Hope Hospice of Atlanta

“Based on record reviews, staff interview, and review of policies titled “;Revocation of Election Statement” and “;Discharge- Transfer,” it was determined the hospice failed to involve the patient or family in the plan of care for one patient (P) (P13) of two sampled discharged patients. Findings include: Review of undated policy titled “;Revocation of Election Statement,” Reference #11002, reveals the following: Policy A patient, family or caregiver may revoke the election of Hospice care, in writing, at any time during an election period. Procedure To revoke the election of Hospice care for the remainder of that election period, the patient, or patients legal representative, must sign a Revocation of Hospice Care Statement that will be filed in the patients clinical record. Review of the undated policy titled “;Discharge- Transfer,” Reference #9301, reveals the following: Procedure The Hospice Manager shall ensure that the necessary paperwork is completed at the time of discharge. This shall include a signed Revocation Form, if necessary, and completion of a discharge summary. Review of the clinical records reveals P13 was admitted to hospice on 11/3/2023 and revoked the hospice benefit on 12/15/2023. Review of form “;Revocation of Hospice Benefit” reveals the reason for revocation: “;The PCP called and demanded that we discharge patient because some surgical procedures have been scheduled for her.” The revocation form failed to reveal a patient or caregiver signature. Review of form titled “;Discharge Summary” reveals reason for discharge: “;Pts NP called asking us to d/c due to scheduled procedure.” Notification section of the Discharge Summary reveals Attending Physician and Facility were notified on 12/15/2023. The form fails to reveal the patient or family were involved in the discharge plan. Further review of the clinical chart failed to reveal discussions with the patient or family regarding the discharge of the patient. On 8/28/2024 at 1:00 pm, an interview with the Administrator confirmed all documentation had been provided and that the revocation form lacked patient or representative signatures.”

“Based on record reviews, and staff interview, it was determined that the agency failed to complete the Social Worker (SW) assessment within five calendar days after the election of hospice care for two patients (P) (P1, P4) of 14 patients reviewed. Findings include: 1. P1 was admitted to hospice services on 4/15/2024. Record review revealed the SW visit was completed on 4/22/2024. 2. P4 was admitted to hospice services on 5/28/2024. Record review revealed the SW visit was completed on 6/3/2024. During an interview on 8/27/2024 at 1:15 pm the Administrator confirmed that the agency failed to complete Social Worker assessments on two patients of 14 sampled patients. The facility failed to complete SW visits within required timeframe for P1 and P4.”

“Based on record review, staff interview, and review of the policy titled “;Performance Improvement Projects,” it was determined the hospice failed to develop and implement performance improvement projects (PIP). Findings include: Review of an undated policy titled “;Performance Improvement Projects,” Reference #8002, reveals the following: Policy Hope Hospice of Atlanta, Inc shall develop, implement and evaluate performance improvement projects. Review of documents in binder identified as the Quality Assurance Performance Improvement (QAPI) book revealed no active performance improvement projects (PIPs). On 8/27/2024 at 12:50 pm, an interview with the Administrator confirmed no current PIPs and revealed no active PIPs because the agency lacked any deficiencies.”

“Based on record reviews, staff interview, and review of policy titled “;Infection Control Plan,” it was determined that the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control of infectious and communicable diseases for three patients (P) (P1, P2, P3) of 14 sampled patients. Specifically, an infection control log and surveillance data failed to be collected for three patients with ordered antibiotic and antifungal medications. Findings include: 1. Review of the clinical record revealed P1 had an order for Nystatin (used to treat fungal infections). The facility failed to provide an infection control log and surveillance data. 2. Review of the clinical record revealed P2 had order for Ciprofloxacin (used to treat infections). The facility failed to provide an infection control log and surveillance data. 3. Review of the clinical record revealed P3 had orders for Ciprofloxacin. The facility failed to provide an infection control log and surveillance data. During an interview on 8/27/24 at 12:00 pm with the administrator it was revealed that the agency failed to log infections and collect surveillance data for three patients of 14 sampled patients.”

“Based on record reviews, staff interview, and review of policy titled “;Bereavement Phase of Hospice Care,” the hospice failed to develop a bereavement plan of care noting services to be offered and frequency of services for two patients (P) (P11, P12) of two bereavement records sampled. Findings Include: Review of an undated policy titled “;Bereavement Phase of Hospice Care,” Reference #9014 reveals the following: Policy Hospice Staff Provide Bereavement Services That Include: Bereavement assessments and writing a bereavement plan of care 1. Record review reveals P11 was admitted to hospice on 3/6/2024 and expired on 5/6/2024. Further review of the patients chart failed to reveal a bereavement plan of care. 2. Record review reveals P12 was admitted to hospice on 4/26/2024 and expired on 5/5/2024. Further review of the patients chart failed to reveal a bereavement plan of care. On 8/27/2024 at 1:30 pm, an interview with the Administrator confirmed the clinical records lacked bereavement care plans.”

“Based on record reviews and staff interview, it was determined the hospice failed to implement and monitor the day-to-day operation of the hospice, including the quality of care and services and performance improvement. Findings include: 1. Review of the clinical records revealed the agency failed to complete an infection control log and collect surveillance data. Refer to L0580 relating to control 2.The clinical record revealed that the agency failed to develop performance improvement projects. Refer to L0571 relating to Performance Improvement Projects 3. The agency failed to complete comprehensive assessments on two patients (P) (P1, P4) of 14 patients sampled. Refer to L0523 relating to timeframe for completion of assessments During an interview on 8/27/24 at 11:45 am with the Administrator, it was revealed that the agency failed to develop an infection control log or surveillance data. The Administrator revealed that the agency failed to assess for a performance improvement project as they had been deficiency free. The Administrator confirmed that were two late comprehensive assessments for P#1 and P#4.”

“Based on record reviews, staff interview, and a review of the policy titled “;Verbal and Written Orders,” it was determined the hospice failed to appropriately authenticate verbal physician orders for five patients (P) (P1, P2, P3, P4, P6) of 14 sampled patients. Findings include: Review of the undated policy titled “;Verbal and Written Orders,” Reference #7017, reveals the following: Procedure Verbal/ telephone orders of medication shall be received and recorded by the Pharmacist or licensed nurse. Indicate either telephone or verbal order in the written record Sign the written record and indicate level of licensure 1. Review of the clinical records for P1 revealed a document titled Physician Order Form, dated 7/19/2024, containing a verbal order for Aldactone (a diuretic) and Nystatin Powder (an antifungal). The document was signed by the physician but failed to reveal a signature of the receiving nurse. 2. Review of the clinical records for P2 revealed a document titled Physician Order Form, dated 8/6/2024, containing a verbal order for Ciprofloxacin (an antibiotic). The document was signed by the physician but failed to reveal a signature of the receiving nurse. 3.Review of the clinical records for P3 revealed a document titled Physician Order Form, dated 6/30/2024, containing a verbal order for Cipro (an antibiotic). The document was signed by the physician but failed to reveal a signature of the receiving nurse. 4. Review of the clinical records for P4 revealed a document titled Physician Order Form, dated 5/27/2024, containing a verbal order for chaplain services to start. The document was signed by the physician but failed to reveal a signature of the receiving nurse. 5. Review of the clinical records for P6 revealed a document titled Physician Order Form, dated 7/15/2024, containing a verbal order to discontinue aide services. The document was signed by the physician but failed to reveal a signature of the receiving nurse. On 8/28/2024 at 1:00 pm, an interview with the Administrator confirmed the verbal orders lacked signatures of the nurse receiving the orders.”