Prohealth Hospice-Georgia, LLC

“Upon patient record review, 2 of 14 (Patient #1, #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1: On RN admission documentation dated 02-16-24, the RN indicated the patient was using 2L of O2 via NC, and on 03-03-24 the RN documented the patient was using 5L of O2. O2 was not listed on the medication profile. Patient #6:The F2F by the NP dated 06-05-24 indicated the patient was using 3 L O2 via NC. The medication profile listed the oxygen was used at 2L per NC. COS”

“Upon patient record review, 1 of 14 (Patient #13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #13: On plans of care for IDG dated 06-06-24, 06-20-24 and 07-03-24, there was no evidence of documentation of SW frequency. The SW visited 2 x in the month of June 2024. COS”

“Upon patient record review, 7 of 14 (Patient #1, #2, #3, #4, #9, #10, #11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: On RN admission documentation dated 02-16-24, the RN indicated the patient was using 2L of O2 via NC, and on 03-03-24 the RN documented the patient was using 5L of O2. There was no evidence of an order for oxygen on the plan of care. Patient#2: Triamcinilone was listed on the medication profile with instructions to “apply to the affected area” without indicating the location of the affected area. In addition, Oxygen at 2L was listed without a route of administration. Patient #3: Zinc was listed on the medication profile without evidence of a location to apply. Patient #4: Lidocaine patch was listed on the medication profile without an area for application. Patient #9: Diclofenac gel was listed on the medication profile without evidence of documentation of the area of intended application. Patient #10: O2 was listed on the medication profile without evidence of a route of administration. COS Patient #11: O2 was listed on the medication profile without evidence of a route of administration. COS”

“Upon client record review, 3 of 14 (Patient #6,#11,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The POC for IDG date 07-03-24 indicated SC was declined. There were 2 visits during the next 15 days. In addition, the plan of cares dated 07-18-24 and 08-01-24 indicated SC was 1 x month. There were 4 visits made during these 4 weeks on 07-24, 07-31, 08-06 and 08-14-24. Patient #11: The Plans of care dated 06-13-24, 07-03-24 and 07-18-24 indicate aide visits are 5 x week. There was 1 aide visit made during that time on 06-19-24 and supervisory visits were completed on 07-01-24 and 07-26-24 indicating positive results. Patient#14: The plan of care dated 07-03-24 indicated SN visits were 2 x week, and for the week of 06-30-24 - 07-06-24, there was only 1 visit evidenced by an SN. Additionally, for the week of 07-28-24 - 08-03-24, there was no visit by the SN.”

“Upon patient record review 2 of 14 (Patient #12, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #12: For plans of care dated 06-13-24 and 07-03-24 the aide was ordered 5 x week. The aide was discontinued on the plan of care dated 07-18-24 and also via an order dated 07-22-24. However, there is no evidence of aide visits after 06-19-24. Patient #13: On 05-23-24, HHA visits were ordered 1wk1, 5 wk 8. For the week beginning 06-09-24, there were 4 visits made on June 10, 12, 13 and 14. COS”

“Upon patient client record review, 3 of 14 (Patient #3, #4, #6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The Medicaid Hospice election form was signed by a representative of the patient without evidence of documentation of the relationship to the patient. Patient #4: The Informed Consent was signed by the patient’s son without evidence of documentation indicating the reason the patient was unable to sign. Patient #6: The election statement indicated the patient’s choice for attending physician without listing the phone number, as required, or other information which would identify this attending physician.”