Every finding on record at Procare Hospice Inc

Upon patient record review, 15 of 15 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11,#12,#13,#14,#15) did not have evidence that the patients received information about the charges or patient responsibility for care/service covered under the hospice benefit.

Upon patient record review 3 of 15 (Patient #2, 4, 8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2: There was no evidence of a spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence that another discipline completed this part of the assessment. Patient #4: There was no evidence of a psychosocial assessment of the patient or family. There is no evidence that another discipline completed this part of the comprehensive assessment. Patient #8: There was no evidence of a spiritual care assessment of the patient or family. There is no evidence that another discipline completed this part of the comprehensive assessment.

Upon patient record review, 6 of 15 (Patients #2,#6,#7,#12,#13,#15) 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 #2: The visit frequency for the social worker was indicated at 1x/month. The patient was admitted on 5/25/23. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the psychosocial aspect of the patient. The patients revised plan of care on 05/26/23 does not address pain as a problem and was not updated to include continuous care to manage pain. Pain was identified on 05/25/23 when the nurse documents the patient had a pain level of 8/10 in the leg. The nursing documentation stated the physician ordered continuous care. Patient #6: The visit frequency for the spiritual care provider and social worker were indicated at 1x/month. The patient was admitted on 8/9/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the spiritual and psychosocial aspect of the patient. Patient #7: The RN assessment on 3/1/23 indicated the patient was started on oxygen @ 2l nasal canula. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to dyspnea. Patient #12: The visit frequency for the spiritual care provider and social worker were indicated at 1x/month. The patient was admitted on 10/3/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the spiritual and psychosocial aspect of the patient. Patient #13: The visit frequency for the spiritual care provider and social worker were indicated at 1x/month. The patient was admitted on 11/23/22. There was no evidence of problem statements with goals, interventions and progress toward outcomes related to the spiritual and psychosocial aspect of the patient. Patient #15: The RN assessment on 2/24/23 identified the patient as high risk for aspiration. No evidence of problems, goals, and interventions for aspiration precautions included in the plan of care. In addition, no problems, goals and interventions on the plan of care for identified cachexia or identified increased dyspnea.

Upon patient record review, 1 of 15 (Patient #2) 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 medications and treatments. Patient #2: The plan of care dated 5/26/23 contained an order for daily wound care to the left leg. The order does not specify who is to perform the wound care.

Upon client record review, 2 of 15 (Patient #2 and 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The plan of care dated 5/26/23 indicated social work visits 1x/month. There was no evidence of any visits and no evidence of refusal of visits at time of survey. Patient #4: SW ordered for one time eval within 5 days. The medical record did not contain evidence that the patient received social work services within 5 days.

Upon patient record review, 4 of 15 (Patients #1,#5,#8,#11) 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 #1: The RN documentation included "oxygen @ 2 liters nc". The aide care plan did not include evidence of oxygen precautions. Patient #5: The medication profile included aspirin daily for anticoagulation. The aide care plan did not contain evidence of bleeding precautions. In addition, RN documentation included "oxygen @ 2 liters nc". The aide care plan did not include evidence of oxygen precautions. Patient #8: The RN documentation included "oxygen @ 2 liters nc". The aide care plan did not include evidence of oxygen precautions. Patient #11: The certification of terminal illness and RN documentation included "difficulty swallowing". No evidence of aspiration precautions on aide care plan. In addition, RN documentation included "oxygen @ 2 liters nc". No evidence of oxygen precautions on the aide care plan.

Upon patient record review 1 of 15 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: There was no evidence of aide supervisory visits from 5/24/23-7/6/23.

Upon patient client record review, 1 of 15 (Patient #2) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: The Hospice Medicare Election statement does not clearly identify the effective date of election.

Upon patient client record review, 4 of 15 (Patients #1,#2,#3,#4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The IDG/plan of care update and all subsequent plan of care updates were not signed by an RN at the time of survey. Patient #2: The IDG/plan of care dated 6/22/23 was not signed by the social worker, chaplain, and RN at the time of survey. Patient #3: The spiritual assessment was not signed by the chaplain at the time of survey. Patient #4: The medical record did not contain clear and concise documentation. The IDG/plan of care dated 7/6/23 indicates "the POA is unavailable due to scheduled surgery" and the POA will call the SC and schedule and initial evaluation. The medical record contains a completed spiritual assessment by the chaplain on 7/3/23.