Every finding on record at Sms 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 1 of 6 (17%) clinical records reviewed, the patient’s individualized written plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 4: This patient elected the hospice benefit 02/27/2024 with a terminal diagnosis of non stemi myocardial infarction. The initial Registered Nurse (RN) assessment dated 02/27/2025 documented the patient had pain 10/10 with no pain killers upon admission. Orders were received for morphine 0.5ml-1 ml by mouth every 2 hours for pain/ shortness of breath, and Tramadol 50 mg every 6 hours as needed for pain. The plan of care was reviewed for the dates of 02/27/2025-03/27/2025. The patient goal for pain stated the patient would be assessed for pain levels at every skilled nursing visit. This patient goal documented in the care plan was not individualized or measurable. An interview was conducted with the Administrator on 03/27/2025 and he stated that the goal in the plan of care was not individualized or measurable.