Every finding on record at Luna Hospice, Inc.

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 document review, clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the individualized plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy 9-017 The Plan of Care dated 01/21 stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. This plan will focus on identified problems, goals, and interventions." Clinical Record 10: The patient elected the hospice benefit on 10/27/2023. The initial spiritual assessment was completed on 10/31/2023. The chaplain stated in the narrative that follow-up spiritual visits would be provided one time per month to address the feelings of abandonment of faith and generalized anxiety. The individualized POC dated 11/07/2023 lacked goal(s) and intervention(s) for spiritual care. The Administrator/Director of Patient Care Services Designee and Quality Coordinator confirmed in an interview on 11/28/2023 that the plan of care lacked goals and interventions for spiritual care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 9 (33%) clinical records reviewed with aide services provided, the agency did not ensure that the aide provided services included on the plan of care (POC). Agency Policy 9-020 Hospice Aide Services dated 01/21, stated in part, "Hospice aides will document care provided in accordance with the hospice aide assignment." Clinical Record 1: The hospice aide POC dated 09/23/2023 assigned the aide the tasks of linen change every visit. The aide visit notes dated 11/08/2023 and 11/13/2023 contained no documented evidence that the aide completed a linen change and no documentation of why the linen was not changed. Clinical Record 2: The hospice aide POC dated 06/02/2023 assigned the aide the tasks of linen change every visit. The aide visit notes dated 11/08/2023 and 11/13/2023 contained no documented evidence that the aide completed a linen change and no documentation of why the linen was not changed. Clinical Record 3: The hospice aide POC dated 05/05/2023 assigned the aide to provide peri care every visit. The aide visit note dated 10/25/2023 contained no documented evidence the aide provided peri care and no documentation to explain why the peri care was not provided. The Administrator/Director of Patient Care Services Designee and the Quality Coordinator confirmed in an interview on 11/28/2023 that the aide did not provide services included on the aide plans of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 9 (33%) clinical records reviewed with aide services provided, the agency did not ensure that the aide reported changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse (RN) as the changes related to the plan of care (POC). Agency Policy 9-020 Hospice Aide Services dated 01/21 stated in part, "Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities." Clinical Record 1: The hospice aide POC dated 09/23/2023 assigned the aide the tasks of linen change every visit. The aide visit notes dated 11/08/2023 and 11/13/2023 contained no documented evidence that the aide notified the RN the linen change was not completed during the aide visit. Clinical Record 2: The hospice aide POC dated 06/02/2023 assigned the aide the tasks of linen change every visit. The aide visit notes dated 11/08/2023 and 11/13/2023 contained no documented evidence that the aide notified the RN the linen change was not completed during the aide visit. Clinical Record 3: The hospice aide POC dated 05/05/2023 assigned the aide to provide peri care every visit. The aide visit note dated 10/25/2023 contained no documented evidence the aide notified the RN that peri care was not completed during the aide visit. The Administrator/Director of Patient Care Services Designee and the Quality Coordinator confirmed in an interview on 11/28/2023 that the aide did not report changes in the patient's medical, nursing, rehabilitative, and/or social needs to a RN as the changes related to the POC.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26, 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 document review, clinical record review, and interview. In 1 of 2 (50%) clinical records reviewed with a patient discharge, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. Agency policy 1-025 Discharge from Hospice Program dated 1/21 stated in part, "A copy of the discharge summary will be sent to the attending physician." Clinical Record 14: The patient elected the hospice benefit on 06/03/2022. The agency discharged the patient for no longer being terminally ill on 06/30/2023. The clinical record contained no documented evidence that the discharge summary was forwarded to the patient's attending physician. The Administrator/Director of Patient Care Services Designee and the Quality Coordinator agreed in an interview on 11/28/2023 the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 1 (100%) clinical record reviewed of patient's receiving hospice services in a skilled nursing facility (SNF), the agency did not ensure care and services ordered on the plan of care specifically identified which provider was responsible for performing respective functions. Agency policy 1-030 Provision of Care to Residents of SNF/NF or ICF/IID dated 01/21 stated in part, "The plan of care must: Identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions." Clinical Record 11: The patient elected the hospice benefit on 08/26/2023. The patient resided in a SNF. The clinical record contained no documented evidence of delineation of services to be provided by the hospice and by the SNF. The Administrator/Director of Patient Care Services Designee and the Quality Coordinator confirmed in an interview on 11/28/2023 that the agency did not ensure care and services ordered on the plan of care specifically identified which provider was responsible for performing respective functions.