Every finding on record at Progress Palliative Care Inc

Upon patient record review, 1 of 14 records (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: The visit frequency for the LVN dated 4/24/25 was 2 times/week and prn. On 5/12/25, it was decreased to 1x/week and prn. There was not evidence of a quantifier for the prn visits.

Upon patient record review, 10 of 14 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9,#10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Upon admission, the psychological goals and interventions for the social worker included, 'Social Worker will accomplish initial evaluation visit within 5 days and implement plan of care if applicable.' Also, the spiritual goals and interventions for the spiritual care provider included, 'Spiritual Care will accomplish initial evaluation to determine spiritual needs of patient/family within 5 days.' With all patients, the initial evaluation visit was conducted within the 5 days but there was not evidence that the initial goals and interventions were resolved, with new goals and interventions developed post visit and evaluation.

Upon client record review, 7 of 14 records (Patient #2,#3,#4,#5,#6,#7,#8) 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 visit frequency for the LVN dated 5/12/25, was 1x/week and prn. The record indicated 2 routine visits for the weeks of 5/11/25-5/17/25, 5/18/25-5/24/25 and 6/1/25-6/7/25. Patient #2,#3,#4,#5,#6,#7,#8: The initial assessment and most monthly visits were conducted via telephone remotely by the spiritual care counselor. There was not evidence of a consent for telehealth, or that the patient/representative requested remote visits. There was not evidence of 2-way audio-video communication. There was not evidence of COVID or other rapidly spreading infection at the patients location.

Upon personnel record review, 1 of 13 records (Personnel #11) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #11: There was not evidence that the aide provided care on a patient or pseudo-patient for the tasks of recording rectal, axillary or digital temperature, or tub, and shower bath.

Upon patient client record review, 1 of 14 records (Patient #6) 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. Patient #6: The record indicated an order dated 5/23/25 to perform peri care. Change Foley catheter monthly and as needed. There was not evidence that the patient had a Foley catheter at the time of this order.