Every finding on record at Northeast Georgia Medical Center, Inc.

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 clinical record review and interview. In 3 of 3 (100%) clinical records reviewed, for patients with indwelling catheters being provided bathing services by the hospice aides, it was revealed that the agency did not ensure the aide care plan provided instructions for catheter care. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/03/2025 with a diagnosis of Gastric Adenocarcinoma and resided at home. Per the Registered Nurse (RN) visit note on 05/12/2025 a Foley catheter was inserted during that visit and an RN assessment on 07/14/2025 documented that the Foley catheter remained in place. The aide plan of care, dated 05/04/2025, included orders for aide visits two times per week with the following relevant tasks ordered for every visit: assist with bathing, assist with incontinent care, and change adult diapers. The aide plan of care did not alert the aide to the Foley catheter or instruct the aide to provide catheter care. CLINICAL RECORD 9: The patient elected the hospice benefit on 09/23/2024 with a diagnosis of Parkinson's disease and resided at home. Per the RN visit notes a Foley catheter insertion was documented on 05/14/2025 and the comprehensive nursing assessment on 07/21/2025 documented the Foley catheter remained in place. The aide plan of care dated 09/24/2024 included orders for aide visits two times per week with the following relevant tasks ordered for every visit: assist with shower, assist with incontinent care, and change adult diapers. The aide plan of care did not alert the aide to the Foley catheter or instruct the aide to provide catheter care. CLINICAL RECORD 17: The patient elected the hospice benefit on 03/26/2025 with a diagnosis of Severe Protein Calorie Malnutrition and resided in an assisted living facility. The RN documentation reported patient had urinary retention and an order was obtained to place a Foley catheter during the initial assessment on 03/26/2025. The aide plan of care was initiated on 03/27/2025 and included orders on every visit for the aide to assist with bathing (bed bath), assist with incontinent care, and change adult diapers. On 07/22/2025 the RN documented the Foley remained in place. The aide plan of care did not alert the aide to the Foley catheter or instruct the aide to provide catheter care. During the record review and interview on 07/22/2025 the Quality Assurance Performance Improvement Nurse said, "there is an aide catheter care" task that should have been selected for patients and reported that "the nurses may have thought catheter care was implied as part of the assist with incontinent care instructions."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 24 (4%) clinical records reviewed, in which aide services were accepted, revealed that the agency did not ensure that the registered nurse (RN) was notified of changes in the patient's condition as it related to the aide's plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/11/2025 with a diagnosis of Multiple Sclerosis and resided in a Skilled Nursing Facility. On 07/18/2025 the visit type titled "Aide Attempted Visit" was utilized and the hospice aide documented, "patient not feeling well and had been cleaned by facility CNA (certified nursing assistant)." The clinical record lacked documentation that the hospice aide notified the RN the patient did not feel and that the aide tasks on the plan of care were not completed. During the record review and interview, on 07/22/2025, the Quality Assurance Performance Improvement Nurse reported that the "Aide Attempted Visit" note does not prompt the aide to document RN notification therefore it was missed. She confirmed there was no additional documentation elsewhere in the record that the aide had notified the RN.

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification for the hospice care benefit is informed by the medical director or physician designee’s review of the patient’s clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 12 (8%) clinical records reviewed, in which a recertification of terminal illness was required, it was revealed that the agency did not ensure the written physician narrative met the Federal regulation. Per the Code of Federal Regulation: § 418.22 Certification of terminal illness. (b) Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: (3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms. CLINICAL RECORD 3: The patient was readmitted to hospice in their 18th benefit period on 05/07/2025. The certification of terminal illness (CTI) document for the benefit period 05/07/2025 to 07/05/2025 included a section titled 'Brief Narrative Statement' which stated, "Patient discharged from hospice on 05/07/2025." The CTI was signed by the physician on 05/14/2025. The clinical record had orders and documented visits on-going from 05/07/2025 to date of review 07/22/2025. The Quality Assurance Performance Improvement Nurse confirmed the patient was admitted on 05/07/2025 and that the narrative statement on the CTI was not accurate. The Administrator reviewed the record and was unable to determine why the CTI included a discharge statement and not a narrative statement describing the patient's clinical information to support the life expectancy of 6 months or less. Per the Code of Federal Regulation: § 418.22 Certification of terminal illness. (b) Content of certification. Certification will be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness. The certification must conform to the following requirements: (3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

