Every finding on record at Margaret's Vineyard Hospice and Healthcare Services, LLC

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) records reviewed, the hospice did not ensure that the plan of care included documentation of patient and family goals with defined and measurable outcomes. Clinical Record 1: The patient elected hospice 08/02/2023. with a diagnosis of CHF. A comprehensive assessment was completed on 08/02/2023. Review of the plan of care established on admission, identified " Problem with terminal diagnosis." The goal statement did not define how the desired outcome of "pt will have symptom management for terminal illness" would be specifically measured. Clinical Record 2: The patient elected hospice 08/02/2023, with a diagnosis of Alzheimer's. A comprehensive assessment was completed on 08/02/2023. Review of the plan of care established on admission, identified " Risk for falls. The goal statement did not define how the desired outcome of "pt will understand functional limitations" would be specifically measured. Clinical Record 3: The patient elected hospice 08/02/2023 with a diagnosis of CHF. A comprehensive assessment was completed on 08/02/2023. Review of the plan of care established on admission, identified " problems with coping". The goal statement did not define how the desired outcome of "pt will have emotional support" would be specifically measured. Clinical Record 4: The patient elected hospice 08/07/2023, with a diagnosis of Cirrhosis of the Liver. A comprehensive assessment was completed on 08/07/2023. Review of the plan of care established on admission, identified " Anxiety". The goal statement did not define how the desired outcome of "symptoms of anxiety, agitation or delirium will be controlled at a level acceptable to pt/cg" would be specifically measured. Clinical Record 5: The patient elected hospice 08/08/2023, with a diagnosis of Heart Disease, A comprehensive assessment was completed on 08/08/2023. Review of the plan of care established on admission, identified " problems with safety." Goal "pt will remain safe in current environment." The goal statement did not define how the desired outcome of "will remain safe in current environment" would be specifically measured. The DON was interviewed on 09/27/2023 and confirmed the goals did not include outcomes that were measurable.