Every finding on record at Nova Hospice Care, LLC

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure the initial bereavement assessment was completed as part of the comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 12/21/2023. There was no evidence that an initial bereavement assessment was completed to include the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed that the initial bereavement assessment was not completed.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure the patient's individualized plan of care was updated as frequently as their condition required. Clinical Record 5: The patient elected the hospice benefit on 06/02/2023, for the diagnosis of malignant neoplasm of the left lung. A nursing assessment dated 06/22/2023, documented that the patient had a new "Stage II pressure ulcer." The plan of care (POC) initiated upon admission, dated 06/02/2023, documented a problem of "potential for skin breakdown and goals of preventing skin breakdown." This problem did not change throughout the patient's hospice admission from 06/02/2023 to 07/27/2023, to reflect the actual skin breakdown. It continued as "potential," rather than actual. A nursing assessment dated 07/24/2023, documented the patient as "actively transitioning, bedbound, no longer eating or able to communicate." The POC documented the patient as "ambulatory, adequate nutrition goals, able to voice needs." The POC was not updated to reflect the current status of the patient. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed that the plan of care was not updated based on the comprehensive assessments.

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 5 (100%) clinical records reviewed, in which aide services were provided, it was revealed that the agency did not ensure the hospice registered nurse (RN) provided the aide with specific instructions. Clinical Record 1: The patient elected the hospice benefit on 01/24/2024. The aide care plan dated 01/26/2024, included the following tasks: vital signs (VS); bed bath; shampoo hair; and assist with dressing. The VS task documented parameters for the vital signs. However, the frequency for the VS task was not specified, and there were no instructions for the aide to notify the RN of vital signs outside the parameters. . The initial nursing assessment dated 01/24/2024, documented that the patient was on continuous oxygen at 2 liters per minute. The aide care plan did not provide the aide with specific instructions for the oxygen. Clinical Record 2: The patient elected the hospice benefit on 12/21/2023. The aide care plan dated 12/21/2023, documented the following tasks: vital signs; shower; and assist with dressing. The VS task documented parameters for vital signs. However, the frequency for the VS task was not specified, and there were no instructions for the aide to notify the RN of vital signs outside the parameters. . Clinical Record 3: The patient elected the hospice benefit on 12/21/2023. The aide care plan dated 12/21/2023, documented the following tasks: shower; vital signs; dress; and shave. The initial nursing assessment documented that the patient was on continuous oxygen at 2-4 liters per minute. The aide care plan did not provide specific instructions for the oxygen. The VS task documented parameters for vital signs. However, the frequency for the VS task was not specified, and there were no instructions for the aide to notify the RN of vital signs outside the parameters. . Clinical Record 4: The patient elected the hospice benefit on 12/21/2023. The aide care plan dated 12/21/2022, documented the following tasks: shower; shampoo; assist with dressing; and vital signs. The initial nursing assessment dated 12/21/2023, documented that the patient had seizures and was on Depakote. The aide care plan did not provide instructions regarding seizure precautions. The VS task documented parameters for vital signs. However, the frequency for the VS task was not specified, and there were no instructions for the aide to notify the RN of vital signs outside the parameters. Clinical Record 5: The patient elected the hospice benefit on 06/02/2023. The aide care plan dated 06/02/2023, documented the following tasks: shower; shave; assist with dressing; and vital signs. The initial nursing assessment dated 06/02/2023, documented a Stage II wound on the coccyx. However, there were no instructions regarding the wound on the aide care plan. The VS task documented parameters for vital signs. However, the frequency for the VS task was not specified, and there were no instructions for the aide to notify the RN of vital signs outside the parameters. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed the findings. No additional documentation was provided.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, in which aide services were provided, it was revealed that the agency did not ensure the hospice aide provided services included in the plan of care (POC). Clinical Record 2: The patient elected the hospice benefit on 12/21/2023. The aide care plan dated 12/21/2023, included the task of obtaining the patient's vital signs. The aide visit notes dated 02/06/2024, 02/09/2024, 02/13/2024, and 02/16/2024, did not have evidence that vital signs were taken as ordered. Nor was there evidence that the patient refused vital signs, or the registered nurse was notified. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed that the hospice aide did not provide services included in the plan of care.

It is required that a patient's clinical record contains correct clinical information including any advance directives. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure the clinical record contained correct information including advance directives. Clinical Record 4: The patient elected the hospice benefit on 12/21/2023. A physician's order of life-sustaining treatment (POLST) signed by the family member on 12/21/2023, indicated a do not resuscitate (DNR) status. The physicians certification of terminal illness dated 12/21/2023, stated "full code." The aide care plan dated 12/21/2023, stated "perform CPR." A physician's admission order dated 12/21/2023, stated DNR. The information in the clinical record was conflicting regarding advance directives, specifically the DNR status. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed the finding and stated that the POLST signed by the family indicated the appropriate code status.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 5 (40%) clinical records reviewed, it was revealed that the agency did not ensure the entries in the clinical record were appropriately authenticated by the person performing the care. Agency policy, Clinical Records (dated 2021), stated in part, "Each entry is dated and signed, including title and credential, by the person providing the care/services." Clinical Record 3: The patient elected the hospice benefit on 12/21/2023. The hospice aide notes did not include the aide credentials for the following dates: 12/25/2023, 12/28/2023, 01/01/2024, 01/04/2024, 01/08/2024, 01/11/2024, 01/15/2024, 01/18/2024, 01/22/2024, 01/25/2024, 01/29/2024, 02/01/2024, 02/05/2024, 02/08/2024, 02/12/2024, and 02/15/2024. Clinical Record 5: The patient elected the hospice benefit on 06/02/2023. The hospice aide notes were not authenticated for the following dates: 06/05/2023, 06/08/2023, 06/12/2023, 06/15/2023, 06/19/2023, 06/22/2023, 06/26/2023, 06/29/2023, 07/3/2023, 07/6/2023, 07/10/2023, 07/10/2023, 07/13/2023 and 07/20/2023. During a joint record review and interview on 02/22/2024, the Director of Nursing confirmed the findings and stated the hospice aide visits did not have credentials and signatures.