Hospice Services of GA LLC

“Based on clinical record review, review of policies and procedures, and staff interviews, it was determined that Interdisciplinary team (IDT) failed to ensure that plan of care reflected the specific problems identified in the assessments, goals and interventions, and services necessary to meet the assessed needs of two patients (P) (P#7 and P#12) of 14 patients who were current hospice beneficiaries. 1. Findings include, review of the clinical record revealed that the plan of care for P#12 did not contain Zinc oxide on the medication profile. Review of the “General Visit Note Information” dated 1/19/25 revealed that Zinc Oxide (used to treat minor skin irritations, diaper rash and burns) was applied because P#12 complained that she was sore from frequent bowel movement and her surrounding skin was red. The record did not reveal that a physician order for zinc oxide was obtained and it did not reveal that changes were coordinated with interdisciplinary group to update the plan of care P#2. During an interview with the Director of Nurses (DON) conducted on 2/12/25 at 11:30 stated that she was unaware an order had not been obtained for the zinc oxide and acknowledged that it was not listed on P#12’s medication profile. Review of Patient of Care policy revised 1/2/18 revealed that plan of care should contain the following documents/components, but limited to: 5. The plan of care is reviewed and revised as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days and is based on the updated comprehensive assessments. 11. b. physician orders c. medication profile Review of the policy #828 titled “;Patient Care-General, Plan of Care” - effective date January 2, 2018, revealed the following: Procedure: I- Drugs, treatments and interventions necessary to meet the needs of the patients. Review of the policy #827 titled “;Patient Care-General, Plan of Care” - effective date January 2,2018 revealed the following: Policy: the RN develop a Plan of Care after completion of the initial assessment and prior to providing care that is consistent with the patient’s immediate needs. 6) The content of the initial plan of care must include, at a minimum: a) An assessment of the individual’s and family ‘s needs. Review of the initial nurse visit note dated 11/12/24 revealed the following: Suprapubic catheter in place, draining bright yellow urine, 200 cc noted in the bag. However, plan of care dated 11/12/24 lacked orders for suprapubic catheter care. On 2/11/25 at 10:30 am., an office interview was conducted with the Director of Nursing (DON) and the Administrator, who verbalized that the plan of care lacks orders for suprapubic catheter. DON verbalized that the agency did not follow the plan of care policy in providing care to P#7. On 2/12/25 at 9:30 am., DON provided the surveyor with a verbal order for suprapubic catheter care, reads as follows: change SP 18 fr catheter monthly and PRN”

