Every finding on record at Unity Hospice Care, LLC

It is required that the comprehensive assessment includes consideration of the following factors: symptoms and symptom severity. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # PC.30, "Plan of Care Process" (revision date 09/01/2024) stated in part, "The IDG/IDT will be proactive in developing each patient's plan of care (POC) by planning ahead for anticipated patient changing needs and measurable outcomes anticipated from implementing and coordinating the plan of care (POC)." In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure that the comprehensive assessment included the severity of anxiety symptoms. Clinical Record 9: The patient elected hospice care on 04/12/2024. The plan of care (POC) dated 04/12/2024 identified the problem: "Anxiety." The POC documented the patient's goal: "Patient /caregiver will rate anxiety 3/10." The comprehensive assessment completed by the RN on 04/12/2024 did not include an anxiety assessment scale or tool to evaluate the severity and presence of the patient's anxiety symptoms. During an interview and a joint record review on 03/19/2025, the Director of Clinical services confirmed that the electronic medical record (EMR) did not include an anxiety assessment scale. No further documentation was provided. Clinical Record 10: The patient elected hospice care on 01/25/2025. The plan of care (POC) dated 01/25/2025 identified the problem: "Anxiety." The POC documented the patient's goal: "Patient /caregiver will rate anxiety 3/10." The comprehensive assessment completed by the RN on 01/25/2025 did not include an anxiety assessment scale or tool to evaluate the severity and presence of the patient's anxiety symptoms. During an interview and a joint record review on 03/19/2025, the Director of Clinical services confirmed that the electronic medical record (EMR) did not include an anxiety assessment scale. No further documentation was provided.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 2 of 11 (18%) applicable records reviewed of patients receiving aide services revealed the hospice did not ensure the aide provided care according to the plan of care. Record #50339 was reviewed and identified the hospice aide's written instruction by the registered nurse (RN) documented the assigned task of shaving. The completed aide visits dated 4/29/2022, 5/7/2022, 5/17/2022, 5/20/2022, 5/23/2022, and 5/28/2022 did not document the aide completed the assigned task of shaving. Record #60627 was reviewed and identified the hospice aide's written instruction by the RN documented the assigned task of shower. The completed aide visits dated 3/29/2022, 3/30/2022, 3/31/2022, 4/5/2022, 4/6/2022, and 4/7/2022 did not document the aide completed the assigned task of shower. The Director of Clinical Services was interviewed on 6/16/2022 and confirmed the aides had not performed the assigned tasks.