Every finding on record at Southern Legacy Hospice LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met, as evidenced by clinical record review and interview. In 1 of 5 (20%), the agency did not ensure that the written plan of care included patient and family goals and planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The hospice election of benefit was dated 10/08/2023. The spiritual assessment completed by the chaplain was dated 10/09/2023. The problem identified on the assessment and goal per the patient's request read in part 'spiritual pain related to reconciliation of the past.' The problem and associated goal were not included on the 10/08/2023 initial nor the 10/13/2023 interdisciplinary team updated hospice plan of care at the time of the review on 11/01/2023. During the interview on 11/02/2023, the DPCS reviewed the associated record and stated that the problem statement and goal identified during the chaplain assessment had inadvertently not been carried over to the hospice plan of care and had since been corrected.

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 detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met, as evidenced by clinical record review and interview. In 1 of 5 (20%), the agency did not ensure that the written plan of care included a detailed statement of the scope and frequency of services. Clinical Record 3: The hospice election of benefit was dated 10/08/2023. The frequency for the MSW read '1 prn and the frequency for the SC read 3 prn' on the 10/08/2023 initial and the 10/13/2023 interdisciplinary team updated hospice plan of care at the time of the review on 11/01/2023. There was no specific frequency identified. The 10/09/2023 psychosocial and spiritual assessments indicated plans to continue care based on the need for psychosocial support and spiritual support, respectively. During the interview on 11/02/2023, the DPCS reviewed the associated record and stated that the specific frequency had inadvertently been omitted and had since been corrected.