Every finding on record at Madlyn and Leonard Abramson Center for Jewish Life

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care includes: Information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by review of the clinical record and interview. 1 of 13 (8%) clinical records reviewed revealed the plan of care was not revised to include information from the patient’s updated comprehensive assessment. Record #61889: Patient was admitted on February 28, 2022, with a primary diagnosis of heart disease. The SN assessment on 1/13/22 documents, in part, the "patient had a seizure like activity Tuesday, no further issue then came back COVID positive on Saturday." Plans of care dated 1/13/22, 1/27/22, 2/10/22, 2/17/22, 2/24/22, 3/10/22 3/24/22 and 4/7/22 were not revised to include these findings from the assessment. During an interview on 4/13/22 the Administrator and Director of Clinical Services agreed the POC was not revised to include the condition changes of the patient.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. This standard was not met as evidenced by a clinical record review and interview with the Administrator and Director of Clinical Services In 3 of 10 (30%) clinical records reviewed with hospice aide services it was revealed the plan of care visit frequency was ordered with no indication as to who would determine the number of visits necessary to meet the patient’s needs. Clinical Record #77583; Patient elected hospice services on October 15, 2021, with a primary diagnosis of COPD. HHA frequency order dated 1/16/2022 states 5-7 x/week for 13 weeks. There was no documentation indicating who determined the number of visits necessary to meet the patient’s needs per week. Making such a decision is not within the HHA’s scope of practice. Clinical Record #28684; Patient elected hospice services on October 6, 2021, with a primary diagnosis of acute pyelonephritis. HHA frequency order dated 4/10/2022 states 5-7 x/week for 9 weeks. There was no documentation indicating who determined the number of visits necessary to meet the patient’s needs per week. Making such a decision is not within the HHA’s scope of practice. Clinical Record #61889; Patient elected hospice services on November 30, 2021, with a primary diagnosis of heart disease. HHA frequency order dated 3/6/2022 states 5-7 x/week for 13 weeks. There was no documentation indicating who determined the number of visits necessary to meet the patient’s needs per week. Making such a decision is not within the HHA’s scope of practice. During an interview with the Administrator and Director of Clinical Services, on 4/13/22, they stated they were unaware that hospice aide visit frequency should not include a range of visits when there are no directions as to who would determine the number of visits necessary to meet the patient’s needs.

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. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by review of the clinical record and interview. 2 of 13 (15%) clinical records reviewed revealed the records did not include all required physician orders. Record #18595: Patient elected hospice services on June 11, 2021, with a primary diagnosis of anorexia. The SN assessment documentation dated 2/9/22, 2/16/22, 2/23/22, 3/4/22, 3/16/22, 3/23/22, and 3/30/22 included completing pulse-ox interventions and readings. The POC order dated 2/10/22, 2/24/22, 3/10/22, 3/24/22 and 4/7/22 did not include orders or interventions for completing a pulse-ox reading. Record #56909: Patient elected hospice services on October 23, 2021, with a primary diagnosis CVA. A coordination note documented in the clinical record stated the patient moved to a non-contracted facility on 12/3/21. There was no documented evidence a physician's order was obtained for the patient's discharge from the agency. Hospice policy titled “Hospice Discharge/Discharge Planning” states, in part, “The hospice will obtain a written physician order from the hospice medical director for discharge prior to discharging a patient for any reason.” During an interview on 4/13/22 the Administrator and Director of Clinical Services confirmed this finding and stated that the POCs did not include orders for pulse-ox or discharge.