Every finding on record at Compassionate Care Hospice of Central Georgia, LLC

Upon patient record review, 1 of 14 (Patient #7) 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 #7: There is evidence in the medical record of an order on 10/9/25 "cleanse wounds with Dakin's 0.25% solution 2X week with wound care". The order does not contain the location of the wound or wound care to be completed. The wound order was corrected on 10/28/25. The agency has a current PIP for wound care that includes writing orders.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The 2024 annual volunteer usage was 4.40%. There is a local PIP and National PIP for volunteer recruitment and retention.

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 IS A CONTINUING PRIOR REQUIRED ACTION. This was previously cited at HCPC 18. I, L538, now cited at new standard HCPC21.I. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the hospice did not ensure the plan of care identified planned interventions and goals based on problems identified during the initial and updated comprehensive assessments. Clinical Record 4: The patient’s date of election was 9/9/2022. The patient's diagnoses were documented as heart disease and diabetes mellitus type 2. The comprehensive assessment completed by the Registered Nurse (RN) on 4/11/2023 documented that the patient was "taking an antidiabetic agent, blood sugars checked daily, and a fasting blood sugar 155." On 4/11/2023, the physician ordered facility staff "may obtain fingerstick blood glucose level using aseptic technique as needed to monitor for hypo/hyperglycemia." The comprehensive assessment completed by the RN on 4/24/2023 documented a new stage 2 pressure ulcer to the left heel. The plan of care effective 4/11/2023 through 5/17/2023 did not include documentation of problems, goals, and interventions for hypo/hyperglycemia and the wound. During a joint review of the record and an interview on 9/25/2023, the Director of Operations agreed there was no documented evidence the plans of care included planned interventions and goals based on the problems identified in the assessments.

It is required that hospice aides are assigned to a specific patient by a registered nurse 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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed in which hospice aide services were accepted, the hospice did not ensure that the written patient care instructions for the hospice aide were updated to reflect changes in the patient's needs. Clinical Record 5: The patient’s date of election was 6/17/2022. The Registered Nurse (RN) visit note dated 8/30/2023 documented that a Foley catheter was placed. The hospice aide plan of care, effective 11/28/2022 through 9/25/2023 (current), assigned the hospice aide the tasks: peri care and incontinence care every visit. The hospice aide plan of care was not revised to include catheter care. During a joint review of the record and an interview on 9/25/2023, the Director of Operations agreed there was no documented evidence the hospice aide plan of care was updated to include catheter care.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure the plan of care specified all the care and services necessary to meet the patient's needs related to safety and fall precautions. Clinical Record 4: On the initial comprehensive assessment dated 10/12/22, the RN documented a fall risk assessment which reported the patient had "3 or more falls in the past 3 months" and had "balance problem while standing and walking" with a total score of "22" and "based on the total score, the risk for falls is: HIGH." Within that visit note, the RN also documented, "Pt (patient) has had 5 falls since July with 1 fall resulting in head laceration" and reported the following interventions were provided: "initiate fall precautions" and "reviewed use of assistive devices." The plan of care, with an effective date of 10/12/22 to current, did not contain any problems, goals, or inventions related to safety or fall prevention. In an interview on 11/16/22, the Clinical Manager confirmed the care plan did not address the risk of falls.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: As frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 11 (9%) clinical records reviewed the agency did not ensure that the interdisciplinary group (IDG) documented a care plan review as the patient's condition required, but no less frequently than every 15 days. Clinical Record 1: The patient elected the hospice benefit on 9/30/22, the first documented IDG meeting for this patient was 10/19/22 and within that note, it stated "Previous IDG meeting date:" which was blank and "IDG meeting reason: New admission." In an interview with the Clinical Manager (Staff 4) and the AVP of Operations (Staff 14), conducted on 11/17/22, it was confirmed that there was no additional documentation to support that an IDG care plan review/meeting was conducted within the required 15 days.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse 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 a review of clinical records and interviews. In 1 of 8 (12%) clinical records reviewed, in which aide services were accepted, the agency did not ensure that the aide care plan was updated to reflect changes in patient needs. Clinical Record 3: The patient elected the hospice benefit on 10/21/22. Clinical nursing note dated 11/1/22 documented an indwelling Foley catheter was placed. The hospice aide plan of care effective from 10/21/22 to the current was not revised to include catheter care. Peri care and incontinence care were listed as a task for every visit. In an interview conducted on 11/15/22, the Administrator (Staff 7) agreed that the aide's plan of care should have been updated to include catheter care since the aide was providing peri-care and incontinence care.

