Every finding on record at Prohealth Hospice-Georgia, LLC

Upon patient record review, 2 of 14 (Patient #1, #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Actual or potential drug interactions • Drug therapy currently associated with laboratory monitoring Patient #1: On RN admission documentation dated 02-16-24, the RN indicated the patient was using 2L of O2 via NC, and on 03-03-24 the RN documented the patient was using 5L of O2. O2 was not listed on the medication profile. Patient #6:The F2F by the NP dated 06-05-24 indicated the patient was using 3 L O2 via NC. The medication profile listed the oxygen was used at 2L per NC. COS

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #13: On plans of care for IDG dated 06-06-24, 06-20-24 and 07-03-24, there was no evidence of documentation of SW frequency. The SW visited 2 x in the month of June 2024. COS

Upon patient record review, 7 of 14 (Patient #1, #2, #3, #4, #9, #10, #11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: On RN admission documentation dated 02-16-24, the RN indicated the patient was using 2L of O2 via NC, and on 03-03-24 the RN documented the patient was using 5L of O2. There was no evidence of an order for oxygen on the plan of care. Patient#2: Triamcinilone was listed on the medication profile with instructions to "apply to the affected area" without indicating the location of the affected area. In addition, Oxygen at 2L was listed without a route of administration. Patient #3: Zinc was listed on the medication profile without evidence of a location to apply. Patient #4: Lidocaine patch was listed on the medication profile without an area for application. Patient #9: Diclofenac gel was listed on the medication profile without evidence of documentation of the area of intended application. Patient #10: O2 was listed on the medication profile without evidence of a route of administration. COS Patient #11: O2 was listed on the medication profile without evidence of a route of administration. COS

Upon client record review, 3 of 14 (Patient #6,#11,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The POC for IDG date 07-03-24 indicated SC was declined. There were 2 visits during the next 15 days. In addition, the plan of cares dated 07-18-24 and 08-01-24 indicated SC was 1 x month. There were 4 visits made during these 4 weeks on 07-24, 07-31, 08-06 and 08-14-24. Patient #11: The Plans of care dated 06-13-24, 07-03-24 and 07-18-24 indicate aide visits are 5 x week. There was 1 aide visit made during that time on 06-19-24 and supervisory visits were completed on 07-01-24 and 07-26-24 indicating positive results. Patient#14: The plan of care dated 07-03-24 indicated SN visits were 2 x week, and for the week of 06-30-24 - 07-06-24, there was only 1 visit evidenced by an SN. Additionally, for the week of 07-28-24 - 08-03-24, there was no visit by the SN.

Upon patient record review 2 of 14 (Patient #12, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #12: For plans of care dated 06-13-24 and 07-03-24 the aide was ordered 5 x week. The aide was discontinued on the plan of care dated 07-18-24 and also via an order dated 07-22-24. However, there is no evidence of aide visits after 06-19-24. Patient #13: On 05-23-24, HHA visits were ordered 1wk1, 5 wk 8. For the week beginning 06-09-24, there were 4 visits made on June 10, 12, 13 and 14. COS

Upon patient client record review, 3 of 14 (Patient #3, #4, #6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: The Medicaid Hospice election form was signed by a representative of the patient without evidence of documentation of the relationship to the patient. Patient #4: The Informed Consent was signed by the patient's son without evidence of documentation indicating the reason the patient was unable to sign. Patient #6: The election statement indicated the patient's choice for attending physician without listing the phone number, as required, or other information which would identify this attending physician.

Based on clinical record review, staff interview, and policy and procedures, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one Patient (P) (P#4) of 13 sampled patients (P#1, P#2, P#3, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, and P#13). --- Based on clinical record review, staff interview, and policy and procedures, it was determined the interdisciplinary group failed to ensure that the initial comprehensive assessment was completed within 5 days of admission for one Patient (P) (P#4) of thirteen sampled patients (P#1, P#2, P#3, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, and P#13). Review of agency policy titled ";PC. S25 Spiritual Care Services, 3.a." revealed ";Assessment of the patients and families spiritual needs as indicated and appropriate, is completed within 5 days of admission, unless declined by patient/family." The agency failed to ensure the spiritual assessment was completed within five days of admission. Review of the clinical record for P#4, admitted on 1/2/2023, with a diagnosis of malignant neoplasm of head of pancreas revealed that the initial spiritual assessment was completed on 1/12/2023, 10 days after the patient's admission. The clinical record failed to include documentation regarding the staff's delay in completing the assessment. In an interview on 2/15/2023 at 10:26 a.m., the Director of Nursing (DON), revealed she did not know why the spiritual assessment was done late. The DON revealed that the chaplain was not available for interview because he was on jury duty for that week. The DON also confirmed that the surveyor has been provided with all available documentation for the patients record.

