Every finding on record at Nj Cuidado Casero Hospice, LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the hospice agency did not ensure the spiritual and social work assessment was completed within the 5 day requirement. Clinical Record 1: The patient was admitted to hospice on 8/2/23. The spiritual assessment was dated 8/8/23, 6 days after the election of the hospice benefit. There was no documentation to explain the delay in completing the assessment. Clinical Record 11: The patient was admitted to hospice on 4/5/23. The social work assessment was dated 4/16/23, 11 days after the election of the hospice benefit. There was no documentation to explain the delay in completing the assessment. During a joint record review and interview on 9/28/23, the Clinical Director confirmed the finding and stated that the comprehensive assessment should have been completed within the 5 day timeframe.

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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure that the patient's individualized plan of care included all goals and interventions related to problems identified in the initial comprehensive assessment. Clinical Record 1: The nursing assessment dated 8/2/23, documented that the patient had +2 pitting edema in both feet. However, the plan of care dated 8/2/23, did not include goals or interventions regarding the edema. The patient had Oxygen ordered at 2L prn or continuous as per need on 8/2/23. However, the plan of care dated 8/2/23, did not include goals or interventions regarding the use of Oxygen. During a joint record review and interview on 9/26/23, the Clinical Director confirmed the finding, and stated that all problems identified on the initial assessment, should have goals and interventions in the plan of care.

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires. Reassessment of the patient’s response to care. The assessment update is complete as frequently as the condition of the patient requires. This standard was not met as evidenced by a review of clinical records, and interview. 5 of 5 records reviewed revealed that there was no evidence of care plan updated by the IDG and disciplines providing care. There was no evidence of updated care plan assessmnets to identify the patient's current response to care, treatment and services provided, and the patient's progress toward outcomes. Record #48176: The IDG notes dated 1/14/2022, 1/19/2022, 2/2/2022, 3/02/2022 did not contain any updates by nursing, social work, or spiritual services. The Director of Nursing stated that the IDG meeting was conducted via Zoom, and no one documented what was discussed concerning the needs of the patient or any progress towards the goal. Record #69620: The IDG note dated12/22/2022, 1/5/2022 did not contain any updates by nursing, social work, or spiritual services. The Director of Nursing stated that the IDG meeting was conducted via Zoom, and no one documented what was discussed concerning the needs of the patient or any progress towards the goal. Record #91965: The IDG note dated12/28/2021,12/22/2021 did not contain any updates by nursing, social work, or spiritual services. The Director of Nursing stated that the IDG meeting was conducted via Zoom, and no one documented what was discussed concerning the needs of the patient or any progress towards the goal. Record #19372: The IDG note dated 1/15/2022, 01/19/2022 , 02/02/2022 did not contain any updates by nursing, social work, or spiritual services. The Director of Nursing stated that the IDG meeting was conducted via Zoom, and no one documented what was discussed concerning the needs of the patient or any progress towards the goal. Record #54461: The IDG note dated 12/28/2021, 01/05/2022, 01/19/2022 did not contain any updates by nursing, social work, or spiritual services. The Director of Nursing stated that the IDG meeting was conducted via Zoom, and no one documented what was discussed concerning the needs of the patient or any progress towards the goal. CONTINUING PRIOR REQUIRED ACTION. These findings were reviewed and confirmed during an interview with the Director of Nursing on 03/28/2022.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interview. 5 of 5 (100%) clinical records reviewed, there was no documented evidence that the plan of care was developed by the Interdisciplinary Group (IDG), in consultation with the patient's attending physician. Record #48176 - The plan of care dated 01/14/2022 did not contain any signatures of any IDG team members or any signature of the attending physician and there was no evidence found that the information was shared with the attending physician. No evidence found that the document was faxed to the attending for review. Record #69620 - The plan of care dated 12/18/2021 did not contain any signatures of any IDG team members or any signature of the attending physician and there was no evidence found that the information was shared with the attending physician. No evidence found that the document was faxed to the attending for review. Record #91965 - The plan of care dated 12/8/2021, 12/22/2021, 01/05/2022 did not contain any signatures of any IDG team members or any signature of the attending physician and there was no evidence found that the information was shared with the attending physician. No evidence found that the document was faxed to the attending for review. Record #54461- The plan of care dated 12/28/2021, 01/05/2022, 01/19/2022 did not contain any signatures of any IDG team members or any signature of the attending physician and there was no evidence found that the information was shared with the attending physician. No evidence found that the document was faxed to the attending for review. Record #19372- The plan of care dated 01/152022, 01/19/2022, 02/02/2022 did not contain any signatures of any IDG team members or any signature of the attending physician and there was no evidence found that the information was shared with the attending physician. No evidence found that the document was faxed to the attending for review. CONTINUING PRIOR REQUIRED ACTION. During an interview, the Director of Nursing confirmed there was no documentaiton to support the physician's involvement in developing and reviewing the POC.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by clinical record review and interview. 3 of 5 (60%) records reviewed revealed that the hospice provided nursing carewithout fololwing fhr frequency of the IDG directed plan of care. Record #69620 - Patient elected hospice on 12/18/2021 Skilled nursing visits ordered 2x/week. No visit was documented the week of 12/26/2021. There was no documentation explaining the missed visit. Record #91965 - Patient elected hospice on 12/08/2021. Skilled nursing visits ordered 2x/week. No visit was documented the week of 01/02/2022. There was no documentation explaining the missed visit. Record #54461- Patient elected hospice on 12/28/2021. Skilled nursing visits ordered 2x/week. 1 visit was documented the week of 01/02/2022, 01/11/2022, and 01/16/2022. There was no documentation explaining the missed visits. CONTINUING PRIOR REQUIRED ACTION. The above evidence was reviewed and confirmed during an interview on 03/28/2021 with the Director of Nursing. The DON was in agreement that documentatioon on the reason the visits were not compmlelted was missing.

