Every finding on record at Tlc Hospice Inc

Based on interview and record review, the hospice failed to ensure the updated comprehensive assessments included the changes that had occurred since the initial assessment, information on the patient's progress, and reassessment of the patient's responses for one of two sampled patients (Patient 2).  This failure had the potential of not addressing the care needs for this patient.Findings: --- Review of Patient 2's closed clinical record was initiated on 9/19/25.  The closed clinical record showed the SOC was on 5/29/25.  The patient was certified for hospice services during the certification period from 5/29/25 to 8/25/25.  The patient was discharged from hospice on 8/14/25.Review of the SN visit note dated 5/31/25, showed the patient was assessed to have plus one pitting edema on the bilateral lower extremities. Further review of the SN visit note dated 6/4/25, showed the patient was assessed to have a non pitting edema on the bilateral upper and lower extremities. Moreover, review of the SN visit notes dated 6/12, 6/15, 6/18, 6/25, 6/26, 7/3, 7/9, 7/17, 7/23, 7/25, 7/31, 8/8 and 8/12/25, showed the patient was assessed with edema on the bilateral lower extremities.However, the POC/IDG dated 6/5, 6/18, 7/3, 7/17, 7/31, and 8/14/25, failed to show documented evidence of the IDG discussion on the patient's edema on the bilateral upper and lower extremities.On 9/23/25 at 1130 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and LVN/Case Manager.  They were asked if the patient's edema was discussed during the IDG meetings.  They reviewed the closed clinical record.  The Administrator/DPCS replied, did not see it, and it was not written in the IDG note.  They were  informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the care and services were provided in accordance with the POC for one of two sampled patients (Patient 1).  This failure created the risk of not providing appropriate, consistent, and quality care to this patient. Findings: --- The hospice's P&P titled The Plan of Care revised May 2024 showed a written individualized patient and family/caregiver plan of a care will be established and maintained for each individual admitted to the hospice program.  The care provided to the patient must be in accordance with the plan of care. Review of Patient 1’s closed clinical record was initiated on 9/18/25.  The closed clinical record showed the SOC was 1/24/25.  The patient was certified for hospice services during the certification periods from 1/24/25 to 4/23/25, 4/24/25 to 7/22/25, and 7/23/25 to 9/20/25.   The patient was discharged from hospice on 9/9/25.   *  The certification period from 4/24/25 to 7/22/25, included the POC/IDG Review dated 4/24, 5/8, 6/5, 6/18, 7/3, and 7/17/25.  Documentation showed a care plan problem addressing the patient's "Gastro-Intestinal."  The interventions included to assess bowel status every visit and the ongoing assessment of alteration in bowel elimination.Review of the SN notes dated 4/29, 5/5, 6/10, 6/17, 6/24, 7/1, 7/15, and 7/21/25, showed the LVN had performed the gastrointestinal signs and symptoms screening. However, there was no documented evidenced the patient's last bowel movement was assessed as a symptom of the patient's bowel status and alteration in bowel elimination as per the POC. *  The certification period from 7/23/25 to 9/20/25, included the POC/IDG Review dated 7/31, 8/14, and 8/28/25.  Documentation showed a care plan problem addressing patient's "Gastro-Intestinal."  The interventions included to assess bowel status every visit and the ongoing assessment of alteration in bowel elimination.Review of the SN notes dated 8/1, 8/6, 8/20, 8/26, and 9/2/25, showed the LVN had performed the gastrointestinal signs and symptoms screening.   However, there was no documented evidence of the patient's last bowel movement assessed as a symptom of the patient's bowel status and alteration in bowel elimination as per the POC. On 9/23/25 at 1420 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS and LVN/Case Manager. They were asked if the patient's last bowel movement was needed to be documented as part of the assessment.  They reviewed the closed clinical record.  The Administrator/DPCS replied, yes.  They were informed and acknowledged the findings.

