Every finding on record at Loving Hands Hospice Inc

It is required that the hospice designates a registered nurse member of the IDG to provide hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician, the patient or patient representative and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed on 03/28/2023 revealed the hospice did not ensure that the nursing care and services were provided in accordance with the plan of care established by the hospice IDG. Clinical Record 3: The record was reviewed on 03/28/2023 and revealed SN frequency orders written for 1XWeek. The record did not have documentation for a SN visit for the week of 03/13/23 and the week of 03/20/2023. There was no documented evidence of a missed visit or physician notification.

It is required that each patient’s individualized written plan of care 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 observation. 2 of 5 (40%) clinical records reviewed on 03/28/2023 revealed the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the comprehensive assessment. Clinical Record 1: The patient elected hospice services on 01/12/2023. The plan of care identified "other expressive aphasia" as a problem on 01/12/23. The plans of care dated 01/12/23 through 03/28/23 did not identify aphasia as a problem with interventions and goals. Clinical Record 3: The patient elected hospice services on 01/06/2023 with a diagnosis of Chronic Combined Systolic Heart Disease. The plan of care identified "pitting edema" as a problem on 01/06/2023. The plans of care dated 01/06/23 through 03/28/23 did not identify pitting edema as a problem with interventions and goals.

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. Each patient’s record includes, at a minimum: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, and document review. In 4 of 5 (80%) clinical records reviewed it was revealed that the hospice did not ensure that signed copies of the patient's right and election form contained the correct name of the hospice agency. Clinical Record 3: The patient elected hospice services on 01/06/2023. The copies of the patient's rights and the notices of election did not have the correct hospice agency's name. The document had " The Hospice Company." Clinical Record 2: The patient elected hospice services on 01/11/2023. The copies of the patient's rights and the notices of election did not have the correct hospice agency's name. The document had " The Hospice Company." Clinical Record 1: The patient elected hospice services on 01/12/2023. The copies of the patient's rights and the notices of election did not have the correct hospice agency's name. The document had " The Hospice Company." Clinical Record 4: The patient elected hospice services on 11/02/2022. The copies of the patient's rights and the notices of election did not have the correct hospice agency's name. The document had " The Hospice Company." Document 1: Review of copies of the Patient's Rights and the Notice of Hospice Election Form were titled "The Hospice Company".