disease. A psychosocial assessment completed by the medical social worker on 02/24/2025 documented, "Pt reports that she would like to apply for discount on energy bill if she qualifies. SW educated patient on Green Cross program and offered to contact them on pt behalf. SW applied for EAP program for pt and educated pt on time frames and application." The plans of care effective 12/24/2024-03/23/2025 and 03/24/2025-06/21/2025 did not include planned interventions and patient and family goals for the patient's identified psychosocial needs. CLINICAL RECORD 2: The patient elected hospice care on 04/16/2025 with the senile degeneration of the brain. A spiritual assessment completed by the chaplain on 04/17/2025 documented, "Chaplain to provide visits for spiritual presence and support. Chaplain will monitor patient for spiritual crises and distress. Patient will take communion on next visit and Chaplain will bring other enrichment items" The plan of care effective 04/16/2025-07/14/2025 did not include planned interventions and patient and family goals for the patient's identified spiritual needs. CLINICAL RECORD 3: The patient elected hospice care on 12/23/2024 with the diagnosis of chronic obstructive pulmonary disease. A spiritual assessment completed by the chaplain on 12/27/2024 documented, "Chaplain to provide visits for spiritual presence and support. Chaplain will monitor patient for spiritual crises and distress." The plans of care effective 12/23/2024-03/22/2025 and 03/23/2025-06/20/2025 did not include planned interventions and patient and family goals for the patient's identified spiritual needs. CLINICAL RECORD 4: The patient elected hospice care on 12/24/2024 with the diagnosis of alcoholic liver disease. A psychosocial assessment completed by the medical social worker on 12/29/2024 documented, "Patient would like MOW [Meals on Wheels], SW [Social Worker] will apply." The plan of care effective 12/24/2024-03/23/2025 and 03/24/2025-04/07/2025 did not include planned interventions and patient and family goals for the patient's identified psychosocial needs. CLINICAL RECORD 5: The patient elected hospice care on 12/25/2024 with the diagnosis of chronic obstructive pulmonary disease. A spiritual assessment completed by the chaplain on 12/29/2024 documented, "Chaplain to provide monthly visit for spiritual presence and support. Chaplain will monitor for spiritual crises and distress." The plan of care effective 12/25/2024-03/24/2025 did not include planned interventions and patient and family goals for the patient's identified spiritual needs. During the joint record review and interview on 06/16/2025, the Assistant Director of Nursing confirmed that the plan of care did not include goals or interventions related to psychosocial and spiritual needs.

It is required that hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 6 (50%) clinical records reviewed, in which aide services were accepted, revealed the agency did not ensure the hospice aides completed the visits as ordered by the interdisciplinary group (IDG). CLINICAL RECORD 1: The patient elected hospice care on 12/24/2024 with a diagnosis of chronic obstructive pulmonary disease. The plan of care effective 03/24/2025 included orders for a hospice aide (HA) visit frequency of two times per week. The record revealed the patient received HA visits twice weekly through 05/21/2025. The clinical record did not contain documentation of completed HA visits the week of 05/25/2025 through the date of review on 06/16/2025 or physician orders to discontinue HA visits. The clinical record lacked evidence that HA visits were provided as ordered by the interdisciplinary group. CLINICAL RECORD 2: The patient elected hospice care on 04/16/2025 with a diagnosis of senile degeneration of the brain. The plan of care effective 04/16/2025 included orders for hospice aide (HA) visit frequency of three times per week. The record revealed the patient received HA visits three times weekly through 05/23/2025. The clinical record did not contain documentation of completed HA visits the week of 05/25/2025 through the date of review on 06/16/2025 or physician orders to discontinue HA visits. The clinical record lacked evidence that HA visits were provided as ordered by the interdisciplinary group. CLINICAL RECORD 3: The patient elected hospice care on 03/23/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care effective 04/16/2025 included orders for hospice aide (HA) visit frequency of three times per week. The record revealed the patient received hospice aide visits twice weekly through 05/21/2025. The clinical record did not contain documentation of completed HA visits the week of 05/25/2025 through the date of review on 06/16/2025 or physician orders to discontinue HA visits. The clinical record lacked evidence that HA visits were provided as ordered by the interdisciplinary group. The Assistant Director of Nursing confirmed the findings in a joint record review and interview on 06/16/2025, and stated in part, "Our full-time aide had to go on an unexpected leave, we have another aide in the onboarding process."