Based on record review and interview, the hospice failed to ensure the written POCs were developed to reflect the patient and family goals and interventions based on the problems identified for two of two sampled patients (Patients 1 and 2).  This failure created the risk of not addressing the care needs for these patients.Findings: --- The hospice's P&P titled the Plan of Care revised May 2024 showed a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program.1.  Review of Patient 1’s closed clinical record was initiated on 9/18/25.  The closed clinical record showed the SOC was 1/24/25.  The patient was certified for hospice services during the certification periods from 1/24/25 to 4/23/25, 4/24/25 to 7/22/25, and 7/23/25 to 9/20/25.   The patient was discharged from the hospice on 9/9/25. a. The Recertification Assessment dated 4/11/25, for the certification period from 4/24/25 to 7/22/25, showed the RN had performed the nutrition assessment. The nutrition assessment showed the patient had a weight loss of more than 10% in six months.  Documentation showed the patient had poor appetite and inadequate fluid intake.  The narrative section showed the patient had a weight loss "8 -10" since the start of care.However, the POC/IDG Review dated 4/24, 5/8, 6/5, 6/18, 7/3, 7/17, and 7/31/25, failed to show documented evidence of an individualized POC developed to address the patient’s identified weight loss.In addition, review of the recertification assessment dated 4/11/25, showed the patient's terminal diagnosis was "Secondary" malignant neoplasm of unspecified kidney and renal pelvis. However, the POC/IDG Review dated 4/24, 5/8, 6/5, 6/18, 7/3, 7/17 and 7/31/25, failed to show documented evidence of an individualized POC developed to address the terminal diagnosis of "Secondary" malignant neoplasm of unspecified kidney and renal pelvis on the patient’s genitourinary system.b.  The Recertification Assessment dated 7/21/24, for the certification period from 7/23/25 to 9/20/25, showed the patient had significant unintentional weight loss over the past 60 days as evidenced by the use of loose-fitting clothes, weight loss, and an increased need for assistance with ADL's (activities of daily living).  Documentation showed the "LA MAC" decreased by 0.8 cm since the last recertification. However, the POC/IDG Review dated 7/31, 8/14, 8/28 and 9/11/25, failed to show documented evidence of an individualized  POC developed to address the patient’s significant unintentional weight loss.On 9/23/25 at 1315 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS and LVN/Case Manager.  They were asked if a care plan was developed to address weight loss.  They reviewed the closed clinical record.  The Administrator/DPCS replied, no. They were also asked as to what care plan was needed to be developed to address the weight loss, and the Administrator/DPCS stated the nutrition care plan. They were informed and acknowledged the findings.2.  Review of Patient 2's closed clinical record was initiated on 9/19/25.  The clinical record showed the SOC was on 5/29/25.  The patient was certified for hospice services during the certification period from 5/29/25 to 8/25/25.  The patient was discharged from the hospice on 8/14/25.a. The Comprehensive Nursing Assessment dated 5/29/25, showed the patient had a weight loss of more than 10% in six month.  Documentation showed the patient had fair appetite and inadequate fluid intake.Review of the SN visit notes dated 5/31, 6/4, and 6/12/25, showed the patient acknowledged a weight loss of approximately 10 lbs. in recent months.  Documentation showed the appetite was described as fair. However, the POC/IDG Review failed to show documented evidence of an individualized POC developed to address the patient's weight loss of approximately 10 lbs. in the recent months. b.  Review of the SN visit notes dated 5/31/25, showed the patient was assessed to have plus one pitting edema on the bilateral lower extremities. Further review of the SN visit notes dated 6/4/25, showed the patient was assessed to have non pitting edema on the bilateral upper and lower extremities. Moreover, review of the SN visit notes dated 6/12, 6/15, 6/18, 6/25, 6/26, 7/3, 7/9, 7/17, 7/23, 7/25, 7/31, 8/8, and 8/12/25, showed the patient was assessed with edema on the bilateral lower extremities.However, the POC/IDG dated 6/5, 6/18, 7/3, 7/17, 7/31, and 8/14/25, failed to show documented evidence of an individualized POC was developed to address the patient's edema on the bilateral upper and lower extremities. On 9/23/25 at 1130 hours, an interview and concurrent closed clinical record review was conducted with the Administrator/DPCS and LVN/Case Manager.  They were asked if a care plan was developed for the patient's edema on the bilateral upper and lower extremities.  The Administrator/DPCS replied, no. They were  informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the initial and revised POCs included the indication for the PRN discipline visits for two of two sampled patients (Patients 1 and 2).  