Every finding on record at Lilycare of New Hampshire 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 4 of 7 (57%) clinical records reviewed, it was revealed that the patient's individual written plan of care (POC) did not have goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 10/13/23. The initial nursing assessment dated 10/13/23, stated the patient had depression (prescribed Citalopram), agitation (prescribed Lorazepam), ascites (managed with PleurX peritoneal catheter drainage system) and bladder incontinence requiring a 16 French Foley catheter. The interdisciplinary group (IDG) POC dated 10/19/23, 11/2/23, 11/16/23, 11/30/23, 12/14/23 and 12/28/23, included these identified problems, but did not include goals and interventions for depression, agitation, ascites, bladder incontinence and Foley care. Clinical Record 2: The patient elected the hospice benefit on 10/13/23. The initial nursing assessment dated 10/13/23, stated the patient had depression (prescribed Lexapro, and Zyprexa), agitation (prescribed Ativan), insomnia (prescribed Melatonin), dysphagia, tremors, fall precautions and bowel/bladder incontinence. The IDG POC dated 11/2/23, 11/16/23, 11/30/23, 12/14/23, and 12/28/23, included these identified problems, but did not include goals and interventions for depression, agitation, insomnia, dysphagia, tremors, fall precautions, and bladder/bowel incontinence. Clinical Record 3: The patient elected the hospice benefit on 11/22/23. The initial nursing assessment dated 11/22/23, stated the patient had depression (prescribed Mirtazapine), constipation (prescribed MiraLAX and Senna) and bladder/bowel incontinence. The IDG POC dated 11/30/23, 12/14/23 and 12/28/23, included these identified problems, but did not include goals and interventions for depression, constipation and bladder/bowel incontinence. Clinical Record 5: The patient elected the hospice benefit on 12/1/23. The initial nursing assessment dated 12/1/23, stated the patient had depression (prescribed Escitalopram, Quetiapine, and Trazodone), anorexia (prescribed Remeron), and constipation (prescribed MiraLAX, and Senna). The IDG POC dated 12/14/23 and 12/28/23, included these identified problems, but did not include goals and interventions for depression, anorexia and constipation. During an interview on 1/10/24, the Executive Director and Director of Clinical Operations confirmed the finding and stated that the POCs did not include goals and interventions.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. This standard was not met as evidenced by personnel record review, document review, and interview. In 2 of 9 (22%) personnel records reviewed, it was revealed that the agency did not assess the skills and competencies of all individuals who provided care. Agency policy 4.28.1, Staff Competency Program, stated in part, "(Hospice) will provide initial and ongoing competency assessments for all patient care staff by qualified individuals....Patient care staff will be competency assessed at defined intervals: For each new employee (including contract employees) during orientation...(Hospice) has established competency criteria for each job category... The competency evaluation checklist will be completed and retained in the employee's record." Personnel Record 3: The Master of Social Work/Volunteer Coordinator/Bereavement Coordinator was hired on 7/19/23. As of 1/11/23, there was no evidence of an initial skills competency for the social worker, volunteer coordinator, and bereavement coordinator roles. Personnel Record 4: The Chaplain/Bereavement Coordinator was hired on 9/6/23. As of 1/11/23, there was no evidence of an initial skills competency for the chaplain and bereavement coordinator roles. During an interview on 1/11/24, the Executive Director/Registered Nurse and Director of Clinical Operations/Registered Nurse confirmed the finding and stated that, an initial skills competency was not completed per agency policy.