Every finding on record at Moments Hospice of Chicago South, LLC

It is required that each patient’s individualized written plan of care: reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; [and] includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the patient's plan of care (POC) reflected patient and family goals and identified interventions based on problems identified in the initial comprehensive assessment. Clinical Record 10: The patient elected hospice care on 09/12/2024 with a diagnosis of Alzheimer's disease with late-onset. The initial nursing assessment dated 09/12/2024 documented that "the patient has had two (2) choking episodes that necessitated changing his diet to pureed." The IDG POC dated 09/12/2024 did not include documentation of goal(s) and intervention(s) for the patient's identified problem with dysphagia. During an interview on 10/04/2024, the Vice President of Clinical Operations, Regional Director of Clinical Operations/Alternate Director of Patient Care Services, and Team Director stated that the POC did not include patient and family goals and interventions based on problems identified in the initial comprehensive assessment.

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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient's plan of care (POC) included drugs and treatments necessary to meet the patient's needs. Clinical Record 1: The patient elected hospice care on 09/10/2024 with the diagnosis of end-stage renal disease. The patient resided in a skilled nursing facility (SNF). The initial nursing assessment dated 09/10/2024 documented the patient was receiving oxygen 2-4 liters per minute via nasal cannula as needed/pro re nata (PRN) for shortness of breath (SOB). The genitourinary initial assessment documented the patient had a 16-French (FR) Foley catheter with a 10-cc balloon. The POC dated 09/10/2024 ordered "Oxygen per physician order" and "Foley catheter per physician order." The POC did not document the specifics of the care and maintenance of the Foley catheter or the route of administration, frequency, or oxygen, including the flow rate, frequency of use, or route of administration. Clinical Record 6: The patient elected hospice care on 12/29/2023 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). The initial nursing assessment dated 12/29/2023 reported the patient had five (5) wounds: 1) Left heel - unstageable; 2) Left greater trochanter (left hip) - Stage 3; 3) Left lower buttock (left inner buttock) - Stage 2; 4) Left proximal calf (posterior left calf) - Stage 3; and 5) Right proximal thigh (right hip) - Stage 3; each requiring specific wound care. The physician order dated 01/02/2024 ordered wound care for the five (5) wounds: "1) Left heel: Facility staff to cleanse with wound cleanser daily; pat dry, cover with ABD, wrap with kerlix dressing and secure with tape. Hospice nurse to measure wound weekly; change daily and/or prn if dressing becomes dislodged or soiled. 2) Left Hip: Facility nurse to cleanse with wound cleaner daily, pat dry, cover with 4x4 gauze, and foam dressing. Hospice nurse to measure wound weekly; change daily and/or prn if dressing becomes dislodged or soiled. 3) Left inner buttock fold: Facility nurse to cleanse left inner buttock with wound cleanser daily, pat dry, and cover with foam dressing. Hospice nurse to measure wound weekly; change daily and/or prn if dressing becomes dislodged or soiled. 4) Posterior left calf: Facility nurse to cleanse posterior left calf with wound cleanser daily; pat dry, smear bacitracin zinc ointment to wound bed, and cover with border gauze. Hospice nurse to measure wound weekly; change daily and/or prn if dressing becomes dislodged or soiled. and 5) Right hip: Facility nurse to cleanse right hip with wound cleanser daily; pat dry, apply collagen matrix dressing with silver QJD cover with foam dressing. Hospice nurse to measure wound weekly; change daily and/or prn if dressing becomes dislodged or soiled." The POC dated 01/02/2023 ordered, "Perform wound care per physician orders." The POC did not include documentation of the physician's orders for the wound care for each wound. During an interview on 10/04/2024, the Vice President of Clinical Operations, Regional Director of Clinical Operations/Alternate Director of Patient Care Services, and Team Director stated that the plans of care did not include all drugs and treatments.

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 clinical record review and interview. In 1 of 9 (11%) clinical records reviewed for the patients who received Hospice Aide (HA) services and had a change related to the plan of care, the agency did not ensure the HA reported the changes in the patient's medical needs to the Registered Nurse (RN). Clinical Record 2: The patient elected hospice care on 05/31/2024 with a diagnosis of other sequelae of cerebral infarction. The patient resided in a skilled nursing facility (SNF). The HA care plan dated 09/06/2024 assigned the HA the relevant task of: "Assist with feeding" every visit. The HA visit note dated 09/23/2024 documented, "Assist with feeding...Task already completed." A clinical record review revealed no evidence that the HA notified the RN of the changes in the patient's needs related to the HA care plan. During an interview on 10/04/2024, the Vice President of Clinical Operations, Regional Director of Clinical Operations/ Alternate Director of Patient Care Services, and Team Director stated that the Hospice Aide had not reported the change in the patient's needs to the RN.