Every finding on record at Paramount Palliative and Hospice of Texas LLC

It is required that each patient’s individualized written plan of care 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, document review and interview. 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the patient's written plan of care was updated with planned interventions to address new data obtained from the patient's updated comprehensive assessment. Document 1: The agency policy "Plan of Care" (JCC 013115) was reviewed and adopted on 11/13/2022 and included the following, "Based on the updated comprehensive assessments...the IDG will review, revise, and document the individualized plan as frequently as the patient's condition requires .... The written plan of care ... will include the following: problems identified, patient and family goals, interventions...measurable outcomes anticipated from implementing and coordinating the plan of care..." The agency policy "Interdisciplinary Group" (JCC 013115) reviewed and adopted 11/13/2022 read, "... The meetings will include ... a report on all care, treatment and services provided since the previous meeting for each patient, including but not limited to problems, goals, intervention, outcomes/progress toward goals... discussion by the IDG for the update or ongoing plan of care for each problem ...the discussions and updates will be documented on the Plan of Care..." Clinical Record 2: The patient elected the hospice benefit on 6/10/2023. The Patient's Plan of Care for the benefit periods 6/10/2023 to 9/7/2023 and 9/8/2023 to 12/6/2023 did not include any interventions that addressed the patient's two identified UTIs or the paranoid behaviors or medication identified in the patient's assessments. The nurse documented on 6/10/2023 in the Initial Nursing Assessment that the patient "...fixates on situations, suspicious of others..." At admission, the patient's medication list contained Quetiapine Fumarate 50mg: one tab PO BID (dated 6/10/2023) and Trazodone 50mg: one tab PO QHS (dated 6/10/2023). The Patient's Plan of Care for the benefit periods 6/10/2023 to 9/7/2023 and 9/8/2023 to 12/6/2023 did not include any interventions that addressed the patient's two identified UTIs or the paranoid behaviors or medication identified in the patient's assessments The Plan of Care - Initial/Comprehensive, dated 6/10/2023, included the following identified problems: Alteration in Mobility, Pain, Lack of Resources, Safety/Potential for Injury, and Spiritual Grief. Then, on 7/13/2023, the Nursing Clinical Progress Note included that the patient was suspicious of staff and others in the neurological section. "...States residents were robbed last night by agency members...denies any missing articles... staff report intermittent episodes described as saying things that are not true..." Next, on 7/19/2023, the nurse documented in the Nursing Clinical Progress Note, "...on an antipsychotic and antidepressant daily which have been effective in controlling any episodes of agitation..." The Chaplain documented in the Spiritual Progress Note dated 8/27/2023 that the patient was "...very paranoid about things from being fed different food than the other residents to her clothes missing ..." In the Nursing Clinical Progress Note dated 7/6/2023, the nurse documented, "Staff report strong odor from urine; Staff reported patient has a very strong smell of urine...order received for abx for possible UTI..." On 7/6/2023, there was a Physician Order for Cefdinir 300mg by mouth to be taken twice a day for seven days for a urinary tract infection (UTI). In the Interdisciplinary Group (IDG) Meeting dated 7/6/2023, the IDG Problems identified were Alteration in Mobility, Pain, Lack of Resources, Safety/Potential for Injury, and Alteration in Grief. The Registered Nurse (RN) update read, "Weekly SNV for assessment and sx mgmt. Monitoring pain control with present regimen...." The following IDG Meeting dated 7/20/2023 included the following identified problems: Alteration in Mobility, Pain, Lack of Resources, Safety/Potential for Injury, and Alteration in Grief. The RN documented updated stated, "Review of present pain management regimen ineffective based on weekly pain assessment and patient's continued report of pain and facial indicating pain. New orders received. ..." Then, on 8/8/2023, the nurse noted in the Nursing Clinical Progress Note, "staff report malodorous urine..." A Physician order dated 8/9/2023 included Septra DS one tab by mouth twice a day for five days for UTI. The IDG Meeting for 8/17/2023 included Alteration in Mobility, Pain, Lack of Resources, Safety/Potential for Injury, and Alteration in Grief as the only identified problems. The RN documented, "Ongoing monitoring of pain, agitation, other s/s reported. Not requiring PRN Norco as often. Will continue to monitor. Tolerated abx for possible UTI and no further episodes of agitation reported..." Personnel Record 2: On 10/18/2023, the Director of Clinical Operations (Staff 2) acknowledged that there were no interventions on the care plan to address the patient's two urinary tract infections or the behaviors related to the patient's hospice diagnosis.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the current subjective and objective medical findings when making this determination: This standard was not met as evidenced by clinical record review, document review and interview. 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the patient's Certification of Terminal Illness included documentation of any subjective or objective assessment data. Document 1: "Certification of Terminal Illness" (JCC 013115) reviewed and approved 11/13/2022. "...The Physician will reach a decision to certify...factors to be considered are terminal diagnosis, secondary conditions if any, comorbidities and medical management, current subjective and objective medical findings, current medication, and treatment orders...The written certification will include ...a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less reflecting the patient's individual clinical circumstances..." Clinical Record 4: The patient elected the hospice benefit on 6/8/2023. Documented by the Medical Director in the Initial Certification of Terminal Illness for the benefit period 6/8/2023 to 9/5/2023 signed 6/9/2023 was the following, "... is admitted to hospice with a primary diagnosis of end stage liver disease, she has comorbid conditions including anemia, hypertension, hypothyroidism and IVC filter. Code status is DNR. VSS". There is no documentation of laboratory results or clinical assessment findings to support the physician's certification. During an interview and record review on 10/19/2023, the Director of Clinical Services (Staff 2) confirmed that the CTI that the CTI did not include any supporting objective or subjective assessment data to support the physician's certification of terminal illness.