Every finding on record at Lanier Hospice, LLC

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Registered Nurse (RN) completed supervisory visits no less frequently than every 14 days. Clinical Record 1: The patient elected hospice care on 11/23/2024. The plan of care ordered Hospice Aide (HA) services two (2) times a week. The first HA visit was documented on 11/25/2024. The RN completed the HA supervisory visit on 12/30/2024, with 36 days outstanding. Clinical Record 2: The patient elected hospice care on 11/23/2024. The plan of care ordered HA services two (2) times a week. The first HA visit was documented on 11/25/2024. The RN completed the HA supervisory visit on 12/27/2024, with 32 days outstanding. Clinical Record 8: The patient elected hospice care on 01/25/2025. The plan of care ordered HA services one (1) time a week. The first HA visit was documented on 01/28/2025. No HA supervisory visit was documented as of this review on 03/12/2025, with 43 days outstanding. Clinical Record 12: The patient elected hospice care on 02/21/2025. The plan of care ordered HA services one (1) time a week. The first HA visit was documented on 02/25/2025. No HA supervisory visit was documented as of this review on 03/12/2025, with 15 days outstanding. During an interview on 03/12/2025, the Manager of Accreditation and Regulatory Compliance confirmed the findings.

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. This standard was not met as evidenced by review of records and interview. 1 of 13 (8%) records reviewed the record was missing evidence of an updated patient plan of care, completed by the hospice interdisciplinary group, based on the documented patient assessment. Record #69539: The Hospice Benefit of Election began on 12/2/2020, and the period under review was for the 8th recertification of 3/26/2022 through 5/24/2022. The patient was admitted to Hospice Services for CHF, Cardiac Disease, RA, COPD, Oxygen Dependent, Chest Pain, Anxiety, Obesity, and SOB upon Minimum Exertion. Review of the nursing narrative, dated 4/21/2022, revealed: "Pain rated by the patient at 7/10, of back and BLE." Review of the Nurse Visit Note dated 4/27/2022 documented: "Pain is 7/10 of bilateral knees", blood pressure was measured at "151/91", and "Patient has not taken a pain pill“. The nursing visit note dated 5/5/2022 stated: “Pain continues at a 7/10", and "BP at 172/95". The nurse documented in a Communicate Note: "... encourages current medication regimen for comfort, comfort measures, monitor effectiveness and report changes... patient took pain meds before visit." On 5/9/2022, nurse narrative stated: "No pain but worst pain in 24 hours is 7/10." There was no documented evidence of the IDG's review of the patient's continued episodes of pain reported as "7/10" and no evidence of revisions made to the patient's plan of care based on assessment of the patient's pain during the period from 4/21/2022 through 5/9/2022. In an interview with the Administrator, during the exit conference on 5/20/2022, it was stated that the RN is required to provide documentation and/or communication to ensure care and services meet the needs of the patients.

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 interview. 1 of 13 (8%) records reviewed lacked evidence of a physician orders for a prescribed treatment. Record #26594: Review of the nursing visit narrative dated 5/03/2022 revealed that the physician was contacted regarding a "new skin tear to the right arm below elbow, with serosanguinous drainage, from a fall walking down the hall, yesterday.” There was no documented evidence of a physician order that described treatment interventions related to the patient's skin tear. In an interview on 5/20/2022 with the Administrator and hospice management team, they confirmed the clinical record was missing documentation of the physician order and stated they will provide a Plan of Correction to ensure compliance in the future.