Every finding on record at Quality Care Services LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. It includes all services necessary for the palliation and management of the terminal illness, including 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 1 of 11 (9%) clinical records reviewed, the agency did not ensure the plan of care was individualized and included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 11: This patient elected the hospice benefit 08/03/2024 with a terminal diagnosis of atherosclerotic heart disease. In review of the Registered Nurse (RN) comprehensive assessment dated 08/03/2024, the RN documented “the patient was laying on the bed requesting help and saying ouch and was complaining of abdominal tenderness. The patient's daughter reported the patient had been given "OXY" for a tailbone fracture. The patient was unable to provide a numerical number for pain and was assessed as moderate for pain by the RN. The RN advised the daughter to give the patient Tylenol for pain if the patient could tolerate.” The plan of care, dated 08/03/2024, stated the patient’s goal for pain was "patient will achieve maintain optimal physical comfort". This goal was not individualized or measurable. The Registered Nurse Performance Improvement Coordinator/ Compliance Officer/Alternate Clinical Director was interviewed 11/26/2024 and confirmed that the plan of care should include goals that are individualized and measurable.