Every finding on record at Tender Care Hospice PA LLC

It is required that each patient’s individualized written plan of care Measurable outcomes anticipated from implementing and coordinating the plan of care 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 14 of 14 (100%) clinical records reviewed revealed the agency did not ensure that measurable outcomes were included in the plan of care. CLINICAL RECORD 1: The Plan of Care (POC) dated 02/04/2025-05/04/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver verbalizes understanding of anorexia and dehydration in the terminal patient/caregiver demonstrates offering but not forcing food or fluids to patient. Changes in neurological status will be addressed appropriately. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Caregiver verbalizes understanding of signs and symptoms of imminent death, plan for symptom management, and what to do at time of death." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 2: The Plan of Care (POC) dated 03/06/2025-05/04/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Facility staff is knowledgeable and involved in hospice plan of care for patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown.” However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 3: The Plan of Care (POC) dated 01/19/2025-04/18/2025 included the following goals: "A nursing plan of care will be established. Hospice nurse to monitor patient's pain level and report ineffective pain control to the physician. Hospice nurse to assess effectiveness of cardiopulmonary symptom relief measures including oxygen treatment and comfort modalities. Hospice nurse to coordinate plan of care with facility staff. Hospice nurse to provide instruction related to prevention/management of skin breakdown. Hospice nurse to assess medication response and instruct on schedule, actions, purpose, side effects, compliance, and need to report side effects to hospice staff.” However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 4: The Plan of Care (POC) dated 01/22/2025-04/21/2025 included the following goals: "A nursing plan of care will be established. Patient/Caregiver will verbalize/demonstrate appropriate pain management. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Patient/Caregiver will demonstrate independence of inhalation therapy and care of equipment. Patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease. Patient/caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown.” However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 5: The Plan of Care (POC) dated 03/08/2025-05/06/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Caregiver understands change in level of consciousness as it relates to disease process and approaching end of life. Patient/caregiver verbalizes understanding of anorexia and dehydration in the terminal patient/caregiver demonstrates offering but not forcing food or fluids to patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Patient will have safety needs met. Caregiver verbalizes understanding of signs and symptoms of imminent death, plan for symptom management, and what to do at time of death." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 6: The Plan of Care (POC) dated 02/26/2025-05/26/2025 included the following goals: "A nursing plan care plan will be established. Medications will be managed appropriately as evidenced by steady symptom control. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. Pain will be managed at a level acceptable to the patient. Patient will verbalize/demonstrate reduction/relief of cardiopulmonary symptoms. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Changes in neurological status will be addressed appropriately." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 7: The Plan of Care (POC) dated 01/17/2025-04/16/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient exhibits signs of symptom reduction or relief. Patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Changes in neurologic status will be addressed appropriately. Patient/caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown. Caregiver verbalizes understanding of signs/symptoms imminent death, plan for symptom management, and what to do at time of death. Medications will be managed appropriately as evidenced by steady symptom control. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. Patient's anxiety/agitation is minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 8: The Plan of Care (POC) dated 02/16/2025-05/16/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Changes in neurologic status will be addressed appropriately. Facility staff is knowledgeable and involved in hospice plan of care for patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient will have safety needs met." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 9: The Plan of Care (POC) dated 12/20/2024-03/19/2025 included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver verbalizes demonstrates proper mouth care. Patient will follow an effective bowel program to prevent/relieve constipation. Patient/caregiver will verbalize/demonstrate adequate knowledge of ostomy care. Patient/caregiver will verbalize/demonstrate adequate knowledge of gastrostomy feedings and care. Caregiver will verbalize demonstrate measures to prevent/manage skin breakdown. Caregiver will verbalize/demonstrate appropriate and safe wound care. Wound will be managed without infection and pain will be controlled." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 10: The Plan of Care (POC) dated 02/27/2025-05/27/2025 included the following goals: "Pain will be managed at a level acceptable to the patient. Caregiver will verbalize understanding of effects of urinary incontinence. Patient/caregiver will verbalize/demonstrate understanding of care required secondary to bowel incontinence. Caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 11: The Plan of Care (POC) dated 12/23/2024-03/22/2025 included the following goals: "A nursing plan of care will be established. Patient/caregiver will verbalize/demonstrate appropriate pain management. Patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease. Patient/caregiver will verbalize/demonstrate understanding of how to use oxygen safely and effectively. Indwelling urinary catheter will remain patent. Patient/caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient. Patient's anxiety/agitation is minimized/controlled, and caregiver verbalizes understanding of its effects/origin/treatment. Caregiver will verbalize/demonstrate measures to prevent manage skin breakdown." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 12: The Plan of Care (POC) dated 11/29/2024-02/26/2025 included the following goals: "A nursing plan of care will be established. Caregiver will verbalize/demonstrate appropriate pain management. Patient will follow an effective bowel program to prevent/relieve constipation. Patient's nausea/vomiting will be controlled or reduced. Patient/caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluids to patient." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 13: The Plan of Care (POC) dated 02/23/2025-05/23/2025 included the following goals: "A nursing plan of care will be established. Medications will be managed appropriately as evidenced by steady symptom control. Patient/caregiver will verbalize/demonstrate compliance with medication regimen. Patient/caregiver will demonstrate competency in management of self-administered medications. Pain will be managed at a level acceptable to the patient. Patient will have safety needs met. Patient will follow an effective bowel program to prevent/relieve constipation. Patient/caregiver verbalizes/demonstrates understanding of management of diabetes to prevent a diabetic event. Patient/caregiver verbalizes understanding of anorexia/dehydration in the terminal patient and caregiver demonstrates offering but not forcing food/fluid to the patient. Changes in neurologic status will be addressed appropriately. Caregiver understands change in level of consciousness as it relates to disease process and/or approaching end of life. Patient/caregiver will verbalize knowledge of preventative measures response in the event of hemorrhage. Bleeding/hemorrhage will be recognized early for management. Caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. CLINICAL RECORD 14: The Plan of Care (POC) dated 08/10/2024-11/07/2024included the following goals: "A nursing plan of care will be established. Pain will be managed at a level acceptable to the patient. Patient/caregiver will verbalize understanding of effects of urinary incontinence. Patient will follow an effective bowel program to prevent/relieve constipation. Patient/caregiver will verbalize demonstrate adequate knowledge of gastrostomy feedings and care. Caregiver understands change in level of consciousness as it relates to disease process and/or approaching end of life. Caregiver will verbalize/demonstrate appropriate and safe wound care. Wound will be managed without infection and pain will be controlled. Facility staff is knowledgeable and involved in hospice plan of care for patient." However, these goals did not include measurable criteria or a specific time frame for achieving these goals. The Nurse Manager (Personnel Record 2) was interviewed on 03/11/2025 and stated, "I see how we should be more detailed in developing the patient goals and make them individualized."

