Every finding on record at Ghc-Savannah, LLC

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 standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 15: The patient elected hospice care 04/12/23. The registered nurse (RN) documented in the initial comprehensive assessment the patient had a left chest PleurX drain present. The plan of care dated 04/12/23 did not include interventions and goals related to care of the PleurX drain. Clinical Record 9: The patient elected hospice care 03/31/23. The RN documented in the initial comprehensive assessment that the patient had a pressure area located on the right ankle and an optifoam dressing applied. The plan of care dated 03/31/23 did not include interventions and goals related to care of the pressure area and optifoam dressing. Clinical Record 10: The patient elected hospice care 02/04/23. The RN documented in the initial comprehensive assessment the patient had a 16 French Foley catheter. The skilled nurse documented for the visits dated 02/06/23, 03/07/23, and 04/13/23 that a 16 French Foley catheter was inserted during each of the visits. The 02/04/23 plan of care did not include interventions or goals for the Foley catheter. During a joint record review and interview on 06/02/23, the Administrator stated the associated records had been reviewed and missing treatment orders that the clinician had received but inadvertently failed to enter had since been corrected.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) of clinical records reviewed, the agency did not ensure that the plan of care documented the frequency of services necessary to meet the patient and family needs. Clinical Record 8: The patient elected hospice care 04/23/23. The plan of care dated 04/23/23 documented a diagnosis of Diabetes with an intervention to instruct patient/caregiver on monitoring of blood sugars. The intervention for blood sugar monitoring did not document a frequency. During an interview on 06/02/23, the Administrator stated the associated record had been reviewed and was missing treatment orders that the clinician had received.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that care and services provided are in accordance with the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) records reviewed the agency did not ensure the services were provided in accordance with the plan of care. Clinical Record 6: The hospice plan of care dated 03/22/23 ordered the skilled nurse visit frequency: two times a week for 13 weeks. Clinical record review revealed there was one skilled nursing visit provided for the weeks of 04/19/23 and 04/26/23, There was no evidence of documented missed visits or documented communication with the physician. Clinical Record 8: The hospice plan of care dated 04/23/23 ordered the skilled nurse visit frequency: "3wk1 2wk 12." Clinical record review revealed there was one skilled nursing visit provided for the week of 04/30/23, There was no evidence of a documented missed visit or documented communication with the physician. Clinical Record 17: The hospice plan of care dated 04/05/23 ordered effective 04/02/23: skilled nursing "6wk1, 9wk1, 2wk8." For the week of 04/02/23 the skilled nurse completed visits on 04/04/23, 04/05/23, 04/06/23, 04/07/23 and 04/08/23. There was no evidence six visits were completed for the week. During an interview on 06/02/23, the Administrator reviewed the associated records and stated missed visit entries had been inadvertently omitted.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed that included the provision of aide services, the agency did not ensure that the hospice aide provided services as ordered. Clinical Record 4: The 10/29/22 aide care plan completed by the Registered Nurse (RN) assigned the aide the task, temperature check every visit. The task was not completed for visits dated 04/13/23 to 05/25/23. The aide documented the task was not completed per the direction of the RN. There was no evidence that the aide care plan had been updated by the RN. Clinical Record 5: The 01/24/23 aide care plan completed by the RN assigned the aide the task, temperature check every visit. The task was not completed for visits dated 03/28/23 to 05/16/23. The aide documented the task was not completed per the direction of the RN. There was no evidence that the aide care plan had been updated by the RN. Clinical Record 6: The 03/22/23 aide care plan completed by the RN assigned the aide the task, linen change weekly. The task was documented as completed.at each visit for visits dated 05/15/23 to 05/31/23 with the visit frequency of five (5) times week. There was no evidence that the aide care plan had been updated by the RN. Clinical Record 7: The 04/10/23 aide care plan completed by the RN assigned the aide the task, temperature check every visit. The task was not completed for the visit dated 04/13/23. The aide documented the task was not completed per the direction of the RN. There was no evidence that the aide care plan had been updated by the RN. Clinical Record 13: The aide care plans dated 01/24/23 and 05/03/23 completed by the RN assigned the task for nail care and shampoo once a week. Aide visits were ordered two (2) times a week from 04/25/23 to 05/11/23 and five (5) times a week from 05/15/23 to 05/26/23. The aide documented the tasks as completed at each aide visit dated 04/25/23 to 05/26/23. There was no evidence that the aide care plan had been updated by the RN. Clinical Record 17: The physician's order dated 04/02/23 read aide "4wk1, 5wk1.2wk1." For the week of 04/04/23 the frequency was ordered four (4) times a week. The aide documented visits completed on 04/04/23, 04/06/23, and 04/07/23. There was no evidence that the aide care plan had been updated by the RN. During an interview on 06/02/23, the Administrator reviewed the associated records and stated that the aides had since been provided remedial education.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the entries in the patient record were appropriately authenticated. Clinical Record 6: The hospice aide care plan updated on 05/31/23, the registered nurse did not document credentials with associated signature and date. Clinical Record 12: The hospice aide care plan updated on 05/31/23, the registered nurse did not document credentials with associated signature and date. During an interview on 06/01/23, the Administrator stated the credentials were missing on the associated records and have since been corrected.