Every finding on record at Unitypoint at Home

Upon patient record review, 2 of 19 (Patient #6, #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 6:The medical record includes documentation of an active SmartPort Plastic Implantable Port in place in patient's right chest. There is no evidence that the plan of care includes problems, goals and interventions for the management of the port. Patient 12:The medical record includes documentation that, upon admission the patient had a diagnosis of pneumonia that has since been resolved. The plan of care includes problems, goals and interventions for an active infection.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1:The medical record contains nursing documentation of a wound care to the bile drainage device in the right upper quadrant of the patient. There is no evidence of an order for the treatment.

Upon patient record review, 2 of 19 (Patient #3,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 3:The medical record includes documentation that the patient requires oxygen therapy for shortness of breath. There is no evidence that the aide plan of care includes oxygen precautions. Patient 10:The medical record includes documentation that the patient is at risk for falls. There is no evidence that the aide plan of care includes fall precautions.

Upon patient record review 2 of 13 (Patient #8, #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #8: The psychosocial comprehensive assessment was completed late on 2/7/2022. Patient was admitted on 2/1/2022. Patient #11: The spiritual comprehensive assessment was completed late on 1/27/2022. Patient was admitted on 1/16/2022. No evidence to support any other disciplines completed a comprehensive spiritual assessment

Upon patient record review 1 of 13 (Patient #5) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #5: No evidence to support that a comprehensive spiritual care assessment was completed. Spiritual Care was declined by patient and no documentation to support any other discipline completed a comprehensive spiritual assessment. The SN admission assessment contains a spiritual assessment section, but it was blank.

Upon patient record review, 1 of 13 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Patient #8: Patient was admitted on 2/1/2022. The bereavement assessment was completed late on 2/7/2022.

Upon client record review, 3 of 13 (Patient #3, #4, #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: Massage Therapy ordered on the Plan of care 1-3 times every 30 days. It was noted that 5 visits were made during the 30 days span 1/6, 1/13, 1/20, 1/27 and 2/3. Patient #4: SN ordered 1-3 times per week on the Plan of Care. It was noted that SN saw the patient 5 times the week of 12/7 (12/7, 12/8 12/9, 12/10, 12/10). No evidence to support a change in frequency. Patient #6: Patient Plan of care ordered Music Therapy 2-4 times every 30 days. The patient was seen 5 times in 30 days. The Plan of Care ordered SN 1-3 times per week. The week of 9/7 the patient was seen 4 times. Plan of Care ordered SW 1-3 times every 30 days. The patient was seen 5 times by the SW in 30 days. No evidence to support these were PRN visits or any orders increasing the frequency of these disciplines.

Upon patient record review 1 of 5 applicable (Patient #7) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #7: Patient plan of care ordered Aide 2 times a week. Week of 1/9 only one visit was made. No visits were made week of 1/16. Week of 1/23 only one visit was made. Week of 2/23 only one visit was made. No evidence to support a change in frequency or missed visit documentation.