Every finding on record at Optimum 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, interview, and observation. In 2 of 14 (14%) clinical records reviewed for patient's active on service revealed the hospice agency did not ensure the patients individualized written plans of care had identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice on 03/19/2024. The plan of care(POC) was dated 03/19/2024 to 06/16/2024. The patient had documentation of a right-sided nephrostomy tube mentioned in skilled nursing visit notes on 03/19/2024, 03/21/2024, 04/18/2024, and 06/11/2024. The medical director also wrote of the right-sided nephrostomy tube in the recertification of terminal illness narrative on 06/13/2024. There was no documented evidence of interventions, or treatment for the nephrostomy tube's care with goals or outcomes in the clinical record. Clinical Record 3/Home Visit 1: The patient elected hospice on 04/03/2024. The POC was dated 04/03/2024 to 07/01/2024. During the home visit (Home Visit 1) with the hospice aide (Personnel Record 4) on 07/02/2024, the patient was observed using oxygen via nasal cannula at 2.5 liters per minute. The patient also had three e-cylinder oxygen tanks stored at the bedside. There was no documented evidence of a physician's order for oxygen use. The POC did not include interventions, goals or outcomes for the oxygen. The Director of Nursing stated she would get an order and enter it during the joint clinical record review. During an interview on 07/02/2024, the Director of Nursing agreed that oxygen was not listed on the patient's medication profile or plan of care. She stated that it should have been entered by the nurse who admitted the patient. The Director of Nursing agreed there were no written orders for care and treatment or plan of care for the patient of clinical record number two.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview. A review of the volunteer binder revealed the hospice agency did not ensure the appointed Volunteer Coordinator documented and demonstrated viable and ongoing efforts to recruit and retain volunteers. Document 1: The volunteer binder provided by the administrator was reviewed on 07/03/2024. There was no documented evidence of ongoing recruitment and retention for volunteers. During an interview on 07/03/2024, the volunteer coordinator stated she recruits at churches and colleges. She stated she was using a website that has now closed down. The volunteer coordinator expressed she planned to host lunches and social events to bring the volunteers together for appreciation and retention, The volunteer stated she has given small tokens of appreciation to current volunteers but was not aware that efforts had to be documented. The Administrator/Director of Nursing was present during the interview. There were no further explanations provided.