Every finding on record at Mclaren Health Management Group

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessment, 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, drugs, and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical records. 3 of 12 (25%) records revealed that the plan of care (POC) was not updated with additional interventions and measurable goals to reflect new/additional/increased identified problems from updated comprehensive assessments. Record #60584: Physician order dated effective 4/1/2022 for increased visits by Chaplain for "crisis management" due to sudden death of patient's daughter. The patient's care plan dated 4/6/2022 lacked written spiritual interventions or goals related to the patient's needs. There were no changes to the plan of care. Record #58787: Physician order dated 3/242022 for Lasix 20 mg x 7 days, PO ordered due to change in patient condition. The Skilled Nurse assessment states, "FLUID RETENTION" and " UP 6LBS FROM LAST WEEK WITH NOTED WORSENING OF CRACKLES IN BILATERAL LUNG FIELDS." The Skilled Nurse made an emergent visit on 3/27/2022 for evaluation of the "FLUID STATUS". There were no interventions or goals added to the plan of care on 3/31/22 addressing the addition of medication or change in fluid status. Record #60698: Physician order for "Bactrim 2x daily q 10 days PO" for Urinary Tract Infection (UTI) on 3/9/2022. There was no update to the plan of care dated 3/17/2022 or 3/31/2022 to address new medication or UTI.

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 a review of clinical records. 4 of 10 (40%) applicable records with hospice aide services reviewed revealed that the hospice aide (HA) did not provide care according to assigned tasks on the plans of care. Record #58787: HA did not complete 9 of 20 tasks indicated on the Care Plan during the visit of 4/13/22. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 4/6/22. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 3/30/22. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 3/23/22. Record #32539: HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit of 2/8/22. HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit on 2/22/22. HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit on 3/1/22. Record #72720: HA did not complete 1 of 21 tasks indicated on the Care Plan during the visit of 2/8/22. HA did not complete 9 of 21 tasks indicated on the Care Plan during the visit on 2/22/22. Record #39220: HA did not complete 2 of 21 tasks indicated on the Care Plan during the visit of 1/9/22.

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 a review of clinical records. 4 of 10 (40%) applicable records with hospice aide services reviewed revealed that the hospice aide (HA) did not provide care according to assigned tasks on the plans of care or update nurse of these changes. Record #58787: HA did not complete 9 of 20 tasks indicated on the Care Plan during the visit of 4/13/22 with no evidence of communication to the nurse of changes. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 4/6/22 with no evidence of communication to the nurse of changes. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 3/30/22 with no evidence of communication to the nurse of changes. HA did not complete 8 of 20 tasks indicated on the Care Plan during the visit on 3/23/22 with no evidence of communication to the nurse of changes. Record #32539: HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit of 2/8/22 with no evidence of communication to the nurse of changes. HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit on 2/22/22 with no evidence of communication to the nurse of changes. HA did not complete 2 of 17 tasks indicated on the Care Plan during the visit on 3/1/22 with no evidence of communication to the nurse of changes. Record #72720: HA did not complete 1 of 21 tasks indicated on the Care Plan during the visit of 2/8/22 with no evidence of communication to the nurse of changes. HA did not complete 9 of 21 tasks indicated on the Care Plan during the visit on 2/22/22 with no evidence of communication to the nurse of changes. Record #39220: HA did not complete 2 of 21 tasks indicated on the Care Plan during the visit of 1/9/22 with no evidence of communication to the nurse of changes.