Every finding on record at Stch Wayzata Mn 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 measurable outcomes anticipated from implementing and coordinating the plan of care. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review and interview. Agency policy #9-017 stated in part, "The written plan of care will contain, but not limited to, statement of treatment goals and documentation of progress toward outcomes...Measurable outcomes anticipated from implementing and coordinating the plan of care." In 5 of 5 (100%) clinical records reviewed, the agency did not ensure that the patient's plan of care included goals with measurable outcomes anticipated from the implementation and coordination of the plan of care. Clinical Record 1: The patient elected hospice care on 06/13/2024 with a diagnosis of heart disease. The Registered Nurse (RN) comprehensive assessment dated 06/13/2024 identified "a need for skilled teaching regarding bowel [sic] incontinent." The plan of care documented the patient's goal: " Patient/caregiver demonstrates proper care after each episode of bowel movement." The patient's goal did not include a measurable outcome. Clinical Record 2: The patient elected hospice care on 06/28/2024 with a diagnosis of malignant neoplasm of stomach. On admission, the RN's comprehensive assessment documented "alteration in comfort pain." The plan of care documented the patient goal: "Patient's caregiver will administer pain medication as ordered." The patient's goal did not include a measurable outcome. Clinical Record 3: The patient elected hospice care on 06/14/2024 with a diagnosis of heart disease. On admission, the RN’s comprehensive assessment documented the "need for effectiveness of cardiopulmonary care measures." The plan of care documented the patient's goal: "Patient exhibits reduction/relief of any cardiopulmonary symptoms. The patient's goal did not include a measurable outcome. Clinical Record 4: The patient elected hospice care on 06/25/2024 with a diagnosis of malignant neoplasm oral cavity. On admission, the RN's comprehensive assessment documented "alteration in comfort pain." The plan of care documented the patient's goal: "Patient's caregiver will administer pain medication as ordered." The patient's goal did not include a measurable outcome. Clinical Record 5: The patient elected hospice care on 06/28/2024 with a diagnosis of malignant neoplasm overlapping sites of pancreas. On admission, the RN’s comprehensive assessment identified that the patient was a "fall risk." The plan of care documented the patient's goal: "Patient will remain free from falls and injuries." The patient's goal did not include a measurable outcome. During an interview and a joint record review on 07/23/2024, the Regional Director of Clinical Services confirmed that plans of care did not include goals with measurable outcomes. Agency policy No 9-017 states "The written plan of care will contain, but not limited to, statement of treatment goals and documentation of progress toward outcomes." "Measurable outcomes anticipated from implementing and coordinating the plan of care."