Every finding on record at Orange Coast Hospice Services, Inc.

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 a review of clinical records, document reviews and interviews. 2 of 5 (40%) records reviewed revealed the hospice did not ensure plans of care included goals and interventions based on problems identified in the initial comprehensive assessment. Clinical Record #1: was reviewed and identified the patient elected hospice care on 10/8/22. The initial nursing assessment documented that the patient was short of breath with minimal exertion (e. g. while eating, talking, or performing other ADLs or with agitation). The plan of care dated 10/8/22 lacked a goals and interventions for respiratory shortness of breath. Clinical Record #2: was reviewed and identified the patient elected hospice care on 10/8/22. The initial nursing assessment documented that the patient was short of breath with moderate exertion (e. g. while dressing). The plan of care dated 10/8/22 lacked a goals and interventions for respiratory shortness of breath. The agency's policy #9-017 "The Plan of Care" (Revised 11/20), stated in part, "The care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. The plan will focus on identified problems, goals, and interventions." During an interview on 10/13/22, the owner and Director of Compliance reviewed and agreed with the finding above.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 2 (50%) records reviewed revealed the hospice did not ensure that a copy of the patient's discharge summary was sent to the attending physician. Clinical Record #4: was reviewed and revealed the patient elected hospice care on 8/24/22. The patient revoked hospice care on 9/5/22 because the patient was pursuing aggressive treatment. The record did not include evidence that the discharge summary was forwarded to the attending physician. The agency's policy #1-024, "Revocation of Hospice Benefit" (Revised 11/20) stated in part, "A discharge summary will be sent to the attending physician." During an interview on 10/13/22, the Owner and Director of Compliance reviewed and agreed with the above finding.