Every finding on record at Pearl 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 a review of clinical records, document reviews, and interviews. 5 of 5 (100%) records reviewed revealed the agency did not ensure that the written plan of care reflected patient and family goals and identified planned interventions based on problems identified in the initial comprehensive assessment. The agency policy #PC.6 "Plan of Care Process," (revised 5/1/2020) stated in part,"Information will be gathered from the initial assessment and be used by the Agency to develop the Initial Plan of Care (IPOC)/Physician's Orders and to provide care and services to treat a patient's and patient's family's immediate care and support needs...The POC includes, but is not limited to... Interventions to manage pain and symptoms and identified issues/problems...Measurable outcomes are anticipated from implementing and coordinating the POC...Designation of discipline(s) responsible for providing specific services." Clinical Record 1: The patient elected the hospice benefit on 10/18/2022 with the primary diagnosis of cardiac disease. For the benefit period 10/18/2022 through 1/15/2023, the POC dated 10/18/2022 did not include identified problems, goals, and interventions. A review of the form "IDG Plan of Care" (IDGPOC) dated 10/28/2022 revealed the IDG identified planned interventions and goals based on problems identified for "Cardiovascular; Respiratory, Pain, Sleep, Neurological, Musculoskeletal, Safety, Gastrointestinal, Endocrine, Nutrition, Integumentary/Skin, Genitourinary, Anticipatory Grieving, Spiritual, and Coping/Knowledge Deficit." The problems identified during the IDG review were not dated and the interventions did not include the discipline responsible for the implementation. Clinical Record 2: The patient elected the hospice benefit on 10/19/2022 with the primary diagnosis of cardiac disease. For the benefit period dated 10/19/2022 through 1/16/2023, the POC dated 10/19/2022 did not include identified problems, goals, and interventions. Review of the IDGPOC dated 10/28/2022 revealed the IDG identified planned interventions and goals based on problems identified for "Cardiovascular, Respiratory, Pain, Sleep, Neurological, Musculoskeletal, Safety, Gastrointestinal, Nutrition, Integumentary/Skin, Genitourinary, Anticipatory Grieving, Spiritual and Coping/Knowledge Deficit." The problems identified during the IDG review were not dated and the interventions did not include the discipline responsible for the implementation. Clinical Record 3: The patient elected the hospice benefit on 10/24/2022 with the primary diagnosis of hypertensive cardiac disease. For the benefit period dated 10/24/2022 through 1/23/2023, the POC dated 10/24/2022 did not include identified problems, goals, and interventions. Review of the IDGPOC dated 10/28/2022 revealed the IDG identified planned interventions and goals based on problems identified for "Cardiovascular, Respiratory, Pain, Sleep, Neurological, Musculoskeletal, Safety, Gastrointestinal, Nutrition, Integumentary/Skin, Genitourinary, Anticipatory Grieving, and Spiritual." The problems identified during the IDG review were not dated and the interventions did not include the discipline responsible for the implementation. Clinical Record 4: The patient elected the hospice benefit on 8/20/2022. The patient expired on 8/23/2022. For the benefit period dated 8/20/2022 through 11/17/2022, the POC dated 8/20/2022 did not include identified problems, goals, and interventions. The IDGPOC dated 9/2/2022 documented that the patient expired. There was no evidence that problems, planned interventions, and goals were identified for the patient. Clinical Record 5: The patient elected the hospice benefit on 8/25/2022. For the benefit period dated 8/25/2022 through 11/23/2022, the POC dated 8/25/2022 did not include identified problems, goals, and interventions. There were no documented identified problems, interventions, or goals in the record. The IDGPOC dated 9/2/2022 documented "Patient review revoked." There was no evidence that problems, planned interventions, and goals were identified for the patient. During an interview and a joint record review on 12/14/2022, the Director of Nursing (DON) confirmed the plans of care were missing identified problems, interventions and measurable goals for all the records. The DON confirmed the Plan of Care was also missing the dates when the problems, interventions or goals were initiated, and the disciplines were not assigned to the documented interventions. Agency did not document identified problems, interventions or measurable goals on the initial plan of care based on initial nursing assessment. For records with a written plan of care, there were no dates when the problems were initiated, the interventions were not assigned to a discipline, and there were no target dates for the goals.

