Every finding on record at Lumina Hospice and Palliative Care

Based on interview and medical record review, it was determined the hospice failed to complete an initial bereavement assessment as part of the comprehensive assessment within 5 days of the start of care for 15 of 19 patient records reviewed (Patients #2, #4-8, #10, and #12-19). --- Review of the medical record for Patient #2 revealed a start of care of 11/19/2022. A comprehensive assessment was performed on 11/19/2022. The comprehensive assessment covered a variety of topics, such as pain assessment, psychological status and neurological status. The records of the comprehensive assessments did not reflect that it included an initial bereavement assessment. Review of the medical record for Patient #4 revealed that started care began on 12/9/2022. A comprehensive assessment was performed on 12/9/2022. The comprehensive assessment covered a variety of topics, such as pain assessment, activities of daily life and supportive assistance. The records of the comprehensive assessments did not reflect that it included an initial bereavement assessment. Review of the medical record for Patient #5 revealed that started care began on 3/13/2023. A comprehensive assessment was performed on 3/13/2023. The comprehensive assessment covered a variety of topics, such as pain assessment, sleep/rest habits and integumentary status. The records of the comprehensive assessments did not reflect that it included an initial bereavement assessment. Records for Patients #6-8, #10, and #12-19 reflected similar findings. During interview and review of documentation on 4/26/2023 at 2:00 PM, Employee #12 acknowledged these findings and stated that they were surprised the charting software did not pick this up because "The software was supposed to flag areas missing documentation for CMS compliance." It was also stated that this might be a training issue since the agency has hired new staff recently.

Based on interview and medical record review, it was determined the agency failed to include individualized measurable outcomes anticipated from implementing and coordinating the plan of care for 6 of 19 patient care plans reviewed (Patients #1, #6, #7, #14, #16, and #19). --- Review of the medical record of Patients #1 and #16 revealed a document titled "Interdisciplinary Care Plan." Patient problems of "IMPAIRED RESPIRATORY STATUS" and "CHRONIC OBSTRUCTIVE PULMONARY DISEASE" were given with a goal of "Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters" for each problem. The care plan lacked individualized information regarding what "optimal level" meant for each patient and how this goal would be measured for each patient. Review of the medical record of Patients #1 and #6 revealed a document titled "Interdisciplinary Care Plan." A patient problem of "ADL'S/IADL's - HHA" was given with a goal of "Patient's personal care needs will be met." The care plan lacked individualized information regarding how this goal would be measured for each patient. Review of the medical record of Patient #7 revealed a document titled "Interdisciplinary Care Plan." A patient problem of "ALTERED NUTRITION/HYDRATION STATUS" was given with a goal of "Patient/caregiver can describe measures-maintain adequate nutrition/hydration" and " Patient's nutritional needs will be met as patient's condition/comfort allows." The care plan lacked information regarding what "adequate" meant or what "needs will be met" meant, and how these goals would be measured. Review of the medical record of Patients #6 and #19 revealed a document titled "Interdisciplinary Care Plan." A patient problem of "END STAGE DEMENTIA" was given with a goal of "Anxiety/agitation controlled through course of care." The care plan lacked information regarding what "controlled" meant for each patient and how these goals would be measured. Review of the medical record of Patient #14 revealed a document titled "Interdisciplinary Care Plan." A patient problem of " ALTERED NEUROLOGICAL STATUS" was given with a goal of "Patient will maintain optimum level of functioning appropriate for stage of disease process." The care plan lacked information regarding what "optimum" meant and how this goal would be measured. Review of the medical record of Patient #16 revealed a document titled "Interdisciplinary Care Plan." A patient problem of "COPING - PATIENT" was given with a goal of "Patient will maintain optimal coping through hospice care." The care plan lacked information regarding what "optimal" meant and how this goal would be measured. During interview and review of documentation on 4/26/2023 at 2:00 PM, Employee #12 confirmed that the findings were not individualized, nor did they have measurable goals.