Every finding on record at Vitalcare, Inc

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: Measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (08%) records reviewed failed to document measurable goals on the plan of care. Record #58915: The patient was admitted on 03/03/2022. A plan of care for certification period 03/03/2022 - 05/31/2022 documented the following goals: "patient exhibits reduction in cardiac system, pain managed at acceptable level and patient constipation controlled." The documented nursing assessment on 03/03/2022, stated, "3+ edema bilaterally and daily dyspnea and mild pain and desire to decrease this. An interview with the Director of Hospice on 04/21/2022 stated that the documented goals were not measurable and this has been a current process improvement area of focus.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of the clinical record, document review, and interview. 1 of 9 (11%) records reviewed in which a hospice aide was accepted failed to document clear and specific instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record #42064: The patient was admitted on 10/05/2021 and accepted the hospice aide services. On 10/10/2021, a Foley catheter was inserted for bladder control. The hospice aide plan of care which included the task shower failed to include the Foley catheter care through 11/30/2021. There was no written instruction for the aide on how to manage the catheter during the shower. Agency Policy: Aide Plan of Care, H 2-009.1 [Revised day 03/08/2019] stated in part, "The aide plan of care will be individualized to the specific, patient and will include at least: type of services/procedures to be provided, such as hands-on personal care, the performance of simple procedures." An interview with the Director of Hospice on 04/22/2022 stated that the catheter should have been added to the hospice aide assignment when inserted

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of the clinical record, document review, and interview. 1 of 13 (08%) records reviewed failed to document all required physician orders. Record #93675: The RN documented that a Foley catheter was in place on 01/21/2022. A nursing clinical note on 03/02/2022 documented that the patient was incontinent and briefs worn. All nursing notes documented from 03/02/2022 - 04/21/2022 that patient was incontinent and wearing briefs. There was no physician order for the removal of the catheter. Email communication between the Medical Director and nurse, dated 03/01/2022, documented agreement for catheter removal. Agency Policy: Verification of Physician Order, H: 2-032.1 [revised date 11/12/2020] stated in part, "The order or prescription reviewed may be the original order, a facsimile copy if permitted by law, or the direct transcription of a verbal order." Interview with the Director of Hospice on 04/22/2022 that a physician order is required to remove the Foley Catheter. We have an email but the order was not in the record.