Every finding on record at Georgia Mountain Hospice, Inc.

Based on clinical record review, review of policy ";PLAN OF CARE," and staff interview, it was determined that Interdisciplinary team (IDT) failed to ensure that plan of care reflected the specific problems identified in the assessments, goals and interventions, and services necessary to meet the assessed needs of one patient (P) (P#10) of 19 patients who were current hospice beneficiaries. --- Findings include: Review of the undated policy titled ";PLAN OF CARE," revealed the following:1. IDT plan of care will be developed upon admittance into the GMH program for care and will:a. Correspond to the physician's orderb. Assessment will culminate in a patient problem list and the treatment modalities intended to address those problems on a written plan of care. c. Address the problems, needs and desires of the patient/family.2. Documentation in the updated plan of care will include any changes in physical, psychosocial, spiritual or volunteer needs. Review of P#10s record revealed skilled nurse (SN) visit note dated 1/17/2025. The SN documents the following: patients old condom catheter (external urinary catheters that are worn like a condom and collect urine as it drains out of the bladder and sends the urine into a collection bag strapped to your leg) assessed with this nurse noting that urine is staying around the head of patients (external sex organ) this nurse removed old condom catheter with peri care to (external sex organ), this nurse applied a small amount of Chamosyn around head of (external sex organ) and applied a new condom catheter, this nurse educated with demonstration of applying a non-woven sponge around (external sex organ) and to tape over that to help hold condom catheter in place and the sponge would help absorb any excess urine, patient had a small irritation under (external sex organ) on top of scrotum this nurse educated the caregiver to apply drainage sponge under (external sex organ) to prevent a barrier between that area to allow for the direct irritation and pressure to be relieved with patient and the caregiver verbalizing understanding to education. Furthermore, review of nurse visit note dated 12/14/24, nurse documents the following: wound care to patient's right pinky toe with a gauze placed between fourth toe and pinky toe. However, the plan of care failed to address specific problems identified in the assessments, and services necessary to meet the patients assessed needs. The agency failed to ensure the plan of care included wound care assessments and treatments for P#10. On 1/29/2025 at 10:30 a.m., an interview was conducted with the Director of Clinical Services (DOCS). DOCS verbalized that the plan of care lacked wound care orders for right pinky toe, Chamosyn (skin barrier ointment) and treatment for condom catheter care site for P#10.

