Every finding on record at Willowbrook Hospice LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, 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. 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 and interview. In 15 of 15 (100%) records, the agency failed to document measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 1: SOC 10/19/2022 diagnosis: Alzheimer's. The initial comprehensive assessment identified " alteration in comfort: Goal " pt/caregiver will verbalize, demonstrate and understand pain management measures." Clinical Record 2: SOC 08/07/2023 diagnosis COPD. The RN initial comprehensive assessment identified "difficulty breathing." Goal "respiratory changes will be identified promptly and intervention initiated promptly." Clinical Record 3: SOC 06/03/2023 diagnosis Malignant Neoplasm of Pancreas Unspecified. The initial RN assessment identified "alteration in skin integrity." Goal " pt/caregiver verbalizes/demonstrates understanding of prevention of alteration of skin integrity." Clinical Record 4: SOC 02/08/2023 diagnosis Alzheimer's. The initial RN assessment identified " a need for medication management. Goal " pt/caregiver administers prescribed medications properly as a result of nurse filled planner device." This goal is not measurable. Clinical Record 5: SOC 02/01/2023 diagnosis COPD. The RN initial assessment identified " Cardiopulmonary issues. Goal "pt/caregiver verbalizes/demonstrates understanding of proper use of oxygen liter flow and setup." This goal is not measurable. Clinical Record 6: SOC 08/14/2023 diagnosis CVA. The RN initial assessment identified " a need for medication management." Goal "pt/caregiver verbalizes current understanding of medication schedule/setup medication and dispensing." This goal is not measurable. Clinical Record 7: SOC 06/22/2022 diagnosis heart disease. The initial RN assessment identified "alteration in comfort." Goal " pt/caregiver will verbalize, demonstrate and understand pain management measures." This goal is not measurable. Clinical Record 8: SOC 06/07/2023 diagnosis: Alzheimer's. The initial comprehensive assessment identified " altered neurological status." Goal pt/caregiver verbalizes understanding of causes." Clinical Record 9: SOC 06/07/2023 diagnosis MALIGNANT NEOPLASM OF BLADDER. The initial RN assessment identified " need for teaching related to urinary incontinence. Goal " patient/ caregiver verbalizes measures to protect skin integrity from incontinence." Clinical Record 10: SOC 03/23/2023 diagnosis ALZHEIMER'S DISEASE. The initial RN assessment identified " altered cardiopulmonary status." Goal " patient exhibits reduction/relief of any cardiopulmonary symptoms. Clinical Record 11: SOC 03/16/2023 diagnosis ALZHEIMER'S. The initial RN assessment identified " altered cardiopulmonary status." Goal " patient exhibits reduction/relief of any cardiopulmonary symptoms. Clinical Record 12: SOC 06/21/2023 diagnosis ALZHEIMERS The RN initial comprehensive assessment identified "agitation" Goal "caregiver verbalizes causes of agitation." Clinical Record 13: SOC 5/30/2023 diagnosis HEART FAILURE. The RN initial comprehensive assessment identified "difficulty breathing." Goal "respiratory changes will be identified promptly and intervention initiated promptly." Clinical Record 14: SOC 04/25/2023 diagnosis AZHEIMER'S. The initial RN assessment identified "alteration in comfort." Goal " pt/caregiver will verbalize, demonstrate and understand pain management measures." Clinical Record 15: SOC 08/27/2021 diagnosis ALZHEIMER'S The initial RN assessment identified " altered cardiopulmonary status. Goal " patient exhibits reduction/relief of any cardiopulmonary symptoms. This goal is not measurable. The Director of Clinical Services was interviewed on 08/22/2023 and agreed the goals for the plans of care were not measurable. No further information was provided.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 13 (8%) clinical records reviewed of patients who received hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. Clinical Record 5: SOC 02/01/2023 diagnosis COPD. the aide plan of care dated 02/01/2023 instructed the aide to shampoo patient's hair, shave, and shower every visit. On 02/02/2023 the aide documented that the patient refused shampoo. on 02/07/2023 the aide documented that patient refused shaving, on 02/09/2023 the aide documented "shower not required this visit." There was no documented evidence that the RN was notified about the tasks not being completed. The Director of Clinical Services was interviewed on 08/22/2023. She stated that the aide did not follow the aide plan of care ordered by the interdisciplinary team. Document 1: POLICY # 4.20.1 Titled Hospice Aide Services and Training Program stated in part " The duties of Hospice Aide are to provide services that are ordered by the IDG.