Georgia Hospice Care

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document review, clinical record review, and interview. In 6 of 19 (32%) clinical records reviewed, the agency did not ensure the drug profile contained the patient’s current prescription and over the counter (OTC) drugs. Agency policy 2-004 Medication Profile, no date, stated in part, “A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication.” Clinical Record 1: The patient elected the hospice benefit on 05/17/2022. The recertification plan of care dated 11/08/2023 and the updated plan of care dated 11/17/2023 included orders for “Diazepam 10 mg 1 po/sl/pr [by mouth/sublingual/rectal] q4hrs [every four hours] prn [as needed] secretions, MSO4 solution 20mg/ml .5 ml po/sl q2hrs prn pain, Lorazepam .5mg 1-tab po/sl/pr q4hrs prn agitation, Zofran 4mg 1 q6hr po prn nausea/vomiting.” Diazepam, MSO4 solution, Lorazepam and Zofran were not included on the medication profile at the time of record review on 11/27/2023. The medication profile included documentation that it had been reviewed by the interdisciplinary team (IDT) during a meeting on the 11/17/2023. Clinical Record 7: The patient elected the hospice benefit on 09/21/2023. The 11/06/2023 physician’s order entered by the Registered Nurse stated “Golytely drink one bottle now.” The one-time medication order was still active on the medication profile at the time of the review on 11/28/2023. The medication profile was documented as reviewed by the IDT during the 11/14/2023 and the 11/28/2023 meetings. Clinical Record 9: The patient elected the hospice benefit on 01/19/2023. Review of nursing visit notes dated 11/15/2023 through 11/27/2023 revealed documentation that the patient was using “oxygen at 4.5 liters continuously with the ability to titrate as needed for shortness of breath.” IDT care plan review during IDT meetings dated 11/14/2023 and 11/18/2023 documented the patient was using oxygen. Oxygen was not included on the patient’s medication profile at the time of record review on 11/28/2023. Clinical Record 11: The patient elected the hospice benefit on 09/07/2023. The 10/05/2023 physician’s order entered by the Registered Nurse stated “Macrobid 100mg one tablet by mouth twice daily x 10 days.” The medication was still active on the medication profile at the time of record review on 11/28/2023. The medication profile was documented as reviewed by the IDT during the 10/20/2023, 11/03/2023 and the 11/17/2023 IDT meetings. Clinical Record 16: The patient elected the hospice benefit on 06/27/2023. The 09/20/2023 physician’s order entered by the Registered Nurse stated “Cipro 500mg one tablet by mouth twice daily x 10 days.” The medication was still active on the medication profile at the time of record review on 11/28/2023. The medication profile was documented as reviewed by the IDT during the 10/01/2023 IDT meeting. Clinical Record 18: The patient elected the hospice benefit on 09/20/2023. The 10/02/2023 physician’s order entered by the Registered Nurse stated patient to use “Desitin with each brief change.” Desitin was not included on the medication profile at the time of record review on 11/28/2023. During an interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance reviewed the associated records and stated that the medication profiles were incomplete and had since been corrected.”

“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 document review, clinical record review, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the hospice plan of care included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Agency policy 9-017 Interdisciplinary Plan of Care, no date, stated in part, The written plan of care will contain, but not be limited to, the following individualized interventions to assist with end-of -life care, Statement of treatment goals, and Drugs and treatments. Clinical Record 1: The patient elected the hospice benefit on 05/17/2022. The comprehensive assessments dated 11/08/2023 and 11/17/2023 documented “patient grieving loss of spouse and Chaplain visit to be made to assist with grieving process 6m1 [six times for one month], 8m1, 1m1 effective 11/08/2023.” The updated hospice plans of care dated 11/08/2023 and 11/17/2023 did not include interventions and family stated goals related to the patient’s assessed needs and planned Chaplain visits. During an interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance reviewed the associated record and stated that the Chaplain interventions and goals had inadvertently been omitted and had since been added to the hospice plan of care.”

“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 drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the individualized plan of care included drugs and treatments necessary for the palliation and management of the terminal illness. Agency policy 9-017 Interdisciplinary Plan of Care, no date, stated in part, The written plan of care will contain, but not be limited to, the following individualized interventions to assist with end-of -life care, Statement of treatment goals, Drugs and treatments. Clinical Record 14: The patient elected the hospice benefit on 10/03/2023. The comprehensive assessment completed by the Registered Nurse on 10/03/2023 included documentation that the patient used a condom catheter. There were no orders related to condom catheter identified on the 10/03/2023 initial hospice plan of care or on the updated hospice plans of care dated 10/06/2023, 10/20/2023, 11/03/2023, and 11/17/2023. Clinical Record 15: The patient elected the hospice benefit on 06/15/2023. The Registered Nurse documented on the 11/06/2023 nursing visit note “open areas BLE [bilateral lower extremities], cleansed BLE with wound cleanser, Unna boots applied, Kling applied and covered with Coflex and secured with tape.” The hospice plan of care dated 09/13/2023 and the updated hospice plans of care dated 09/22/2023, 10/06/2023, 10/20/2023, 11/03/2023 and 11/27/2023 stated in part “Unna boots BLE Mondays and Thursdays,” but did not include cleansing with wound cleanser and use of Coflex and tape to secure the dressing. Clinical Record 16: The patient elected the hospice benefit on 06/27/2023. The 09/05/2023 physician’s order entered by the Registered Nurse stated “NS [normal saline] flush foley catheter as needed with 60-120cc NS.” The order did not include the reason to administer the flush or the frequency to be administered, for this as needed order. During an interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance reviewed the associated records and stated that the treatment orders were incomplete and had since been corrected.”

