Every finding on record at Five Points Healthcare of Ga, LLC

Based on clinical record reviews it was determined that the hospice failed to ensure that the plans of care reflected the individualized goals and interventions needed to address all the patients' assessed needs and problems for five of eleven patients (P) (P#1, P#5, P#8, P#9 and P#10) reviewed. The findings include: 1. Patient #1 was admitted to the hospice on 3/8/22, with the diagnosis of chronic obstructive pulmonary disease (COPD). The clinical record was reviewed for certification period 3/8/22 to 6/5/22. P#1's clinical record revealed physician's orders for social work and chaplain services to be provided once per month for each discipline. However, P#1's plan of care dated 3/15/22, had no goals or interventions reflecting the assessed needs for P#1 by the social worker or the chaplain. 2. Patient #5 was admitted to the hospice on 1/24/22, with the diagnosis of malignant neoplasm of hypopharynx. The clinical record was reviewed for certification period 1/24/22 to 4/23/22. P#5's clinical record revealed physician's orders for social work and chaplain services to be provided once per month for each discipline. However, P#5's plan of care dated 1/24/22, had no goals or interventions reflecting the assessed needs for P#5 by the social worker or the chaplain. 3. Patient #8 was admitted to the hospice on 7/31/21, with the diagnosis of Parkinson's disease. The clinical record was reviewed for certification period 7/31/21 to 10/28/21. P#8's clinical record revealed a physician's order for social work services to be provided once per month. However, P#8's plan of care dated 8/2/21, had no goals or interventions reflecting the assessed needs for P#8 by the social worker. 4. Patient #9 was admitted to the hospice on 8/10/21, with the diagnosis of intrahepatic bile duct carcinoma. The clinical record was reviewed for certification period 8/10/21 to 11/7/21. P#9's clinical record revealed a physician's order for social work services to be provided once per month. However, P#9's plan of care dated 8/18/21, had no goals or interventions reflecting the assessed needs for P#9 by the social worker. 5. Patient #10 was admitted to the hospice on 11/2/21, with the diagnosis of senile degeneration of the brain. P#10's clinical record was reviewed for certification period 11/2/21 to 1/30/22. P#10's clinical record revealed a physician's order for social work services to be provided twice per month. However, P#10's plan of care dated 11/2/21 , had no goals or interventions reflecting the assessed needs for P#10 by the social worker. In an interview at the agency at 10:30 a.m. on 3/17/22, the Administrator was informed that the plans of care did not reflect the individualized goals and interventions needed to address all the patients' assessed needs and problems for three of seven patients (P) (P#1, P#5, P#8, P#9 and P#10) reviewed.

Based on clinical record review, it was determined that the hospice failed to ensure that the plan of care included complete physician's orders required for the care of the patient for three of seven patients (P) (P#1, P#5 and P#7) sampled. The findings include: 1, Patient #1 was admitted to the hospice on 8/8/22, with the diagnosis of chronic obstructive pulmonary disease (COPD). The clinical record was reviewed for certification period 3/8/22 to 6/5/22. P#1's clinical record contained an initial comprehensive admission assessment by a registered nurse (RN) conducted on 3/8/22. The initial comprehensive admission assessment indicated that P#1 required oxygen at three liters per nasal cannula continuously and was wearing the oxygen during the time of the initial comprehensive assessment. However, P#1's clinical record lacked a physician's order for the oxygen P#1 required. 2. Patient #5 was admitted to the hospice on 1/24/22, with the diagnosis of malignant neoplasm of the hypopharynx. The clinical record was reviewed for certification period 1/24/22 to 4/23/22. P#5's clinical record contained an initial comprehensive admission assessment by a RN conducted on 1/24/22. The initial comprehensive admission assessment as well as the certification of terminal illness written by the agency Medical Director on 2/6/22 indicated that P#5 had a tracheostomy as well as a percutaneous endoscopic gastrostomy (PEG) tube. However, P#5's clinical record lacked a physician's orders for the maintenance and care of the PEG tube and tracheostomy. 3. Patient #7 was admitted to the hospice on 1/22/22, with the diagnosis of malignant neoplasm of middle lobe of bronchus or lung. The clinical record was reviewed for certification period 1/22/22 to 4/21/22. A home visit was conducted with P#7 at 11:20 a.m. on 3/16/22. At the time of the home visit, P#7 was noted to have oxygen being administered by nasal cannula at three liters by this surveyor. However, P#7's clinical record lacked a physician's order for oxygen administration. During interview at the agency at 10:30 a.m. on 3/17/22, the Administrator was made aware of the lack of complete physician's orders required for the care of the patient for three of seven patients (P) (P#1, P#5 and P#7) sampled.