Every finding on record at Park Point Healthcare LLC

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: Physician’s order for SC visits, there is no evidence of a spiritual care plan of care, including problems, goals, and interventions. Constipation and pain are identified as problems in patient’s medical record. There is no evidence of constipation or pain plans of care, including problems, goals, and interventions. Patient 2: Physician’s order for SC visits, there is no evidence of a spiritual care plan of care, including problems, goals, and interventions. High fall risk identified via MAHC assessment during 08/02/2024 SN visit. There is no evidence of a fall risk plan of care including problems, goals, interventions. Patient 3: Physician’s order for SC visits, there is no evidence of a spiritual care plan of care, including problems, goals, and interventions. High fall risk identified via MAHC assessment during 08/08/2024 SN visit. There is no evidence of a fall risk plan of care including problems, goals, interventions. Patient with Braden score of 12 during 08/08/2024 SN visit. There is no evidence of an integumentary plan of care including problems, goals, and interventions. Patient 4: High fall risk identified via MAHC assessment during 08/02/2024 SN visit. There is no evidence of a fall risk plan of care including problems, goals, interventions. Patient identified as an aspiration risk during the 08/02/2024 SN visit. There is no aspiration plan of care including problems, goals, and interventions. Patient 5: Patient with physician’s order for SC visits, there is no evidence of a spiritual care plan of care, including problems, goals, and interventions.

Upon patient record review, 2 of 5 (Patient #2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: Assessed DME need: oxygen concentrator, backup oxygen, wheelchair, raised toilet seat, grab bars. DME listed in the plan of care: wheelchair. There is no evidence of other DME listed in the plan of care. Patient 3: Assessed DME need: chairlift, wheelchair, raised toilet seat, grab bars, hospital bed. DME listed in the plan of care: wheelchair. There is no evidence of other DME listed in the plan of care.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s visit frequency order for SN, effective 08/02/2024: twice weekly. There is no evidence of second SN visit made week of 10/13/2024.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: Task: transfer bed/chair on aide care plan with visit frequency every visit PRN.

Upon patient record review 1 of 5 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2: 08/06/2024 aide visit-No evidence or documentation of aide visit made on this date. No evidence of missed visit in the medical record.

Upon inpatient contract review, 2 of 2 SNF contracts, Mantey Heights and Eagle Ridge, did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon SNF/NF contract review, 2 of 2 SNF contracts, Mantey Heights and Eagle Ridge, did not have evidence of the manner in which the SNF/NF and the hospice are to communicate with each other and how each will document such communications to ensure that the needs of patients are addressed and met 24 hours a day.