Every finding on record at Lucas Hospice Inc

It is required that each patient’s individualized written plan of care reflects patient and family goals 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 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure the patient's individualized plan of care (POC) included goal(s) and intervention(s) based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 2: The initial nursing assessment narrative dated 04/10/2025 stated, "Incontinent in both bowel and bladder". The interdisciplinary group (IDG) POC dated 04/10/2025 lacked evidence of goal(s) and intervention(s) for bowel and bladder incontinence. CLINICAL RECORD 13: The initial nursing assessment - Gastrointestinal - Bowel stated "Colostomy". The IDG POC dated 04/14/2025 lacked evidence of goal(s) and intervention(s) for the Colostomy. The Administrator, Director of Patient Care Services designee, Quality Assurance/Admissions Nurse agreed in an interview on 05/30/2025 that the agency did not ensure the patient's individualized POC included goal(s) and intervention(s) based on problems identified in the initial and updated comprehensive assessments.

It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed that the patient either transferred to another hospice or revoked the hospice benefit revealed the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 6: The patient's family revoked the hospice benefit on 01/24/2025. The record lacked evidence that the hospice forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient's family asked the patient to be transferred to another hospice agency on 04/01/2025. The election of benefit form stated the patient had an attending physician. The record lacked evidence that the hospice forwarded the discharge summary to the patient's attending physician. The Administrator, Director of Patient Care Services designee, Quality Assurance/Admissions Nurse stated in an interview on 05/30/2025 that the agency did not send a copy of the hospice discharge summary to the patient's attending physician.