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 the following medical supplies and appliances necessary to meet the needs of the patient. The documentation in the patient’s record is in accordance ith the hospice’s policies and procedures. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 5 of 5 (100%) records reviewed revealed the hospice did not ensure to include the medical supplies and appliances provided by the agency or used by the patient in the plan of care (POC). The agency policy #PC.6 "Plan of Care Process," (revised 5/1/2020) stated in part, "The POC includes, but is not limited to ... Medical supplies, equipment, and appliances necessary to meet the needs of the patient." Clinical Record 1: The patient elected hospice care on 10/18/2022 with the primary diagnosis of cardiac disease. For the benefit period dated 10/18/2022 through 1/15/2023, the agency form titled "Hospice Initial Plan of Care/Physician Orders" (POC) dated 10/18/2022 ordered, "oxygen (O2) at 2LPM via nasal cannula (NC)." The Registered Nurse (RN) initial comprehensive nursing assessment dated 10/18/2022 documented the patient's respiratory status as moderate shortness of breath with exertion and conversation. The RN documented dyspnea treatment with oxygen at 2LPM via NC as needed for shortness of breath, and the patient had urinary incontinence and used large adult briefs. In addition, the RN documented the patient's functional status as "decreased mobility/endurance, unsteady gait, impaired balance/coordination, and walker for ambulation assistance." The section of the POC labeled “DME to be provided" was blank and there was no evidence of medical supplies provided. During an interview on 12/14/2022, the Director of Nursing (DON) confirmed the oxygen concentrator setup, shower chair, large pullups, wet wipes, gloves, bed pads, and hand sanitizer were all provided by the hospice. The patient owned the walker. Clinical Record 2: The patient elected hospice care on 10/19/2022 with a primary diagnosis of cardiac disease. The RN’s initial comprehensive nursing assessment dated 10/19/2022 documented the patient had urinary incontinence and used large adult briefs. In addition, the RN documented the patient's functional status as "decreased mobility/endurance and ambulates with assistance using a walker." For the benefit period dated 10/19/2022 through 1/16/2023, the POC dated 10/19/2022, the section labeled “DME to be provided" was blank and there was no evidence of medical supplies provided. During an interview on 12/14/2022, the Director of Nursing confirmed large pullups, wet wipes, and gloves were provided to the patient. The patient owned the walker. Clinical Record 3: The patient elected hospice care on 10/24/2022 with a primary diagnosis of hypertensive cardiac disease. The RN’s initial comprehensive nursing assessment dated 10/24/2022 documented the patient had urinary incontinence and used large adult briefs. For the benefit period dated 10/24/2022 through 1/21/2023, the POC dated 10/24/2022, the section labeled “DME to be provided" was blank and there was no evidence of medical supplies provided. During an interview on 12/14/2022, the Director of Nursing confirmed large pullups, wet wipes, bed pads, hand sanitizer and gloves were provided to the patient. Clinical Record 4: The patient elected hospice care on 8/20/2022 with a primary diagnosis of cardiac disease. The RN’s initial comprehensive nursing assessment dated 8/20/2022 documented the patient had urinary incontinence and used adult briefs. For the benefit period dated 8/20/2022 through 11/17/2022, the POC dated 8/20/2022, the section labeled “DME to be provided" was blank and there was no evidence of medical supplies provided. During an interview on 12/14/2022, the Director of Nursing confirmed an oxygen concentrator setup, medium pullups, wet wipes, gloves and bed pads were all provided by the hospice. Clinical Record 5: The patient elected hospice care on 8/25/2022 with a primary diagnosis of colon cancer. The RN’s initial comprehensive nursing assessment dated 8/20/2022 documented the patient had urinary incontinence and used adult briefs. For the benefit period dated 8/25/2022 through 11/22/2022, the POC dated 8/25/2022 ordered "oxygen (O2) at 2LPM via nasal cannula (NC)." The section of the POC labeled “DME to be provided" was blank and there was no evidence of medical supplies provided. During an interview on 12/14/2022, the Director of Nursing confirmed an oxygen concentrator setup, hospital bed, medium pullups, wet wipes, gloves and bed pads were all provided by the hospice. The patient owned the walker. During an interview on 12/14/2022, the Director of Nursing confirmed the medical supplies and DME were missing from the plans of care.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 5 (100%) records reviewed revealed the hospice did not ensure that entries in patient records were legible. Clinical Record 1: was reviewed and identified the patient elected hospice care on 10/18/2022. Review of the record revealed documentation that was not legible or was difficult to read. The completed RN visit note dated 10/19/2022 (page 2 of 2) of the narrative, "use oxygen (not legible) resp distress." The initial certification of terminal illness narrative statement completed by the physician dated 10/19/2022 was not legible to the reader. The completed RN visit note dated 10/27/2022 (page 2 of 2) of the narrative was not legible "awake, A&O x2, no c/o, oxygen in use, pt stated he has to use it few times a day, no c/o (not legible) days now. Safety reviewed and oxygen use with ambulation. Pt/cg aware of 24/7 hospice availability." Clinical Record 2: was reviewed and identified the patient elected hospice care on 10/19/2022. Review of the record revealed documentation that was not legible or was difficult to read. The completed nursing visit note dated 10/20/2022 (page 2 of 2) of the narrative documentation was not legible, "Awake, A&O x2, was not (words not legible) at the time, no c/o pain, no resp distress notes, no c/o chest pain, c/o decreased appetite, c/o (word not legible)/ pain at times... (words not legible) ...at this time...able to manage (word not legible) with minimal assistance at this time, CG manages meds." Clinical Record 3: was reviewed and identified the patient elected hospice care on 10/24/2022. Review of the record revealed documentation that was not legible or difficult to read. The completed nursing visit note dated 10/25/2022 (page 2 of 2) of the narrative documentation was not legible, "Awake A&O, lives alone, son lives close by, and visits daily pt able to manage her needs (words not legible) ...pt c/o feeling very week in the morning...(not legible)...on orthostatic hypotension. (Word not legible) ...on 25/7 hospice availability. The nurse explained the not legible word was "instructed." Clinical Record 4: was reviewed and identified the patient elected hospice care on 8/20/2022. Review of the record revealed documentation that was not legible or difficult to read. The Registered Nurse (RN) initial comprehensive assessment ( page 16 of 16) of the narrative documentation was not legible, , "spouse and a caregiver at home...not legible..." Clinical Record 5: was reviewed and identified the patient elected hospice care on 8/25/2022. Review of the record revealed documentation that was not legible or difficult to read. The completed nursing visit note dated 8/26/2022 documented "Awake, A&O x2 sitting up in chair, c/o no pain but stated she (not legible) took (not legible) medicine only an hour ago...sleep (not legible) on pt (not legible)...all night in Geri-chair only...not legible...reinforced. O2 safety reviewed @ (not legibile) at the time. Family able to assist with all needed." During an interview and a joint review of the records on 12/13/2022, the Director of Nursing confirmed the legibility of the records needed improvement.