Based on record review, review of policy ";Wound Assessment and Description," and staff interview, it was determined that hospice failed to maintain a system of communication and integration, in accordance with patient's needs and assessment and ensure that the care and services are provided in accordance with the plan of care for two patients (P) (P#10, P#12) of nineteen patients who were current hospice beneficiaries. --- Findings include: Review of the undated policy titled ";Wound Assessment and Description," reveals the following:M. Provide Wound care as ordered. 1. Record review for P#12 revealed foley catheter (a thin, flexible tube that's inserted into the body to drain or deliver fluids) order as follows: Insert Foley Catheter; utilizing aseptic technique, insert foley catheter 16 French with 10 cc balloon for incontinence or retention. Change catheter every 30 days or as needed for blockage or displacement. May irrigate catheter with 30 cc NSS or blockage or excessive sediment. Review of nurse visit note dated 1/16/25 reveals the following documentation: Pt's old catheter removed, 16 Coude catheter inserted.10 cc balloon with sterile normal saline (mixture of salt and water). Immediate return of clear yellow urine in the bag. However, the plan of care failed to reveal an order to instill 10 cc sterile normal saline to inflate the balloon. On 1/29/2025 at 11:20 am an office interview was conducted with the Director of Clinical Services (DOCS). DOCS verbalized that the nurse instilled 10 cc of sterile normal saline to inflate the balloon without MD orders. The DOCS verbalized that foley catheter order does not specify the amount of normal saline to be instilled into the balloon. 2. Record review for P#10 revealed wound care dated 12/1/2024 reads as follows: Decubitus/Pressure Ulcer Stage I (reddened, painful area on the skin) / Bilateral Buttocks Coccyx; clean area with wound cleaner and pat dry. Apply medicated cream and cover with comfort foam. Dressing changes twice a week and PRN until healed. Review of the nurse visit note dated 12/2/24 reveals documentation of wound care as follows: stage 2x2 cm diameter wound on center of tailbone. A small amount of Chamosyn and manuka honey applied to the wound. Clinical records fail to reveal orders for Chamosyn and Manuka honey. Review of nurse visit note dated 12/13/24 revealed the following: applied Medi-honey and remedy creams with 4x4 foam comfort dressing. Clinical records fail to reveal orders for Medi-honey and remedy cream. Review of nurse visit note dated 12/14/24 revealed the following: wound care to patient's right pinky toe with a gauze placed between fourth toe and pinky toe. However, the plan of care failed to reveal wound care orders for fourth toe and pinky toe. Review of nurse visit note dated 12/18/24 revealed the following: wound cleansed with wound cleanser applied small amount of antifungal powder, covered with sacral comfort foam adhesive bandages. Clinical records failed to reveal orders for antifungal powder. Review of nurse visit note dated 12/26/24 revealed the following: cleansed wound with wound wash applied small amount of Medi honey. Review of nurse visit note dated 1/17/25 reads as follows: Patients caregiver had concerns about condom catheter placement, reports patients head of (external sex organ) was having blisters with skin breakdown, patients old condom catheter assessed with this nurse noting that urine is staying around the head of patients (external sex organ), this nurse removed old condom catheter with peri care to (external sex organ), this nurse applied a small amount of Chamyosin around head of (external sex organ) and applied a new condom catheter, this nurse educated with demonstration of applying a non-woven sponge around (external sex organ) and to tape over that to help hold condom catheter in place and the sponge would help absorb any excess urine, patient had a small irritation under (external sex organ) on top of scrotum this nurse educated caregiver to apply drainage sponge under (external sex organ) to prevent a barrier between that area to allow for the direct irritation and pressure to be relieved with patient and caregiver verbalizing understanding to education. However, the plan of care failed to reveal physician orders for Chamyosin and specific treatment that was provided to the patient. On 1/29/2025 at 11:20 a.m., an office interview was conducted with the Director of Clinical Services (DOCS). DOCS verbalized that the wound care order did not specify medication and treatment to the wound. The DOCS additionally revealed that the nurse provided wound care without MD's order.

Based on review of facility documents, review of policy ";Quality Assessment & Performance Improvement Program (QAPI)," and staff interview, it was determined the agency failed to measure, analyze, and track quality indicators of performance related to identified projects in the Quality Assessment and Performance Improvement (QAPI) program. --- Findings include:. Review of undated agency policy titled ";Quality Assessment & Performance Improvement Program (QAPI)," revealed the following:A. The QAPI program includes processes for collecting, measuring, analyzing, and tracking relevant data related to patient care, adverse patient events, and other aspects of performance. Review of facility documents confirmed the agency identified Performance Improvement Projects (PIP) during the Quality Assessment and Performance Improvement (QAPI) meetings for quarter one, quarter two, quarter three, and quarter four of 2024 but failed to follow through with documented data for measurements, analysis, tracking and evaluations for each PIP. During a phone interview on 1/28/2025 at 1:00 p.m., the agencys QAPI Coordinator admitted the QAPI committee had identified PIPs, but the agency failed to follow through with evidence of measurements, analysis, tracking and evaluations for each PIP.

