Every finding on record at Willowbrook Hospice, Inc

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 clinical record review, interview and observation. In 2 of 18 (11%) clinical records reviewed of patients who received Hospice Aide Services (HA), the agency did not ensure that all written patient care instructions were included in the aide care plan. CLINICAL RECORD 3: This patient elected the hospice benefit on 09/16/2025 with a terminal illness of hemiplegia following a cerebral infarction. The plan of care (POC) dated 09/16/2025 through 11/20/2025 ordered: indwelling catheter care and Hospice Aide (HA) visits 2x/week. The physician order dated 09/30/2025 included care for the indwelling catheter. The Registered Nurse (RN) comprehensive assessment dated 09/16/2025 documented that the foley catheter was draining well with clear yellow urine. The HA care plan dated 09/18/2024 did not include instructions addressing the care and maintenance of the Foley catheter during personal care. CLINICAL RECORD 11: This patient elected the hospice benefit on 06/19/2025 with a terminal diagnosis of progressive supranuclear ophthalmoplegia. The RN initial comprehensive assessment dated 06/19/2025 documented the patient was receiving oxygen. The POC was reviewed for the initial episode dated 06/19/2025-11/20/2025. The POC included care for oxygen therapy. The HA care plan dated 09/19/2025 listed oxygen under the "additional care considerations" but did not include instructions addressing the care and maintenance of oxygen during personal care. In an interview and a joint record review on 11/20/2025, the Executive Director stated that the HA care plans did not include the written directions for the Foley catheter or the oxygen and also stated it was the agency best practice to include at least three specific written directions in the detail section of the HA care plan which was not present.

It is required that each patient’s individualized written plan of care reflects patient and family goals and includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 8 of 13 (62%) clinical records reviewed, the hospice did not ensure the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. The Agency Policy # 17.03, titled "Hospice IDG Care Planning," states in part, "measurable outcomes anticipated from implementing and coordinating the plan of care." Clinical Record 3: The patient elected hospice care on 12/09/2022. A review of the plan of care (POC) identified the problem as a need for medication management and instructions. The goal is "patient / caregiver will verbalize/ demonstrate understanding of the importance of medication compliance." The POC did not include a measurable outcome for the goal. Clinical Record 7: The patient elected hospice care on 11/19/2022. A review of plan of care (POC) identified the problem as altered coping skills. The goal is for the "patient/caregiver to exhibit improved coping skills." The POC did not include a measurable outcome for the goal. Clinical Record 8: The patient elected hospice care on 11/19/2022. A review of the plan of care (POC) identified the problem as altered coping skills. The goal is for the "patient/caregiver to exhibit improved coping skills." The POC did not include a measurable outcome for the goal. Clinical Record 6: The patient elected hospice care on 08/11/2022. A review of the plan of care (POC) identified the problem as a need for medication management and instructions. The goal is "patient / caregiver will verbalize/ demonstrate understanding of the importance of medication compliance." The POC did not include a measurable outcome for the goal. Clinical Record 5: The patient elected hospice care on 08/25/2022. A review of the plan of care (POC) identified the problem as a need for medication management and instructions. The goal is "patient / caregiver will verbalize/ demonstrate understanding of the importance of medication compliance." The POC did not include a measurable outcome for the goal. Clinical Record 4: The patient elected hospice care on 12/06/2022. A review of the plan of care (POC) identified the problem as a need for medication management and instructions. The goal is "patient / caregiver will verbalize/ demonstrate understanding of the importance of medication compliance." The POC did not include a measurable outcome for the goal. Clinical Record 2: The patient elected hospice care on 10/07/2022. A review of the plan of care (POC) identified the problem as a need for pain management and instructions. The goal is that the "patient / caregiver will verbalize/ demonstrate understanding of pain management." The POC did not include a measurable outcome for the goal. Clinical Record 1: The patient elected hospice care on 11/29/2022. A review of the plan of care (POC) identified the problem as a need for medication management and instructions. The goal is "patient/caregiver will verbalize/ demonstrate understanding of the importance of medication compliance." The POC did not include a measurable outcome for the goal. The Branch Director was interviewed on 01/10/2023 and confirmed that the goals did not include measurable outcomes. No further information was provided. The Branch Director shared with me that their agency had identified these issues during a prior CHAP Site visit at another location and had already implemented their plans of correction in December 2022.

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 clinical records, documents, and interviews. In 4 of 13 (31%) clinical records reviewed of patients who received hospice aide services, the agency did not ensure the hospice aide received specific written patient instructions. The Agency Policy #17.16, titled Hospice Aide Services, states in part, "Hospice Aides are assigned to a specific patient by a RN that is a member of the IDG. Written patient care instructions for a Hospice Aide must be prepared by a RN who is responsible for the supervision of a Hospice Aide." Clinical Record 3: The patient elected hospice care on 12/09/2022 with a primary diagnosis of Alzheimer's. The aide plan of care dated 12/09/2022 assigned the tasks, "bed bath or shower every visit." The aide did not receive specific instructions for the patient's type of bath, and the patient could not provide directions. Clinical Record 8: The patient elected hospice care on 07/29/2022. The aide plan of care dated 12/11/2022 assigned the tasks, "transfer patient from bed to chair PRN and apply barrier cream PRN." The aide did not receive specific instructions for the patient's care. Clinical Record 13: The patient elected hospice care on 10/18/2022. The aide plan of care dated 10/18/2022 assigned the task, "shave patient PRN." The aide did not receive specific instructions for the patient's care. Clinical Record 1: The patient elected hospice care on 11/29/2022. The aide plan of care dated 11/29/2022 assigned the tasks, "bed bath or shower every visit." The aide did not receive specific instructions for the patient's type of bath. The Branch Director was interviewed on 01/10/2023 and confirmed the findings and stated that the RN did not assign specific instructions for the aide to follow in the records identified.