Every finding on record at Town Hospice & Palliative Care, Inc.

It is required that each patient’s individualized written plan of care reflects patient and family goals and [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review. In 2 of 14 (14%) clinical records reviewed, the agency did not ensure that the plan of care identified planned interventions and goals based on problems identified in the comprehensive assessment. Clinical Record 12: The patient elected the hospice benefit on 06/05/2024 with a diagnosis of senile degeneration of the brain. The initial comprehensive assessment completed by the Registered Nurse (RN) on 06/05/2024 documented that “Mild dysphagia was reported and related to the disease process. Patient is missing teeth...Wife wants to keep diet the same for now but [sic] education by RN about dysphagia and agrees to mechanical soft foods for the most part. She will monitor him for changes that require adjusting his diet texture.” The plan of care dated 06/05/2024 through 09/02/2024 did not include documentation of planned interventions and goals addressing the patient’s identified problem of dysphagia. Clinical Record 6: The patient elected the hospice benefit on 03/15/2024. The initial comprehensive assessment completed by the RN on 03/15/2024 documented that the patient “Has a Foley/30ml in place and reports previous changes q2wks due to chronic urinary tract infections (UTIs). Discussed irrigations and acetic acid irrigations and confirmed having NS irrigations in the past but not acetic acid. Would like to try this routinely rather than changing every 2 weeks and taking prophylactic antibiotics.” The RN assessments dated 03/18/2024, 03/21/2024, 03/26/2024, and 04/02/2024 did not include documentation that the RN followed up with this conversation. The plan of care did not include documentation of interventions and goals that addressed the patient’s problems with frequent catheter changes and urinary tract infections, as identified in the initial comprehensive assessment. On 04/15/2024, the RN documented that the Foley catheter was changed due to leaking.