Based on record reviews and staff interview, it was determined that the agency failed to ensure that all entries were legible, clear, and complete as evidenced by incomplete physician order for two patients (P) (P#10 and P#12) of 19 who were current hospice beneficiaries. --- Findings include: 1.Record review revealed a foley catheter order for P#12 as follows: Insert Foley Catheter; utilizing aseptic technique, insert foley catheter 16 French with 10 cc balloon for incontinence or retention. Change catheter every 30 days or as needed for blockage or displacement. May irrigate catheter with 30 cc NSS for blockage or excessive sediment. However, the foley catheter order failed to reveal specific amount of fluid to inflate the 10cc balloon. The agency failed to ensure that the foley catheter order was clear and complete. On 1/29/2025 at 11:20 a.m., an office interview was conducted with the Director of Clinical Services (DOCS). DOCS verbalized that the foley catheter order does not specify the amount of normal saline to be instilled into the balloon. 2. Record review for P#10 revealed wound care order dated 12/1/2024 as follows: Decubitus/Pressure Ulcer Stage I / Bilateral Buttocks Coccyx- clean area with wound cleaner and pat dry. Apply medicated cream and cover with comfort foam. Dressing change twice a week and PRN until healed. However, wound care order failed to reveal specific medication or specific treatment to be applied to the wound. On 1/29/2025 at 11:20 a.m., an office interview was conducted with the Director of Clinical Services (DOCS). DOCS verbalized that the wound care order is incomplete as the order does not specify the type of medication or treatment to be applied to the wound.

Based on administration documentation review and staff interview, it was determined the hospice failed to ensure that an annual assessment of potential risks that could hinder services provided to Medicare beneficiaries was conducted. The findings include: The agency was unable to provide any documentation of an annual risk assessment of potential threats to the agency and community. In an interview with the Administrator at the agency at 3:00 p.m. on 1/25/22, the Administrator confirmed that an all-hazards risk assessment has never been conducted by the agency to assess for potential risks that could affect how the agency would provide care to Medicare beneficiaries.

Based on clinical record review it was determined that the hospice failed to ensure the plans of care reflected individualized goals and interventions needed to address the patients' assessed needs and problems for nine of 11 patients (P) (P#1, P#2, P#4, P#6, P#7, P#8, P#9, P#10 and P#11) reviewed. The findings include: 1. Patient #1 was admitted to hospice on 12/18/20, with the diagnosis of Alzheimer's disease. Co-morbid conditions listed in the clinical record were anxiety, major depressive disorder and anorexia. The clinical record was reviewed for certification period 1/8/22 to 3/8/22. P#1's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 2. Patient #2 was admitted to hospice on 7/17/19, with the diagnosis of neoplasm of unspecified behavior of the brain. The co-morbid condition listed in the clinical record was epilepsy. The clinical record was reviewed for certification period 1/8/22 to 3/8/22. P#2's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid condition. 3. Patient #4 was admitted to hospice on 2/15/21, with the diastolic congestive heart failure. Co-morbid conditions listed in the clinical record were hyperlipidemia, type two diabetes mellitus, diabetic neuropathy, atherosclerotic heart disease and rheumatoid arthritis. The clinical record was reviewed for certification period 12/12/21 to 2/9/22. P#4's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 4. Patient #6 was admitted to hospice on 1/22/21, with the diagnosis of multiple sclerosis. Co-morbid conditions listed in the clinical record were: Covid 19, spinal stenosis, major depressive disorder, bipolar disorder and hypothyroidism. The clinical record was reviewed for certification period 1/17/22 to 3/17/22. P#6's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 5. Patient #7 was admitted to hospice on 8/18/21, with the diagnosis of Alzheimer's disease. Co-morbid conditions listed in the clinical record were personal history of transient ischemic attack and cerebral infarction without residual deficits, unspecified disorder of kidney and ureter and unspecified heart failure. The clinical record was reviewed for certification period 12/16/21 to 2/13/22. P#7's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 6. Patient #8 was admitted to hospice on 3/16/18, with the diagnosis of senile degeneration of the brain. Co-morbid conditions listed in the clinical record were acute myocardial infarction, non-ST elevation myocardial infarction, anoxic brain damage, acute respiratory failure with hypoxia, type two diabetes mellitus with hyperglycemia, acute kidney failure, atopic dermatitis, unspecified altered mental status and unspecified heart disease. The clinical record was reviewed for certification period 8/27/21 to 10/25/21. P#8's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 7. Patient #9 was admitted to hospice on 7/17/21, with the diagnosis of dementia with Lewy bodies. The co-morbid condition listed in the clinical record was dementia in other diseases with behavioral disturbances. The clinical record was reviewed for certification period 7/17/21 to 10/14/21. P#9's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 8. Patient #10 was admitted to hospice on 6/23/21, with the diagnosis of malignant neoplasm of the upper lobe or bronchus of unspecified lung. The clinical record did not list co-morbid. The record was reviewed for certification period 1/8/22 to 3/8/22. P#10's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. 9. Patient #11 was admitted to hospice on 7/10/21, with the diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries. The co-morbid condition listed in the clinical record was muscle wasting and atrophy. The clinical record was reviewed for certification period 1/8/22 to 3/8/22. P#11's plan of care lacked specific goals and interventions related to the hospice diagnosis and co-morbid conditions. During an interview at the agency at 11:30 a.m. on 1/27/22, the Administrator was informed that plan of care for nine of 11 hospice patients (P#1, P#2, P#4, P#6, P#7, P#8, P#9, P#10 and P#11) reviewed did not reflect the specific individualized goals and interventions necessary to address the patients' assessed needs and problems.

