Every finding on record at Winterhaven Hospice, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 5 (20%) clinical records reviewed, the patient's individual written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. The Agency Policy #9-017.1, "The Plan of Care (Dated: 5/2020)," stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. This plan will focus on identified problems, goals, and interventions." Clinical Record 4: The patient elected the hospice benefit on 11/9/22. The Chaplain completed visits on 11/11/22 and 11/29/22. The IDG POC dated 11/9/22 lacked goals and interventions for the Chaplain. Upon interview on 3/9/23, the Director of Clinical Services and the Administrator reviewed and agreed the plan of care lacked goals and interventions for the Chaplain.

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. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, document review, and interview. The Agency Policy #9-020.1, "Hospice Aide Services (Revised: 5/2020)", stated in part, "Procedure: 7. 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." In 2 of 4 (50%) clinical records reviewed for patients that elected Hospice Aide Services revealed the aide did not report changes related to the plan of care (POC) to the Registered Nurse (RN). Clinical Record 4: The patient elected the hospice benefit on 11/9/22. The hospice aide POC dated 11/14/22 assigned the aide to shower the patient. The aide visit note dated 11/17/22 reported the patient refused the shower. The record lacked evidence that the aide notified the RN that the shower was not completed as assigned on the aide POC, per the patient's request. Clinical Record 1: The patient elected the hospice benefit on 2/16/23. The hospice aide POC dated 2/21/23 assigned the aide to shave the patient and complete oral care for the patient. The aide visit note dated 2/21/23 stated the patient refused oral care and to be shaved. The record lacked evidence that the aide notified the RN that the oral care and shave were not completed as assigned on the aide POC, per the patient's request. Upon interview on 3/9/23, the Director of Clinical Services and the Administrator reviewed and agreed that the hospice aide did not notify the RN of changes related to the POC.