“It is required that hospice aides are assigned to a specific patient by a Registered Nurse (RN) 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 and interview. In 1 of 16 (6%) clinical records reviewed with the provision of aide services, the agency did not ensure that the written patient care instructions for the hospice aide were prepared by a RN who is responsible for the supervision of the hospice aide. Clinical Record 2: The patient elected the hospice benefit on 02/01/2023. Review of the hospice aide care plan assignments dated 09/13/2023 and revealed the aide care plan assignments were created, signed, and dated by a Licensed Practical Nurse (LPN). During an interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance reviewed the associated record and stated the Registered Nurse had since entered the hospice aide task assignment.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 16 (38%) clinical records reviewed with the provision of aide services, the agency did not ensure the aide provided services as assigned on the aide care plan. Clinical Record 5: The patient elected the hospice benefit on 06/13/2023. The aide care plan assignment created by the Registered Nurse (RN) on 06/15/2023 assigned the task of linen change weekly. The hospice plan of care dated 09/11/2023 included an order for aide visit frequency three times a week for 13 weeks, the updated hospice plan of care dated 09/17/2023 included an order for aide visit frequency five times a week for twelve weeks. Aide visit notes dated 09/11/2023 through 11/24/2023 included documentation of linen change at each of the aide visits instead of weekly as ordered. Clinical Record 6: The patient elected the hospice benefit on 10/05/2023. The aide care plan assignment created by the RN on 11/10/2023 assigned the task of linen change weekly at first aide visit of the week. Aide visit notes dated 11/13/2023 and 11/16/2023 included documentation of linen change with each visit, which was twice for the week of 11/13/2023 instead of weekly as ordered. Clinical Record 7: The patient elected the hospice benefit on 09/21/2023. The aide care plan assignment created by the RN on 09/21/2023 assigned the task of linen change weekly. The hospice plan of care dated 09/21/2023 included an order for the aide visit frequency once a week for one week, then five times a week for 12 weeks, then twice a week for one week. Aide visit notes dated 09/25/2023 through 11/25/2023 included documentation of linen change with each visit, instead of weekly as ordered. Clinical Record 9: The patient elected the hospice benefit on 01/19/2023. The aide care plan assignment created by the RN on 09/19/2023 assigned the task of linen change weekly. The hospice plan of care dated 11/15/2023 included an order for the aide visit frequency twice a week for one week, then three times a week for eight weeks. Aide visit notes dated 11/15/2023 through 11/28/2023 included documentation of linen change with each visit, instead of weekly as ordered. Clinical Record 11: The patient elected the hospice benefit on 09/07/2023. The aide care plan assignment created by the RN on 09/07/2023 assigned the task of linen change weekly. The hospice plan of care dated 09/07/2023 included an order for the aide visit frequency once a week for one week, then three times a week for 12 weeks, then once a week for one week. Aide visit notes dated 10/04/2023 and 10/06/2023 included documentation of linen change with each visit, which was twice for the week of 10/02/2023 instead of weekly as ordered. Aide visit notes dated 10/11/2023 and 10/13/2023 included documentation of linen change with each visit, which was twice for the week of 10/09/2023 instead of weekly as ordered. Clinical Record 16: The patient elected the hospice benefit on 06/27/2023. The aide care plan assignment created by the RN on 06/29/2023 assigned the task of shampoo and linen change weekly, and bed bath and hair care twice weekly. The hospice plan of care dated 08/26/2023 included an order for the aide visit frequency three times a week for eight weeks, then once a week for one week. Aide visit notes dated 08/28/2023 through 09/29/2023 included documentation of shampoo, linen change, bed bath, and hair care with each visit, instead of the frequency assigned. During record review and interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance stated the aide care plans had not been followed and remedial education would be provided and that the aide care plans had since been reviewed and updated.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients that reside in a skilled nursing facility (SNF), the agency did not ensure the hospice plan of care specified each providers responsibility for performing the functions that were agreed upon and included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 02/01/2023. The plan of care dated 11/12/2023 did not include facility staff interventions. During an interview on 11/29/2023, the Manager of Accreditation and Regulatory Compliance reviewed the associated record and stated that the hospice plan of care had since been updated with delineation of duties.”