Based on review of clinical documents, it was determined that the hospice failed to ensure that the plan of care contained specific individualized frequencies of tasks to be performed by the hospice aide for 10 of 11 patients (P) (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P#11) reviewed. The findings included: 1. Patient #1 was admitted to hospice on 12/8/20, with the diagnosis of Alzheimer's disease. The clinical record was reviewed for certification period 1/8/22 to 3/8/22. P#1 had a physician's order for a hospice aide to provide care five times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 2. Patient #2 was admitted to hospice 7/17/19, with the diagnosis of neoplasm of unspecified behavior. The clinical record was reviewed for certification period 1/2/22. P#1 had a physician's order for a hospice aide to provide care three times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 3. Patient #4 was admitted to hospice on 2/15/21, with the diagnosis of diastolic congestive heart failure. The clinical record was reviewed for certification period 12/12/21 to 2/9/22. P#4 had a physician's order for a hospice aide to provide care two times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 4. Patient #5 was admitted to hospice on 4/24/21, with the diagnosis of unspecified heart failure. P#5 had a physician's order for a hospice aid to provide care three times per week. However, the plan of care did not specify the frequency of tasks to be performed by the hospice aide. 5. Patient #6 was admitted to hospice on 1/22/21, with the diagnosis of multiple sclerosis. The clinical record was reviewed for certification period 1/17/22 to 4/17/22. P#6 had a physician's order for a hospice aide to provide care two times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 6. Patient #7 was admitted to hospice on 8/18/21, with the diagnosis of Alzheimer's disease. The clinical record was reviewed for certification period 12/16/21 to 2/13/22. P#7 had a physician's order for a hospice aide to provide care three times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 7. Patient #8 was admitted to hospice on 3/16/18, with the diagnosis of senile degeneration of the brain. The clinical record was reviewed for certification period 8/27/21 to 10/25/21. P#8 had a physician's order for a hospice aide to provide care three times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 8. Patient #9 was admitted to hospice on 7/17/21, with the diagnosis of dementia with Lewy bodies. The clinical record was reviewed for certification period 7/17/21 to 10/14/21. P#9 had a physician's order for a hospice aide to provide care two times per week. However, the plan of care did not specify the frequency of the tasks to be performed by the hospice aide. 9. Patient #10 was admitted to hospice on 6/23/21, with the diagnosis of malignant neoplasm of the upper lob or bronchus, unspecified. P#10 had a physician's order for a hospice aide to provide care two times per week. The plan of care did not specify the frequency of tasks to be performed by the hospice aide. 10. Patient #11 was admitted to hospice on 7/10/21, with the diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries. P#11 had a physician's order for a hospice aide to provide care five times per week. However, the plan of care did not specify the frequency of tasks to be performed by the hospice aide. In an interview at the agency at 11:30 a.m. on 1/27/22, the Administrator was informed that plan of care for 10 of 11 hospice patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10 and P#11) reviewed did not reflect the specific individualized frequencies of the tasks to be performed by the hospice aide.

