Every finding on record at Truheart Hospice 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 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 12 (25%) clinical records reviewed revealed that the agency did not ensure that each patient's plan of care included all drugs and treatments necessary to meet the needs of the patient. Clinical Record 7: The election of hospice benefits was on 09/18/2023. The initial plan of care dated 09/18/2023 included "Urinary catheterization PRN". The plan of care lacked evidence of specific catheter orders, size of catheter, and maintenance of catheter. The plan of care lacked interventions and goals related to the foley catheter. Clinical Record 8: The election of hospice benefits was on 10/09/2023. The initial nursing assessment dated 10/09/2023 read in part "16Fr Foley catheter". The initial plan of care dated 10/09/2023 read in part "Urinary catheterization PRN". The plan of care lacked evidence of specific catheter orders, size of catheter, and maintenance of catheter. The plan of care lacked interventions and goals related to the foley catheter. Clinical Record 9: The election of hospice benefits was on 02/16/2024. The initial nursing assessment dated 02/16/2024 read in part "Patient has a 16Fr Foley catheter in place". The initial plan of care dated 02/16/2024 read in part "Urinary catheterization PRN". The plan of care lacked evidence of specific catheter orders, size of catheter, and maintenance of catheter. The plan of care lacked interventions and goals related to the foley catheter. The Director of Nursing stated in an interview on 02/28/2024 that the plans of care did not include specific interventions with associated goals.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment; and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed revealed that the agency did not ensure that the plan of care was revised with information from the patient's updated comprehensive assessment. Clinical Record 7: The election of hospice benefits was on 09/18/2023. The initial plan of care dated 09/18/2023 included "Urinary catheterization PRN". The patient was hospitalized on 10/09/2023 and care resumed on 10/13/2023. A review of clinical documentation revealed that a resumption of care nursing visit note dated 10/13/2023 confirmed the presence of a foley catheter, documenting "Patient had a Foley catheter placed while in the hospital and it remains in place". The revised plan of care lacked evidence of specific catheter orders, size of catheter, and maintenance of catheter. The revised plan of care lacked interventions and goals related to the foley catheter. The Director of Nursing stated in an interview on 02/28/2024 that the plans of care did not include specific interventions with associated goals.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) applicable clinical records with aide services ordered reviewed revealed that the agency did not ensure that aide services were provided as ordered. Clinical Record 1: The plan of care dated 11/30/2023 read in part "Hospice Aide 2 times a week". One missing aide visit was noted the week of 11/26/2024. The record lacked documentation as to why the visit was not provided as ordered. The aide visit note dated 01/28/2024 read in part "Client had a full shower, hair shampooed in the shower". The aide care plan dated 11/30/2023 did not contain instructions on bathing the patient however the aide both bathed the patient and shampooed the patient's hair. Clinical Record 5: The plan of care dated 01/26/2024 read in part "Hospice Aide 2 times a week". Two missing aide visits were noted the week of 01/21/2024. One missing aide visit was noted the weeks of 01/28/2024 and 02/04/2024. The record lacked documentation as to why the visits were not provided as ordered. In an interview on 02/28/2024, the Director of Nursing reviewed the records and stated, "We enter missed visit notes when a patient misses a visit but there are no notes for the missed aide visits".