“Based on record review, review of policies and procedures, and staff interview, it was determined that hospice failed to maintain a system of communication and integration in accordance with patient’s needs and assessment and ensure that the care and services are provided in accordance with the plan of care for three patients (P) (P#6, P#12 and P#13) of 14 patients who were current hospice beneficiaries. 1. Findings include, review of the clinical record revealed that the plan of care for P#12 did not contain Zinc oxide on the medication profile. Review of the “General Visit Note Information” dated 1/19/25 revealed that Zinc Oxide (used to treat minor skin irritations, diaper rash and burns) was applied because P#12 complained that she was sore from frequent bowel movement and her surrounding skin was red. The record did not reveal that a physician order for zinc oxide was obtained and it did not reveal that changes were coordinated with interdisciplinary group to update the plan of care P#2. During an interview with the Director of Nurses (DON) conducted on 2/12/25 at 11:30 stated that she was unaware an order had not been obtained for the zinc oxide and acknowledged that it was not listed on P#12’s medication profile. Review of Patient of Care policy revised 1/2/18 revealed that plan of care should contain the following documents/components, but limited to: 5. The plan of care is reviewed and revised as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days and is based on the updated comprehensive assessments. 11. b. physician orders c. medication profile Review of the “Wound Care” policy revised October 2010 revealed: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician’s order for this procedure 2. Review of the revised policy dated October 2010, titled “;Wound Care” reveals the following: Documentation The type of wound care given. (6) All assessment data (i.e., wound bed color, size, drainage.) obtained when inspecting wound. Frequency of Wound Care: 3. wound care will be coordinated with hospice Nursing team and family /facility. 2. Record review for P#13 revealed wound care order dated 8/23/24 reads as follows: Wound care to right hip- apply comfort foam border every 3 days and as needed for preventive measures. Left lateral ankle - cleanse with warm water/soap, pat dry, apply Dakins moistened gauze and wrap with kerlix every day and as needed. Left Ischium- Cleanse with warm water /soap, pat dry, apply Dakins moistened gauze and cover with protective dressing every day and as needed. Review of the initial nurse visit note dated 8/23/24 revealed the following documentation: patient has 3 wounds; left heel, left Ischium and right hip. left Ischium, wound type; pressure ulcer; length 2cm, width 4 cm. Right hip wound type, Pressure ulcer. length 1 cm, width 1.5, Depth 1 cm lateral left ankle wound type- pressure ulcer, length 3 cm, width 3. Review of the nurse visit note dated 9/25/24 revealed the following documentation: patient has wounds noted on left heel, left ischium and right hip. Review of the nurse visit note dated 11/6/24 revealed the following documentation: patient has wounds noted on left heel, and right hip. Facility providing wound care. Review of the nurse visit note dated 1/31/25 revealed the following documentation: patient has wounds noted on left heel, and right hip. Facility providing wound care. Review of the nurse visit note dated 2/10/25 revealed the following documentation: patient has wounds noted on left heel, left ischium and right hip. Nurse visit notes lack documentation of complete assessment of the wound and treatment of the wound as ordered in the plan of care. Nurse visit notes further lack evidence of coordination between the hospice and facility in wound management for P#13. 3. Review of clinical record for P#6 revealed wound care order dated 2/10/25 as follows: Cleanse area to left lateral foot with soap and water, pat dry, then apply betadine soak gauze daily and as needed. Cleanse area to left medial foot with soap and water, pat dry, then apply betadine, soak gauze daily and as needed. cleanse area to left dorsal foot with soap and water, pat dry, then apply betadine soak gauze daily and as needed. Review of nurse visit note dated 2/3/25 revealed the following documentation: wound care provided by facility staff. Review of nurse visit note dated 2/5/25 revealed the following documentation: wound care provided by facility staff. Review of nurse visit note dated 2/10/25 revealed the following documentation: Patient with severe excoriation to scrotum, buttocks, and upper medial thighs due to excessive diarrhea. Wounds noted to left foot and left knee due to arterial disease. Wound care provided by facility staff. Nurse visit notes lack documentation of complete assessment of the wound and treatment of the wound as ordered in the plan of care. Nurse visit notes further lack evidence of coordination between the hospice and facility in wound management for P#6. On 2/12//2025 at 11:20 a.m., an office interview was conducted with the Director of Nursing (DON), verbalized that the facility wound care nurse provides wound care for P#6 and P#13. DON verbalized that the nurse visit notes lack complete assessment of the wound and lack documentation that the facility is providing wound care as per MD orders. The DON additionally revealed that the clinical records lack coordination between hospice and facility in managing wound care for P#6, and P#13 and the nurse failed to follow the wound care policy.”

“Based on record review and staff interview, it was determined that the agency failed to ensure that all entries were legible, clear, and complete as evidenced by incomplete physician order for one patient (P) (P#7) of 14 who were current hospice beneficiaries. Findings include: Record review revealed a suprapubic catheter (a thin flexible rubber or plastic tube used to empty urine from the bladder by an incision in the lower part of the abdomen), order dated 2/10/25 for P#7 as follows:Change SP 18 fr catheter monthly and PRN. However, the suprapubic (SP) catheter order failed to reveal the size of the balloon and specific amount and type of fluid to inflate the balloon. The agency failed to ensure that the suprapubic catheter order was clear and complete. On 2/12/2025 at 11:20 a.m., an office interview was conducted with the Director of Nursing (DON). DON verbalized that the Suprapubic catheter order does not specify the size of the balloon and the amount and type of fluid to be instilled into the balloon.”

“Based on record reviews, policy review, and staff interview, it was determined that the agency failed to complete discharge summaries for two patients (P) (P#8 and P#9) of 14 sampled patients. Findings include: Review of policy titled “Discharge or Transfer of Care Summary,” effective date: 1/2/18 revealed the following: Purpose: To provide a discharge summary when a patient leaves the care of hospice. Policy: Hospice provides a discharge summary. This includes when a patient is transferred to another Medicare//Medicaid certified facility or when the patient revokes or is discharged from hospice. Procedure:1. Discharge summary must include:a. A summary of the patient’s stay including treatments, symptoms and pain management.b. Date and reason for discharge;c. Current plan of care;d. Latest physician orders; and5. Any other documentation that assists in post-discharge continuity of care or that requested by the attending physician or receiving facility. Review of clinical records failed to reveal a discharge summary for P#8 and P#9. In an interview with the Administrator on 2/10/2025 at 11:30 a.m., the Administrator stated that the charting system did not generate a discharge summary form. She acknowledges that the discharge summaries were not completed upon expiration when the patients were discharged from the hospice.”