Every finding on record at Compassionate Care Hospice of Savannah, LLC

Upon patient record review, 3 of 14 (Patient #1,#7,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1:The medical record includes the primary diagnosis of senile degeneration. There is no evidence of active problems, goals and interventions for the management of the primary diagnosis. Patient 7:The plan of care includes orders for the use of anticoagulation therapy. There is no evidence that the plan of care includes problems, goals and interventions for the management of the potential for bleeding/hemorrhage. Patient 10:The plan of care includes an order for the patient to perform self catheterization 4 times daily. There is no evidence that the plan of care includes goals and interventions for the training and management of the patient's self catheterization.

Upon patient record review, 2 of 14 (Patient #3,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3:The plan of care includes an order for a MSW frequency effective 10/7/24 of 3 visits for 1 month , 4 visits for 1 month and 5 visits for 1 month. There is no evidence that the MSW completed 4 visits in the second month. Patient 7:The plan of care includes an order for a MSW frequency of 1 visit every month. There is no evidence that the MSW completed visits in August and November 2024.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 8:The medical record includes documentation that the patient is currently on anticoagulation therapy using Eliquis and is at risk for bleeding . The aide plan of care does not include bleeding precautions.

Upon patient record review 2 of 14 (Patient #4,#9) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4:The aide plan of care included the task of shampoo hair assigned 1st visit of week. The aide documentation notes that the task was completed on 11/1/24, the second visit of week. Patient 9:The aide plan of care included the task of assist with shower. The aide provided a bed bath during visit on 12/10/24.

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, document review, and an interview. 1 of 8 (13%) records reviewed with aide services revealed the plan of care did not document the frequency to perform tasks assigned thus allowing the aide to make decisions that are out of their scope of practice. Record #34198: The plan of care order dated 12/06/2021 did not document the frequency to perform tasks assigned. Policy # AA-015(b) revised 12/07/2021 reads in part, " A registered nurse shall prepare for each personal care aide written instructions for patient care that is consistent with the interdisciplinary plan of care." This finding was reviewed during an interview with the Regional Business Office Manager on 03/01/2022. She indicated that there were no frequencies documented.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41. I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document review, and interview. 1 of 1 (100%) applicable record of a hospice patient who transferred/discharged to a hospital revealed no documented evidence that the discharge/transfer summary was sent to the receiving hospital. Record #95281: This patient was admitted for hospice services on 02/18/2022 and transferred/discharged to a hospital on 02/20/2022 to seek aggressive treatment. There was no documentation that the discharge/transfer summary or additional documents were sent to the receiving facility. Agency policy # AA-013A revised 12/07/2021 stated in part, " When a patient is discharged to another organization, the relevant information is provided to the agency including: a summary of the care provided by the hospice agency." This finding was reviewed during an interview with the Regional Business Office Manager on 03/01/2022. She indicated that a discharge summary was not sent to the receiving hospital.