Based on personnel record review, it was determined that the hospice failed to ensure all staff, volunteers and contracted employees had documentation of the required annual skills competency evaluation for two of seven personnel records reviewed. The findings included: 1. Medical Director (MD) #BB was hired on 9/1/2019. MD #BB's personnel record contained no documentation of the required annual skills competency evaluation since date of hire . 2. Social Worker (SW) #CC was hired on 6/27/2019. SW #CC's personnel record contained no documentation of the required annual skills competency evaluation since date of hire. In an interview at the agency with the Administrator at 11:30 a.m. on 1/27/22, the Administrator was informed that two of seven personnel records reviewed lacked the required annual skills competency evaluation.

Based on clinical record review, it was determined that the hospice failed to ensure a coordinated plan of care that specifically identified the provider responsible for each intervention included in the plan of care for five of 11 patients (P) (P#4, P#6, P#7, P#9 and P#11) reviewed. The findings include: 1. Patient #4 was admitted to hospice on 2/15/21, with the diagnosis of diastolic congestive heart failure. The clinical record for P#4 was reviewed for certification period 12/12/21 to 2/9/22. P# 4's clinical record revealed that the patient resided at a nursing home. The hospice plan of care did not identify the specific provider and discipline at both the hospice and the nursing home that would be responsible and accountable for each intervention, task, and function related to P#4's care and service. 2. Patient #6 was admitted to hospice on 1/22/21, with the diagnosis of multiple sclerosis. The clinical record for P#6 was reviewed for certification period 1/17/21 to 3/17/21. P# 6's clinical record revealed that the patient resided at a nursing home. The hospice plan of care did not identify the specific provider and discipline at both the hospice and the nursing home that would be responsible and accountable for each intervention, task, and function related to P#6's care and service. 3. Patient #7 was admitted to hospice on 8/18/21, with the diagnosis of Alzheimer's disease. The clinical record for P#7 was reviewed for certification period 12/16/21 to 2/13/22. P# 7's clinical record revealed that the patient resided at an assisted living facility. The hospice plan of care did not identify the specific provider and discipline at both the hospice and the assisted living facility that would be responsible and accountable for each intervention, task, and function related to P#7's care and service. 4. Patient #9 was admitted to hospice on 7/17/21, with the diagnosis of dementia with Lewy bodies. The clinical record for P#9 was reviewed for certification period 7/17/21 to 10/14/21. P# 9's clinical record revealed that the patient resided at an assisted living facility. The hospice plan of care did not identify the specific provider and discipline at both the hospice and the assisted living facility that would be responsible and accountable for each intervention, task, and function related to P#9's care and service. 5. Patient #11 was admitted to hospice on 7/10/21, with the diagnosis of diastolic congestive heart failure. The clinical record for P#11 was reviewed for certification period 7/10/21 to 10/7/21. P# 11's clinical record revealed that the patient resided at a personal care home. The hospice plan of care did not identify the specific provider and discipline at both the hospice and the personal care home that would be responsible and accountable for each intervention, task, and function related to P#11's care and service. During interview with the Administrator at the agency at 11:30 a.m. on 1/27/22, the Administrator was made aware that the plans of care did not identify the provider responsible for each intervention included in the plans of care for five of 11 (P#4, P#6, P#7, P#9 and P#11) patients reviewed.