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 a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records, and interview. 3 of 5 (60%) clinical records reviewed, revealed no documentation of interventions or goals on the plan of care. Record #91965- The RN documented that the patient had complicated mental issues. There was no docuemnted evidence of interventions or goals upon admission, and update on the progress toward goals documented from the time of election dated 12/28/2021 through 01/08/2022. Record #19372- The Social Worker documented that the son was overwhelmed at the time of admission dated 01/18/2021. There were no initial plan of care, intervention or goals identified by the Social Worker from time of election dated 01/18/2021 through 02/12/2022. Record #544621- The Social Worker documented that the patient's caregiver was overwhelmed at the time of admission dated 12/28/2021. There were no initial plan of care, intervention or goals identified by the Social Worker from time of election dated 12/28/2021 through 01/22/2022. CONTINUING REQUIRED ACTION. These findings were reviewed and confirmed during an interview with the Director of Nursing. The DON confirmed there was no docuemntation toward progress toward goals.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation and consistent with the hospice aide training. CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by review of clinical records and interview. 1 of 4 (25%) applicable records of patients who received hospice aide services revealed that care provided were inconsistent with the Interdisciplinary Group orders visit frequency. Record #69620: The plan of care ordered hospice aide services five times a week starting 12/18/2021. There was 1 aide visit completed the week of 12/26/2021; and 3 visits completed the week of 1/02/2022. There was no documentation explaining the reason for the missed visits. This finding was reviewed and confirmed during an interview with the Director of Nursing on 03/28/2022. The DON was unable to provide documented reasons for the missed visits.

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 a review of clinical records and interview. In 1 of 10 (10%) records failed to evidence physician's orders to support wound care delivered. Record #69620 on 12/20/2021 the RN documented the presence of a lumbar sacral wound. A low air loss mattress was in use. The RN applied applied zinc oxide to the lumbar sacral wound. There was no documented evidence of a physician order for the treatment for the wound. CONTINUING PRIOR REQUIRED ACTION. During an interview on 03/28/202, the Director of Nursing reviewed this finding and confirmed the wound care order as missing.