It is required that if a patient revokes the election of hospice care or is discharged from hospice (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure a copy of the discharge summary was provided to the attending physician. CLINICAL RECORD 21: The patient elected the hospice benefit on 02/14/2025 and resided in a skilled nursing facility. On 05/15/2025 the patient's daughter informed hospice that she wanted her mom to receive skilled therapy services and revoked the hospice benefit. The discharge summary note documented that the facility Director of Nurses was informed that the hospice services were stopping. The record lacked documentation that the patient's attending physician was provided with a copy of the discharge summary. During the record review and interview on 07/23/2025, the Quality Assurance Performance Improvement nurse said that the physician notification should have been included on the notification section of the discharge summary. At the time of the exit conference that agency was unable to locate any additional documented evidence that the discharge summary was provided to the attending physician.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. The hospice inpatient facility has evacuation diagrams posted and visible to all staff, patients, and family members or visitors. This standard was not met as evidenced by interviews and observations. The hospice inpatient unit, that first accepted patients in March of 2021, did not ensure fire drills were conducted at varied times on all shifts. A review of Life Safety Code fire drills specific to the hospice inpatient unit revealed documented fire drills conducted in 2021 for quarters 2, 3, and 4. There were no fire drills documented in 2022 for quarters 1 and 2. The documented hospital fire drills, where the inpatient unit is located, did not include inpatient staff participation. During an interview, the Inpatient Manager confirmed the finding and stated she recognized the documentation for fire drills was not correct and now has corrected documentation and a plan.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 5 (20%) records reviewed in which a volunteer was accepted, revealed the hospice did not ensure that the hospice care and services furnished to the patient followed the written plan of care (POC). The agency's policy "Volunteer Services", stated in part, "Hospice utilizes specially trained volunteers in all care setting to provide services to terminally ill patients and family units in accordance with the patients plans of care." Clinical Record #19: was reviewed and identified the patient elected hospice care on 3/7/2022. The record included documentation of a volunteer request dated 03/15/2022. The plan of care dated 5/1/2022 through 7/31/2022, ordered volunteer services "2-3 times a month for companionship and music." The month of June 2022, five volunteer visits were completed, and the month of July 2022, six volunteer visits were completed. The volunteer services were not provided as per the plan of care. The record did not include evidence of an updated physician's order or communication with the physician regarding the change of visit frequency. During an interview, the Volunteer Coordinator stated that recently a change had been made with volunteer documentation. Additionally, the Director of Quality stated that the volunteer frequency compliance was a recent identified process improvement project.

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 and interviews. 5 of 16 (31%) records reviewed of patients receiving hospice aide services revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide scope of practice. Clinical Record #9: was reviewed and identified the patient elected hospice care on 6/22/2022. The aide plan of care completed by the RN on 6/27/2022, assigned the aide the tasks, "shower /bed bath." The plan of care listed the patient's diagnosis as Alzheimer's disease and not a decision maker, thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record #1: was reviewed and identified the patient elected hospice care on 4/24/2021. The aide plan of care completed by the RN on 04/24/2021, assigned the aide the tasks, "ambulate with cane, crutches, walker, oxygen." The aide was not provided clear instruction regarding the patient's ambulation, thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record #3: was reviewed and identified the patient elected hospice care on 11/7/2020. The aide plan of care completed by the RN on 12/27/2021, assigned the aide the tasks, "shower... complete bed bath." There was no decision maker identified. A review of the clinical record revealed the patient was a 2 person transfer, used a shower chair to transfer, and had a colostomy. The aide plan of care did not assign tasks and specific instructions related to the patient's transfer and colostomy needs. Clinical Record #5: was reviewed and identified the patient elected hospice care on 7/30/2022. The aide plan of care completed by the RN on 8/17/2022,assigned the aide the tasks, "ambulate with cane, crutch, walker." A review of the clinical record revealed the patient required the assistance of 1 -2 persons to transfer to a wheelchair. The aide plan of care did not assign tasks and specific instructions related to the patient's transfer and ambulation, thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record #7: was reviewed and identified the patient elected hospice care on 6/21/2022. The aide plan of care completed by the RN on 6/24/2022, assigned the aide the tasks, "ambulate with cane crutch, walker...complete bed bath... shower." The aide plan of care did not assign tasks and specific instructions related to the patient's ambulation and type of bath, thus leaving the aide to make decisions outside of the aide's scope of practice. During an interview, the Director of Compliance stated that a process improvement was identified this year for hospice aide plans of care, as the clear directions for aides was identified by the hospice as a problem.

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 interviews. 1 of 18 (6%) records reviewed which required additional physician orders, revealed the hospice did not ensure all physician orders were documented for care of the patient. Clinical Record #6: was reviewed and identified the patient elected hospice care on 6/5/2022. The after hours follow up visit completed by the registered nurse (RN) on 7/3/2022, documented that the was patient having difficulty with increased confusion and constipation. The RN documented that urine for an urinalysis was obtained and taken to the lab for evaluation. The record did not include evidence of a physician's order for the urinalysis, as of 10/05/2022. During an interview, the compliancy staff stated that the lab requisition was documented, but no physician order for the urinalysis was located during the site visit.