This failure had the potential of not providing necessary services for these patients.Findings: --- The hospices' P&P titled the Plan of Care revised May 2024 showed the procedure includes the plan of care will identify the patient's needs and services to meet those needs.  It must state in detail, the scope and frequency of services needed to meet the patient's family/caregiver's needs. 1. Review of Patient 1’s closed clinical record was initiated on 9/18/25.  The closed clinical record showed the SOC was 1/24/25.  The patient was certified for hospice services during the certification periods from 1/24/25 to 4/23/25, 4/24/25 to 7/22/25 and 7/23/25 to 9/20/25.   The patient was discharged from hospice on 9/9/25. The POC/IDG Review dated 7/31, 8/14, 8/28, and 9/9/25, showed LVN visit one time per week plus three PRN visits, RN visit one time per month plus three PRN visits, and MSW and SC recertification and three PRN visits. However, there was no documented evidence the POC included the indication for the PRN visits. On 9/23/25 at 1315 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and the LVN/Case Manager.  They were informed and acknowledged the findings. 2.  Review of Patient 2’s closed clinical record was initiated on 9/19/25.  The closed clinical record showed the SOC was 5/29/25.  The patient was certified for hospice services during the certification period from 5/29/25 to 8/25/25.  The patient was discharged from the hospice on 8/14/25. The POC/IDG Review dated 5/29, 6/5, 6/18, 7/3, 7/17, 7/31, and 8/14/25, showed the frequency of visit included LVN visit one time per week plus three PRN visits, RN visit one time per month plus three PRN visits, and MSW and SC visits for recertification and three PRN visits. However, there was no documented evidence the POC/IDG included the indication for the PRN visits. On 9/23/25 at 1130 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and LVN/Case Manager.  They were asked if the the indication for the PRN visit was needed to be included in the POC.  They reviewed the closed clinical record.  The Administrator/DPCS replied, they blocked the reason for the PRN visits. The Administrator/DPCS stated it was a system issue and they were instructed by the accrediting agency of the no need to create the reason for the PRN in the POC.  They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the POCs included measurable outcomes for two of two sampled patients (Patients 1 and 2).  This failure had the potential of not evaluating the POC and not providing appropriate care and services to these patients. Findings: --- 1. Review of Patient 1’s closed clinical record was initiated on 9/18/25.  The closed clinical record showed the SOC was 1/24/25.  The patient was certified for hospice services during the certification periods from 1/24/25 to 4/23/25, 4/24/25 to 7/22/25, and 7/23/25 to 9/20/25.   The patient was discharged from the hospice on 9/9/25.   The certification periods from 4/24/25 to 7/22/25 and 7/23/25 to 9/20/25, showed the POC/IDG Review was conducted on 4/24, 5/8, 6/5, 6/18, 7/3, 7/17, 7/31, 8/14, 8/28, and 9/9/25.  The POC/IDG Review showed the patient's identified problems with the established goals and interventions. However, the POC failed to include measurable outcomes for the patient's identified problems.  For example:-  for ADL care: all needs are met to an optimum level-  for Mobility and Musculoskeletal: will maintain optimal comfort and safety-  for Gastrointestinal: elimination needs met at an acceptable level-  for sleep: adequate rest to promote comfort.However, there was no documented evidenced as to what an adequate, optimum, and acceptable level were. On 9/23/25 at 1420 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and LVN/Case Manager.  They were informed and acknowledged the findings. 2.  Review of Patient 2's closed clinical record was initiated on 9/19/25.  The closed clinical record showed the SOC was on 5/29/25.  The patient was certified for hospice services during the certification period from 5/29/25 to 8/25/25.  The patient was discharged from the hospice on 8/14/25.The certification period from 5/29/25 to 8/25/25, showed the POC/IDG Review was conducted on 5/29, 6/5, 6/18, 7/3, 7/17, 7/31, and 8/14/25   The POC/IDG Review showed the patient's identified problems with the established goals and interventions. However, the POC failed to include measurable outcomes for the patient's identified problems.  For example:-  for Gastrointestinal: elimination needs met on daily basis at an acceptable level-  for Genitourinary: elimination needs met at an acceptable level and-  for Pain: maintained at a comfortable level during care. However, there was no documented evidence as to what comfortable and acceptable level were. On 9/23/25 at 1130 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and LVN/Case Manager.  They were informed and acknowledged the findings.

