Every finding on record at Truhome Health & Hospice Services 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 the following intervention to manage pain and symptoms. The documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by clinical record review, document review, observation and interview. Policy #PC.29 (revised 01/01/2017), titled "Pain Management Policy Summary", states in relevant parts, "Agency will respect patient's right to receive effective pain management and symptom control for conditions related to the terminal illness." Sub-section five (5) states in part, "Pain assessed to be a level greater than the patient's goal level will include an appropriate intervention be performed by nursing staff. Interventions may include, but are not limited to, contacting the physician for additions/changes in the current pain medication regime." Sub-section six (6) states in part, "When pain is assessed to be a level greater than the patient's goal level, patient will be re-assessed within a timely manner, following this pain intervention. If pain continues to be a level which is unacceptable to patient, further interventions will be performed by the nurse." 1 of 3 (33%) records reviewed in which a patient reported pain as an active problem revealed the agency did not include the problem of pain in the patient's Plan of Care (POC). Clinical Record 1: A patient with a hospice benefit election date of 3/29/2023 had an initial RN assessment completed on 3/29/2023 that identified pain as an active problem. The initial RN assessment documented, "patient has generalized pain relieved by rest and medication. Interferes with daily activities, the pain level is mild to moderate with a current level of three (3)". The patient's target pain goal was "zero (0), none." The patient's POC dated 3/29/2023-6/26/2023 evidenced that pain is not identified as a problem. There are no goals or interventions related to pain. The problems identified in the POC were coping and grief, declining safety and falls, the risk for impaired skin integrity, and poor meal intake. The record did not identify any follow-up care about patient/family satisfaction with pain relief measures. The record did not contain any collaboration notes. The next RN visit was on 4/5/2023. NOTE: A home visit on 4/19/2023 to the patient's home with the DON confirmed the patient was receiving adequate pain management, and the family was happy with the care being provided. The family was pleased with the patient's pain management during the home visit. A joint record review and interview on 4/19/2023 confirmed that the agency did not document pain as an active problem in the care plan even though the initial RN assessment identified active pain. The Director of Nursing (DON) (Staff 3) reported the patient's pain was addressed but not documented.