Every finding on record at Stone Creek Hospice Care Inc.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical record review and interview. 3 of 5 (60%) records reviewed revealed the hospice did not ensure the patient's individualized written plan of care identified planned interventions based on problems identified in the initial comprehensive assessment. Record #12212 was reviewed and identified the benefit period dated 5/12/2022-8/9/2022. The initial comprehensive assessment completed 5/12/2022 by the registered nurse documented, "Date scheduled opioid initiated....5/12/2022...Date PRN opioid initiated or continued 5/12/2022....Date bowel regimen initiated or continued ...5/12/2022." The patient's medication profile dated 5/12/2022 included the medications: Morphine Sulfate, Lorazepam, and Oxygen. The plan of care order dated 5/12/2022 lacked bowel regimen interventions and goals. Record #60077 was reviewed and identified the benefit period dated 5/10/2022-8/7/2022. The initial comprehensive assessment completed 5/10/2022 by the registered nurse documented, "Constipation... Occasional.... Was a bowel regimen initiated... Yes.... Date bowel regimen initiated or continued 5/10/2022." The medication profile dated 5/10/2022 documented, "Docusate Sodium Oral Capsule 100 mg..." The plan of care order dated 5/19/2022 lacked constipation as a problem with interventions and goals. Record #70525 was reviewed and identified the benefit period dated 5/11/2022-8/8/2022. The initial comprehensive assessment completed 5/11/2022 by the registered nurse documented, “Difficulty with constipation.... Was a bowel regimen initiated... Yes.... Date bowel regimen initiated or continued 5/11/2022." The plan of care order dated 5/19/2022 lacked bowel regimen interventions and goals for the patient’s identified problem with constipation. The findings were validated by the Administrator on 5/24/2022 during an interview and a joint review of the records.