Every finding on record at Lily Home and Hospice

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care and that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that nursing services were provided to meet the nursing needs of the patient as identified in the patient's initial and updated assessments. Document 1: Agency policy number PC.P45 titled "Plan of Care" reviewed/revised 7/2023, stated in part, "The patient's plan of care specifies the care and services necessary to meet the needs of the patient/family as identified in the initial, comprehensive and updated assessments of the patient." Clinical Record 6: The initial plan of care dated 11/29/2023 identified the need for nursing visits 2-3/wk through the date of the review. Only 1 nursing visit was documented the week of 12/31/2023 (01/05/2024 date of the completed visit). The clinical record lacked evidence that the nursing frequency of 2-3x/wk was followed the week of 12/31/2023. Personnel Record 3: The Chief Clinical and Compliance Officer/Supervising Nurse confirmed the finding in a joint record review and interview on 02/06/2024, that the clinical record lacked evidence that the nursing frequency of 2-3x/wk was met for the week of 12/31/2023.

It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 12 (25%) clinical records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure that a supervisory visit was made no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that the services provided met the patient's need. Document 1: Agency policy number PC.H30 titled, Hospice Aide Supervision, reviewed/revised 07/2023 stated in part, "A registered nurse makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the hospice aide are meeting the patient's needs. The supervisory visits are documented in the patient's clinical record every two weeks and include notations regarding the aide's competency, whether the aide is following the patient's plan of care and is satisfactory to the patient/family." Clinical Record 6: The clinical record included documentation of completed hospice aide visits two times a week beginning 12/06/2023. Hospice aide supervisory visits were completed on 12/19/2023 and 01/18/2024 (30 days between documented hospice aide supervisory visits). The clinical record lacked evidence that supervisory visits were completed no less frequently than 14 days. Clinical Record 7: The clinical record included documentation of completed hospice aide visits two times a week beginning 12/08/2023. Hospice aide supervisory visits were completed on 12/12/2023 and 01/05/2024 (24 days between documented hospice aide supervisory visits). The clinical record lacked evidence that supervisory visits were completed no less frequently than 14 days. Clinical Record 12: The clinical record included documentation of completed hospice aide visits two times a week beginning 09/28/2023. A hospice aide supervisory visit was completed on 10/17/2023 (20 days after the initiation of hospice aide visits). A second hospice aide supervisory visit was completed on 11/30/2023 (44 days between supervisory visits). The clinical record lacked evidence that supervisory visits were completed no less frequently than 14 days. Personnel Record 3: The Chief Clinical Officer/Supervising Nurse confirmed the findings in a joint record review and interview on 02/06/2024, that the clinical records did not include evidence that hospice aide supervisory visits were completed no less frequently than every 14 days.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record contains at a minimum physician orders. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that physician orders were obtained for all visits provided to patients. Document 1: Agency policy number PC.C15 titled, Clinical Records, section 3.k. reviewed/revised 7/2023, stated in part, "Each patient's clinical record includes, at a minimum, the following: physician orders". Clinical Record 7: The initial plan of care dated 12/01/2023 listed the nursing frequency of 1-2x/wk effective 12/01/2023 through the date of review 02/06/2024. Three nursing visits were provided during the weeks of 01/07/2024 (dates of completed visits 01/08/2024, 01/09/2024, and 01/11/2024) and 01/14/2024 (dates of completed visits 01/16/2024, 01/18/2024, and 01/19/2024). There were no documented orders for the additional visits. Personnel Record 3: The Chief Clinical and Compliance Officer/Supervising Nurse confirmed in an interview and joint record review on 02/08/2024 that additional visits were provided, and that the clinical record lacked evidence that physician orders were obtained for the additional visits.