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 a review of clinical records and interviews. In 1 of 8 (12%) clinical records reviewed, in which aide services were accepted, the agency did not ensure the aide provided services as ordered on the aide plan of care. Clinical Record 3: The patient elected the hospice benefit on 10/21/22. The aide care plan effective as of 10/21/22 included instruction to shampoo with frequency of three times weekly. During the week starting 11/7/22, shampoo was documented as completed by the hospice aide five (5) times on 11/7/22, 11/8/22, 11/9/22, 11/10/22 and 11/11/22. In an interview on 11/15/22, the Administrator (Staff 7) confirmed the ordered frequency for shampoo was three times per week and the aide should not have completed it five times.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 8 (25%) clinical records reviewed, in which aide services were accepted, the agency did not ensure the hospice aide documented changes in the plan of care to the Registered Nurse. Clinical Record 1: The hospice aide care plan that was effective from the patient's admission date of 9/30/22 listed multiple assigned tasks to be completed with every visit. On the aide visit note, dated 11/10/22, the hospice aide documented "N" (no) under completed areas and in each note section stated, "patient/caregiver declined." This included the area "any observations t.o report to RN/CM (Registered Nurse/Case Manager)", which the aide also documented as "patient/caregiver declined". Clinical Record 6: The hospice aide care plan was effective from the patient's admission date of 5/2/22. On the aide visit note, dated 6/23/22, the hospice aide documented "N" (no) under completed areas and in each note section stated, "task already completed"." This included the area "any observations to report to RN/CM", which the aide also documented "task already completed." In an interview on 11/15/22, the Administrator (Staff 7) and Clinical Manager (Staff 4) agreed these were situations in which the hospice aide should have communicated with the RN and confirmed the record did not contain any documentation of the communication.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 11 (18%) clinical records reviewed the agency did not ensure the clinical records contained physician orders specific to meet each patient's needs. Clinical Record 3: Initial comprehensive assessment, dated 10/21/22, documented the patient had Jevity 1.2 calories running continuously at 40 milliliters/hour via PEG tube. Plan of care orders, effective 10/21/22 to current, addressed nutritional requirements as stated, "tube feedings, mechanical soft if tolerated". The specifics of enteral nutrition, including the supplement and prescribed amount, were not included in the medication list or on the plan of care. Furthermore, a nursing note dated 6/23/22 documented that an indwelling Foley catheter (16 French) was inserted due to wound and incontinence, the record did not contain a physician order for the catheter insertion. Clinical Record 4: The patient elected the hospice benefit on 10/12/22. The nursing visit note, dated 11/8/22, stated, "C/O (complains of) dizziness reported, currently managed with Meclizine, episodes not as severe as on admission since managed." The clinical record did not include a physician's order for Meclizine. In an interview with the Clinical Manager (Staff 4), conducted on 11/16/22, it was confirmed that within the electronic medical record (EMR) there were no, current or discontinued, physician orders for these items and they did not have any written orders documented outside of the EMR.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. In 10 of 11 (91%) clinical records reviewed, with the election of benefit dated after 12/11/19 and with controlled substances ordered, the agency did not ensure the patient, or their legal representative was provided with a copy of the hospice's policy and procedure for management and disposal of controlled medications. The admission booklet provided to patients/legal representatives did not contain the agency policy and procedure regarding the management and disposal of controlled medications. The policy consisted of specific guidelines regarding the storage, management, and disposal of medications. The information provided within the patient admission booklet was titled 'drug disposal' and while it contained education regarding disposal it did not contain all the specifics of the policy. The practice of the agency is to order Morphine as a "PRN" (as needed) medication upon admission; thus, it impacted all the patients listed below. The agency policy MA-006 Storage/Disposal of Medications Agency policy consists of specific medication disposal guidelines, including an extensive list of controlled drugs and proper disposal techniques. Hospice Patient Information Booklet Drug disposal is addressed on pages 24 and 25 and stated in the relevant part "Patients and caregivers will be notified of the company policy of destroying medications at the time of admission" however, the agency policy itself was not present. Clinical Record 1: Election of benefit 9/30/22. Morphine was ordered on 9/30/22. Clinical Record 2: Election of benefit 4/21/22. Morphine was ordered on 4/21/22. Clinical Record 3: Election of benefit 10/21/22. Morphine was ordered on 10/21/22. Clinical Record 4: Election of benefit 10/13/22. Morphine was ordered on 10/13/22. Clinical Record 5: Election of benefit 10/15/22. Morphine was ordered on 10/15/22. Clinical Record 6: Election of benefit 5/3/22. Morphine was ordered on 5/3/22. Clinical Record 7: Election of benefit 3/17/22. Morphine was ordered on 3/17/22. Clinical Record 8: Election of benefit 8/23/22. Morphine was ordered on 8/23/22. Clinical Record 10: Election of benefit 5/26/22. Morphine was ordered on 5/26/22. Clinical Record 11: Election of benefit 1/25/22. Morphine was ordered on 1/25/22. In an interview with the Administrator (Staff 7) and Clinical Manager (Staff 4) conducted on 11/15/22, it was confirmed that the policy was no longer being provided to patients/representatives on admission or when controlled medications are ordered. The Administrator stated, "we used to have copies of the policy in the book, but we were told we could remove it." Per an interview with the Administrator (on 11/15/22) and the AVP of operations (on 11/17/22), it was unclear when the directive came to remove the actual policy itself. The admission booklet provided to patients/legal representatives did not contain the agency policy and procedure regarding management and disposal of controlled medications. The policy consisted of specific guidelines regarding storage, management and disposal of medications. The information contained within the patient admission booklet was titled 'drug disposal' and while it contained education regarding disposal it did not contain all the specifics within the policy. The practice of the agency is to order Morphine as a "PRN" (as needed) medication upon admission; thus, it impacted all the patients listed below.

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 a review of clinical records and interviews. In 1 of 11 (9%) clinical records reviewed, in which a patient resided in a skilled nursing facility (SNF), the agency did not ensure the plan of care identified care and services needed and specified which provider was responsible for performing the functions; specifically, when a patient is admitted for a respite stay. Clinical Record 6: The patient elected the hospice benefit on 5/2/22 and was admitted to the SNF on 6/22/22 for a respite stay. The plan of care acknowledged the change in the level of care with an order but did not contain specifics related to collaboration with the facility or identify which provider was responsible for performing the functions listed within the plan of care. In an interview with the Clinical Manager (Staff 4), conducted on 11/16/22, it was reported that the agency had a document titled "facility coordination of care" that was utilized when a hospice patient resided in an SNF, but regarding this patient stated, "I am going to guess there isn't one because I wouldn't have thought we needed it for a respite patient." The AVP of operations (Staff 14) confirmed that the additional document was not completed for this patient and agreed it should have been.