Every finding on record at T. D. Lane Enterprises 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 interventions to manage pain and symptoms. This standard was not met as evidenced by clinical records review, interview and observation. 1 of 5 (20%) records reviewed revealed that the POC lacked interventions to manage pain and symptoms. Record #81243: The patient was admitted to services on 9/30/2021 with a hospice diagnosis of senile degeneration of the brain. The RN initial comprehensive assessment documented the patient received Tylenol approximately one time a week for pain. The interdisciplinary plan of care lacked problems with associated interventions to manage pain. In an interview conducted during a home visit on 10/27/2021, the caregiver stated the patient received Tylenol approximately one time a week for pain in the lower bilateral extremities. This was confirmed by the hospice RN during the home visit. This finding was verified with the Director of Nursing (DON) who confirmed that the POC lacked interventions to address pain and symptoms that were identified in the initial assessment. The DON reported that a problem with interventions for pain was being added to the interdisciplinary plan of care for this record.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, interview, and document review. 2 of 5 (40%) records reviewed were missing evidence of documentation of the patient's name on the signed copies of the notice of patient's rights/hospice election statement. Record #67800: This patient was admitted 9/30/2021 with a hospice diagnosis of senile degeneration of the brain. The Informed Consent/Election of Benefits (EOB) form dated 9/30/2021 listed the name of the POA as the patient and did not include the patient's name on the form. Record #24851: This patient was admitted 10/1/2021 with a hospice diagnosis of senile degeneration of the brain. The Informed Consent/EOB form dated 10/1/2021 listed the name of the POA as the patient and did not include the patient's name on the form. Hospice Policy JCC 013115 "Informed Consent" (undated), stated, in part: "The hospice must provide the patient or representative with the required information, both verbally and written to obtain consent for services meet this requirement”. During an interview, the Director of Nursing stated she did not have an explanation as to why the patient's names were not on the Informed Consent/EOB form.