Every finding on record at Profound Hospice Care, LLC

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, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 9 of 9 (100%) clinical records reviewed, the agency did not ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/13/2025 with a diagnosis of long COVID [Coronavirus]. The initial plan of care dated 05/13/2025 to 08/11/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG [patient/caregiver] will proceed through the grief process with support of the IDG/IDT [interdisciplinary group/interdisciplinary team]. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. The agency used a paper document for the development of the plan of care. The goals section was a standardized check box list and there was no space in the goals section of the form to document individualization of the goal and individualized and measurable goals were not written elsewhere on the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 03/21/2025 with a diagnosis of cerebral infract. The initial plan of care dated 03/21/2025 to 06/18/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. CLINICAL RECORD 3: The patient elected the hospice benefit on 05/13/2025 with a diagnosis of protein calorie malnutrition. The initial plan of care dated 05/13/2025 to 08/11/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/24/2025 with a diagnosis of Parkinson’s disease. The initial plan of care dated 01/24/2025 to 03/25/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. CLINICAL RECORD 5: The patient elected the hospice benefit on 11/04/2024 with a diagnosis of late effect cerebral vascular accident. The initial plan of care dated 11/04/2024 to 12/24/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, and what a comfortable death would be for the patient. CLINICAL RECORD 6: The patient elected the hospice benefit on 01/30/2025 with a diagnosis of heart disease. The initial plan of care dated 01/30/2025 to 04/30/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, and what a comfortable death would be for the patient. CLINICAL RECORD 7: The patient elected the hospice benefit on 01/08/2025 with a diagnosis of congestive heart failure. The initial plan of care dated 11/15/2024 to 02/12/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/08/2025 with a diagnosis of congestive heart failure. The initial plan of care dated 04/08/2025 to 06/06/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/04/2025 with a diagnosis of senile degeneration of the brain. The initial plan of care dated 05/04/2025 to 08/02/2025 included the following goals for the patient: "Symptoms of disease process will be managed. Pt/CG will proceed through the grief process with support of the IDG/IDT. Pt/CG will find comfort through psychosocial/spiritual support. Patient will experience a comfortable death. Pt/CG will be knowledgeable of the disease process and hospice care." The goals on the plan of care were not individualized and measurable when they did not describe how the patient’s specific disease process would be managed, how the patient would be expected to proceed through grief, what a comfortable death would be for the patient, and how the patient would become knowledgeable about the disease process and hospice care. During an interview and joint review of the records on 06/03/2025, the Administrator (Personnel Record 1) stated, "We are using the form for the plan of care that our consultant provided. It doesn't have a place to individualize the goals. We are implementing an Electronic Medical Record system, which will allow clinicians to individualize patient goals and make them measurable."

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, drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure the plan of care included the medications taken by the patient. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 05/13/2025 with a diagnosis of long COVID [Coronavirus]. During the home visit observation on 06/02/2025 with the Registered Nurse (RN) (Personnel Record 2), the patient’s written medication profile dated 05/13/2025 found in the home was reviewed with the patient. The medication profile included the following medications: Ketamine 100mg PO (orally) three times daily; Alprazolam 1mg orally three times daily as needed; Gabapentin 300mg 1-2 tablets PO every 6 hours as needed; Aspirin 81mg PO daily; Baclofen 10mg 2 tabs PO twice daily; Citalopram 40mg PO daily; Tylenol ES 500mg PO three times daily as needed; Colace 100mg PO daily at 6pm; Levothyroxine 25mcg PO every 8 hours; Hydroxyzine 25mg PO every 8 hours as needed; Cyclobenzaprine 10mg, 1/2 tab PO every 8 hours as needed; APAP suppository 650mg per rectum every 6 hours as needed; Haloperidol 0.5-1.0mg sublingually every 6 hours as needed; Lorazepam 0.5mg orally every 6 hours as needed; Hyoscyamine 0.125mg sublingual every 4 hours as needed; Prochlorperazine 10mg orally every 12 hours as needed; Bisacodyl 10mg per rectum daily as needed. The medications listed on the medication profile had a documented start date of 05/13/2025, the hospice start of care date. The patient confirmed the medications were current medications. The clinical record included a copy of the same medication profile found in the home. The written plan of care dated 05/13/2025 included orders for Ketamine, Alprazolam, Gabapentin, Baclofen, Tylenol ES, Hydroxyzine, Cyclobenzaprine, APAP suppository, Haloperidol, Lorazepam, Hyoscyamine, Prochlorperazine, and Bisacodyl. The plan of care did not include medication orders for Aspirin, Citalopram, Colace, and Levothyroxine, and the clinical record did not include interim orders for the medications. During an interview and review of the record on 06/03/2025, the Director of Clinical Services (Personnel Record 2) confirmed the agency is currently documenting on paper records and stated, "There should have been orders on the plan of care for all the medications on the medication profile."

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with patient transfer, the agency did not ensure the discharge summary was forwarded to the receiving facility. CLINICAL RECORD 8: The patient elected the hospice benefit on 04/08/2025 with a diagnosis of congestive heart failure. Clinical record review revealed the patient was transferred to a skilled nursing facility and discharged from hospice on 05/03/2025. The record included documentation that the discharge summary was sent to the patient’s attending physician, but there was no documented evidence that the discharge summary was sent to the receiving facility. During an interview and joint record review on 06/04/2025, the Administrator (Personnel Record 1) stated, "In this case, the discharge summary was not sent to the facility, only to the physician."