Every finding on record at Open Heart Palliative Hospice LLC

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 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 4: The patient elected hospice services on 12/12/2023 with a terminal diagnosis of respiratory failure. The initial nursing assessment dated 12/12/2023 included documentation that the patient had a gastrostomy tube (G-tube) for continuous enteral feedings. The written plan of care dated 12/12/2023 did not reflect patient and family goals and planned interventions associated with the care and maintenance of the patient's G-tube identified in the comprehensive assessment. During joint clinical record reviews and interviews on 09/19/2024, the Administrator/Clinical Director confirmed that the written plan of care did not reflect goals and planned interventions associated with the patient’s identified gastrostomy tube (G-tube). The Administrator/Clinical Director stated that the G-tube remained in place while on service and goals and interventions for its care and maintenance should have been included in the POC.

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 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 1 of 5 (20%) clinical records reviewed, it was revealed that the agency did not ensure the individualized written plan of care included all drugs and treatments necessary to meet specific patient needs. Clinical Record 3: The patient elected hospice services on 08/12/2024 with a terminal diagnosis of congestive heart failure. A comprehensive assessment dated 08/12/2024 documented a drug profile that included Plavix 75mg once a day. The initial plan of care dated 08/12/2024 did not include an order for Plavix. During joint clinical record reviews and interviews on 09/18/2024, the Administrator/Clinical Director confirmed the plan of care (POC) identified did not include an order for Plavix as documented on the drug profile from the comprehensive assessment. The Administrator/Clinical Director stated that the medication was continued and should have been included in the POC.

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 revised plan of care includes information from the patient’s updated comprehensive assessment and records the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed, it was revealed that the agency did not ensure the Interdisciplinary Group (IDG) revised and documented the patient's progress toward the outcomes and goals specified in the individualized plan of care. Clinical Record 1: The patient elected hospice services on 08/21/2024 with a terminal diagnosis of muscle atrophy. The plan of care dated 08/21/2024 was reviewed and revised on 08/27/2024 and 09/10/2024, specifying goals associated with agitation, anxiety, pain, cardiopulmonary symptoms, impaired swallowing, hyper/hypoglycemic control, altered urinary and bowel elimination, skin integrity, general inpatient care, nutrition and hydration, and impending death. The revised plans did not include the patient’s progress toward the specified outcomes and goals. Clinical Record 3: The patient elected hospice services on 08/12/2024 with a terminal diagnosis of congestive heart failure. The plan of care dated 08/12/2024 was reviewed and revised on 08/13/2024, 08/27/2024, and 09/10/2024, specifying goals associated with agitation, anxiety, pain, cardiopulmonary symptoms, impaired swallowing, altered urinary and bowel elimination, skin integrity, nutrition and hydration, and impending death. The revised plans did not include the patient’s progress toward the specified outcomes and goals. Clinical Record 4: The patient elected hospice services on 12/12/2023 with a terminal diagnosis of respiratory failure. The patient revoked the hospice benefit on 12/27/2023. The plan of care dated 12/12/2023 was reviewed and revised on 12/26/2023, specifying goals associated with impending death, fall prevention, cardiopulmonary symptoms, altered urinary and bowel elimination, skin integrity, nutrition and hydration, and psychosocial, emotional, and spiritual issues. The revised plans did not include the patient’s progress toward the specified outcomes and goals. Clinical Record 5: The patient elected hospice services on 01/04/2024 with a terminal diagnosis of chronic obstructive pulmonary disease. The patient died at home on 01/30/2024. The plan of care dated 01/04/2024 was reviewed and revised on 01/09/2024 and 01/23/2024, specifying goals associated with impending death, fall prevention, cardiopulmonary symptoms, altered urinary and bowel elimination, skin integrity, nutrition and hydration, and psychosocial, emotional, and spiritual issues. The revised plans did not include the patient’s progress toward the specified outcomes and goals. During joint clinical record reviews and interviews on 09/18/2024, the Administrator/Clinical Director confirmed the plans of care identified did not include documentation of the patient's progress toward the outcomes and goals specified in the plans.

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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 5 (80%) clinical records reviewed, it was revealed that the agency did not ensure the patient's clinical record contained physician orders for all care and services provided. Clinical Record 1: The patient elected hospice services on 08/21/2024 with a terminal diagnosis of muscle atrophy. The plan of care dated 08/21/2024 included a visit frequency order for skilled nursing once a week. For the week of 08/18/2024, nursing visits were completed on 08/21/2024 and 08/23/2024. The clinical record did not include a physician's order for the scheduled visit made on 08/23/2024. Clinical Record 3: The patient elected hospice services on 08/12/2024 with a terminal diagnosis of muscle atrophy. The plan of care dated 08/12/2024 included a visit frequency order for skilled nursing once a week. For the week of 08/12/2024, nursing visits were completed on 08/12/2024 and 08/15/2024. The clinical record did not include a physician's order for the scheduled visit made on 08/15/2024. Clinical Record 4: The patient elected hospice services on 12/12/2023 with a terminal diagnosis of respiratory failure. The plan of care dated 12/12/2023 included a visit frequency order for skilled nursing once a week. For the week of 12/10/2023, nursing visits were completed on 12/12/2023 and 12/13/2023. The clinical record did not include a physician's order for the scheduled visit made on 12/13/2024. Clinical Record 5: The patient elected hospice services on 01/04/2024 with a terminal diagnosis of muscle atrophy. The plan of care dated 01/04/2024 included a visit frequency order for skilled nursing once a week. For the week of 12/31/2023, nursing visits were completed on 01/04/2024 and 01/05/2024. The clinical record did not include a physician's order for the scheduled visit made on 01/05/2024. During joint clinical record reviews and interviews on 09/18/2024, the Administrator/Clinical Director confirmed the clinical records identified did not include physician orders for the second nursing visits made. The Administrator stated the second visits for each week were scheduled and made as a follow-up on the newly admitted patients.