Based on interview and record review, the hospice failed to ensure the IDG had reviewed/revised the patient's POCs no less frequently than every 15 calendar days for one of two sampled patients (Patient 1).  This failure had the potential risk for not providing appropriate, consistent, and quality care to this patient.Findings: --- The hospice's P&P titled Interdisciplinary Group Meeting revised 10/2019 showed the procedure includes a plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment.Review of Patient 1’s closed clinical record was initiated on 9/18/25.  The closed clinical record showed the SOC was 1/24/25.  The patient was certified for hospice services during the certification periods from 1/24/25 to 4/23/25, 4/24/25 to 7/22/25, and 7/23/25 to 9/20/25.   The patient was discharged from hospice on 9/9/25.   *  The POC/IDG Review dated 4/24, 5/8, 5/22, 6/5, 6/18, 7/3 and 7/17/25, during the certification period from 4/24/25 to 7/22/25, showed a care plan problem for "Cardiovascular,"  which addressed chest pain.Review of the closed clinical record showed the SN had performed vital signs assessment.  The vital signs included BP readings on the following dates:-  on 5/13/25, 95/60 mmHg-  on 6/2/25, 95/66 mmHg-  on 7/1/25, 94/56 mmHg-  on 7/7/25, 98/62 mmHg-  on 8/12/25, 97/59 mmHg -  on 8/26/25, 96/54 mmHg However, the care plan problem for "Cardiovascular" was not revised to address the patient's low blood pressure readings. * The POC/IDG Review dated 7/31 and 8/14/25, during the certification period from 7/23/25 to 9/20/25, showed a care plan problem for "Cardiovascular" which addressed chest pain.Review of the SN notes dated 8/12/25, showed the SN had performed the vital signs assessment.  The vital signs included the BP reading.  The BP reading was documented as 97/59 mmHg. However, the care plan problem for "Cardiovascular" was not revised to address the patient's low blood pressure.On 9/23/25 at 1315 hours, an interview and concurrent closed clinical record review were conducted with the Administrator/DPCS and the LVN/Case Manager. They were informed and acknowledged the findings.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization did not plan the patient's care by ensuring the written plan of care was based on the patient's goals and time frames, settings, and services to meet the goals. In HV#1, HV#2, HV#3, RR#1, RR#3, RR#4, RR#6, RR#7, and RR#8 the goals for the patient's constipation were generally stated as Optimal bowel elimination and comfort - Facilitate optimum bowel movement. The goals were not patient-specific or measurable. This was discussed/verified with the Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not plan/revise the patient's plan of care based on information from updates to the comprehensive assessment and address the patient's progress toward goals and outcomes. In RR#8, it was documented in the interdisciplinary team discussion note that nine days prior the physician was contacted by the visiting nurse regarding the patient's new complaint of nausea and vomiting. A new order was received for Zofran 4mg by mouth every 6 hours as needed. The plan of care was not updated to reflect the patient's nausea and vomiting and related goals/outcomes/progress. This was discussed with the Director of Patient Care Services and clinical team.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not provide care, treatment, or services according to the patient's individualized plan of care. In RR#1, the aide plan of care indicated two person transfer assistance. This transfer was not documented (checked) on hospice aide visit note. The aide did document in the narrative section of the visit note Assisted in shower chair with no clear documentation that two person transfer was performed. This was discussed with the Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned by using standard precautions to reduce the risk of infection. During HV#1, the skilled nurse did change gloves several time during the patient assessment, but did not perform hand hygiene with the glove changes. In HV#2, the skilled nurse performed quick hand hygiene during the visit using very small amounts of hand gel with brief hand friction (less than 15 seconds). These practices were not consistent with the organization's policy/CDC guidelines for standard precautions and hand hygiene. This was discussed with the Director of Patient Care Services.