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) records reviewed, the agency did not ensure that all orders for patient treatments were included in the plan of care. CLINICAL RECORD 1: The initial nursing comprehensive assessment dated 02/04/2025 included an assessment and measurements of a left ear stage 1 wound and a left distal pretibial stage 1 wound and that wound care was being provided. There was no documented evidence that wound care was provided during this visit. The skilled nurse (SN) visit note dated 02/05/2025, stated wounds were "not assessed", and the nurse did not perform wound care because the "caregiver completed [wound] care. Instructed in performing wound care. Details/Comments: Wound care procedure- [no details inserted]". The plan of care (POC) dated 02/04/2025-05/04/2025 did not include wound care orders nor were there any interim verbal orders present in the record for wound care. CLINICAL RECORD 9: The nursing initial assessment dated 12/20/2024 included documentation that the patient had a gastrostomy tube. The Plan of Care (POC) dated 12/20/2024 included an intervention (order) that stated, "Hospice nurse for instruction/reinforcement regarding administration of gastrostomy tube feedings to include safety measures, care of equipment and preparation of feedings." The order on the POC did not include an indication for the type of feeding, amount, frequency, or duration of the tube feed. CLINICAL RECORD 14: The nursing initial assessment dated 08/10/2024 included documentation that stated, "Receives nutrition via feeding tube." All of the medications on the Plan of Care (POC) were ordered to be administered via the G-Tube, except for morphine, which was ordered to be administered under the tongue. The POC dated 08/10/2024 included an intervention (order), "Hospice nurse for instruction/reinforcement regarding administration of gastrostomy tube feedings to include safety measures, care of equipment and preparation of feedings.” The POC did not include orders indicating the type, amount, frequency, or duration of tube feed, nor did it include flushes for medication administration. The Administrator (Personnel Record 1) was interviewed on 03/12/2025 and stated, "The admitting nurses need to add all of the orders for care on the plan of care."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure that clinical personnel followed the agency's policy on hand hygiene. POLICY: The agency's "Hand Hygiene Policy and Compliance Program" policy (5.7.1, undated) stated in part, "Indications for hand hygiene are...before and after direct patient care...before re-entering nursing bag or patient's clean supplies." HOME VISIT 1: A home visit was conducted with the Registered Nurse (RN) (Personnel Record 2) on 03/11/2025. During the observation visit, the RN was observed entering the clinical bag several times to retrieve and return equipment without sanitizing her hands. The RN did not follow the agency's policy on hand hygiene. The Administrator (Personnel Record 1) was interviewed on 03/11/2025 and stated, "The nurse did not follow our policy on hand hygiene."

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) record for patients transferred to a hospital (hospice revocation), the agency did not ensure that the receiving facility received a copy of the hospice discharge summary. CLINICAL RECORD 14: A review of the clinical record revealed that the patient elected the hospice benefit on 08/10/2024. A communication note in the record dated 08/16/2024 indicated the skilled facility where the patient resided notified the hospice agency that the patient was admitted to the hospital. A discharge summary was present in the record. There was no documentation in the record that the discharge summary was sent to the receiving facility. The Administrator (Personnel Record 1) was interviewed on 03/12/2025 and stated, "We send the discharge summary to the patient's physician when a patient is discharged or transferred to the hospital, but we were not aware that it needed to be sent to the hospital too when a patient is transferred."