Every finding on record at Athens Hospice, Inc.

Observed in Record Review. In 2 of 2 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan of care included all the services and interventions needed for the palliation and management of the terminal illness. For example: review of RR# 1's IDG/POC revealed a frequency for the MSW for one visit a month and one as needed visit for crisis management. However, further review of the IDG/POC revealed no psychosocial goals or interventions. Review of RR# 2's IDG/POC revealed a frequency for Skilled Nurse for two visits a week. However, further review of the IDG/POC revealed no nursing goals or interventions. This was reviewed, discussed, and validated with the DPCS.

Observed in Document Review. During review of the organization consent and Election of Benefit form it was noted it lacked the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” effective 10/1/2020.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR#3, it was noted on the RN initial comprehensive assessment the patient's pain rating was documented as 10/10 using the painad scale. There was no further documentation of interventions identified or performed to relieve the pain during the visit. During RR#4, the pain rating at the RN initial visit was documented as 6/10 on the painad scale. There is no further documentation in the comment section of the pain assessment and there was lack of documentation in the POC of assessment of pain, interventions and goals. This was discussed with the DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV#1 record review it was noted the patient had a fall documented on a communication note in the beginning of April 2022. On that date interventions and goals were written by the RN on fall assessment and prevention. At the next IDG meeting after the fall there is lack of documentation in the RN summary of the fall occurrence.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#4 it was noted the MSW psychosocial summary on the IDG meeting after the initial comprehensive assessment did not reflect the complexity of patient and family psychosocial issues identified during the MSW initial assessment. This was discussed with the DPCS.

Observed in Record Review. In 10 of 11 patient records reviewed, During HV#1 record review it was noted the goals/outcomes identified on the POC were not measurable. For example: ADL deficit: Pt will have optimum level of independence through assistance with personal care, safety deficit: No fall will be reported this episode, Pt will remain free of injury, Pt/Family/PCG will verbalize understanding of increased risk of fall, Pt/Family/PCG will verbalize understanding of safety intervention and for pain deficit: Reduce pain to < 3 or stated comfort. HV#3 record review POC goals were not measurable. For example under pain it is documented Uncomfortable upon admission and the goal was Bring down the pain level to <3. RR#1 goals not measurable. Example: deficit Progressive weakness, goal: - Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. During review of RR#2 it was noted lack of measurable goals on the POC, for example: - Pt has a potential for falls and injury with goal: Minimize complications due impaired mobility. During RR#4 it was noted lack of measurable goals in the POC, for example constipation identified as a deficit with the goal better elimination. During RR#5, 7 and 8 the goals established in the POCs were not measurable, for example in RR#7 for the deficit; altered bowel movements, the goal was optimal BMs. For example in RR#8 a deficit identified as Allergy wit the goal, minimize risk for allergies. The findings were discussed with the DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, During HV#1, HV#3 record review, RR#2 , RR#5 and RR#6 it was noted the MSW had a frequency of visit identified on the POCs. The IDG/POCs lacked interventions and goals related to the psychosocial issues identified in the MSW assessments. In addition in RR#6, it was noted the chaplain established a frequency of visits, but POC lacked interventions and goals for the Chaplain. During RR#1 it was noted lack of interventions and goals for the patient's dietary/swallowing issues. Patient has had weight loss due to decreased appetite. ... has dysphagia and ... regurgitates food after eating was documented during the initial RN assessment. The findings were discussed with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, During RR#8, it was noted the frequency for the SN was 1x/week and as needed. The frequency lacked the number and reason for as needed visits. Findings discussed with DPCS.

Observed in Data Tracer. During review of the QAPI data collection for 2021, it was noted although the organization collected data on their identified performance measures there is lack of documentation that the data was analyzed to identify opportunities and priorities for improvement.

Observed in Data Session. During review of the QAPI data presented to the surveyor it was noted lack of documentation that the Hospice QAPI program was evaluated annually.

Observed in Data Session. During review of the QAPI data presented to the surveyor it was noted lack of a written QAPI plan that gave priority to high-volume, high-risk, or problem-prone processes for performance improvement activities and did not identify the frequency of data collection for performance improvement activities. The Governing Body minutes reviewed for 2020 and 2021 lacked written documentation that the organization’s governing body approved the QAPI data collection measures reviewed by the surveyor.

Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted lack of a goal limiting the spread of infections associated with procedures. This was discussed with the DPCS and Administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, During HV#1 record review it was noted the SN frequency on the POC of 3x/week plus 2 PRN for crisis management was not followed. In 6 of the 10 weeks reviewed the patient was visited twice to perform skilled care. There is lack of documentation of orders to change the frequency of visits. This was discussed with the DPCS. During RR#6 it was noted the Frequency of visits for the Chaplain was SC: 2 per Month +2 PRN Visits - Per Week + 1 PRN Visits without an indication for the PRN visits to be performed. During RR#7 it was noted the frequency of SN, MSW and chaplain visits in the most recent recertification did not identify the number of PRN visits needed or the reasons. All disciplines had a frequency documented with PRN visits as needed.

Observed in Record Review. In 4 of 11 patient records reviewed, During HV#1 record review it was noted an order for O2 continuous at 2.5L/min that was not included on the hospice aide assignment form. During RR#1 record review it was noted the diet order on the aide assignment form was as tol. The diet order on the POC was puree with update in January 2022 to elevate the HOB to 45 degrees when eating or feeding. During RR#4 it was noted the order for O2 at 2L/min PRN SOB was not included on the hospice aide assignment form. The diet order on the aide POC was documented as tol, the diet order on the POC was Puree with aspiration precautions. During RR#5 it was noted the diet order on the aide assignment form was marked as tol. The diet order on the POC was mechanical soft. This was discussed with the DPCS.

Observed in Document Review. During review of the organization patient admission information it was noted lack of a copy of its written policies and procedures on the management and disposal of controlled medications to the patient or the patient’s representative and family. This was noted also in the patient's home who had controlled medications prescribed and in documentation in the EMR when controlled substances were ordered.

Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(ix), did not have a process for ensuring the tracking and securing of documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(B), did not include a statement by the authenticating practitioner recommending that the staff member be exempted from the organization’s COVID-19 vaccination requirements for staff based on recognized clinical contraindications, as evidenced by lack of a policy and process Observed in Infection Control Tracer. It was determined that the organization’s documentation of clinical contraindications, as required by Infection Control CoP 418.60(d)(3)(viii)(A), did not include information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications, as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vii) did not have a process for tracking and securely documenting information provided by those staff who have requested, and for whom the organization has granted, an exemption from the staff COVID-19 vaccination requirements based on recognized clinical contraindications or applicable federal laws as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(iii) did not have a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(viii) did not have a process for ensuring that all documentation that confirms recognized clinical contraindications to COVID-19 vaccines and supports staff requests for medical exemptions from vaccination had been signed and dated by a licensed practitioner who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable state and local laws as evidenced by lack of a policy and process. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(vi) did not have a process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable federal law as evidenced by lack of policy and process. Observed in Infection Control System Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(v) did not have a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC as evidenced by lack of a policy and process. The organization has 100% compliance with staff COVID-19 vaccinations. Observed in Infection Control Tracer. It was determined that the organization, as required by Infection Control CoP 418.60(d)(3)(x) did not have contingency plans for staff who are not fully vaccinated for COVID-19 as evidenced by lack of a policy and process.