Based on observations, staff interviews, and review of agencys policy and procedures, it was determined that the hospice agency staff failed to follow standard precautions to prevent the transmission of infectious and communicable diseases during bed bath for one Patient (P) (P#1) of 13 sampled patients (P#1. P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, and P#13). --- Review of document titled ";Bathing the bedbound resident" revealed ";14. Change the bath water. Turn resident on side, facing away from you, ....... 15. Provide perineal care last. Perineal care involves cleaning the private parts......... For females: Spread the fold of genital skin......and wipe each side from the front toward the back in one motion. Use a clean part of the cloth for each side. Replace cloth as necessary. Repeat until clean, then rinse and pat dry." The facility failed to ensure agency staff followed standard precautions during bed bath for P#1. Review of policy titled ";PC. I1O INFECTION CONTROL-HAND HYGIENE AND BAG TECHNIQUE 1. (b)." dated 2018 reveals ";Use of alcohol-based hand sanitizer is preferred (until dry). If antimicrobial hand soap is used, it must be for a period of at least 15 seconds. Between tasks on the same patient and particularly when there is prolonged intense contact with patient: i.e., bathing." During a home visit with P#1 on 2/14/2023 at 10:45 a.m., this surveyor observed Certified Nursing Aide (CNA) AA, perform bed bath care to P#1. During the entire bathing procedure, CNA AA did not change the water; she also wiped the female patient from back to front three times. CNA AA dropped the washcloth and towel on the floor upon completion of P#1s bath. On 2/14/2023 at 10:50 a.m., an interview was conducted with CNA AA, who confirmed that she did not change the bathing water, and that she wiped P#1 from back to front three times. CNA AA said that she was nervous during the bathing procedure. During an interview on 2/14/2023 at 4:39 p.m., the Director of Nursing (DON), acknowledged that the CNA AA did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases. Cross references Z1203 as it relates to P#1

Based on observation, record review, staff interviews, and review of agencys policy and procedures, it was determined that the agency failed to comply with regulations, and their policy regarding wound care, for one Patient (P) (P#1) of 13 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, and P#13). --- On 2/14/2023 at 10:45 a.m., this surveyor observed hospice aide perform wound care to P#1, remove the old dressing on sacral area, apply barrier cream and cover sacral open wound with bordered silicone adhesive foam dressing sacral size 9 by 9 inches. On 2/14/2023 at 11:00 a.m., an interview was conducted with Certified Nurse Aide (CNA) AA, who confirmed that she performed a duty that was beyond the scope of her practice. On 2/14/23 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), who stated that the aide was not allowed to perform wound care per agency policy and procedures, and they dont have policy but in their procedure guidelines, it does state CNAs cannot perform wound care. The DON also stated that the agency would conduct in-service training for the hospice staff immediately. The hospice agency failed to provide a policy related to a Certified Nurse Aide (CNA) cannot perform wound care.

Based on clinical record review, staff interviews, and policy and procedures review, it was determined that the agency failed to follow their policy and procedures, to obtain physicians order for a patient with left foot (shin), open wound care for one Patient (P) (P#3) of 13 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13). --- On 2/14/2023 at 12:40 p.m., this surveyor reviewed Hospice Agency Policy and Procedures, dated 2018, (Page 1-2, number 3.d-e): ";Some of the reasons orders are obtained from physicians include, but are not limited to: number (3.d Care, treatment, and services. 3.e. Dressing changes and wound care);" Patient #3 was admitted to Hospice Agency on 8/25/2022, with a diagnosis of chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, pneumonia, acute kidney failure, and hypertensive chronic kidney disease, and hyperkalemia. On 2/14/2023 at 12:30 p.m., this surveyor observed Registered Nurse (RN) BB, performing left foot shin wound care to P#3, used wound cleanser to clean left foot shin wound, pat dry, then covered it with bordered gauze adhesive island wound dressing. The facility failed to produce a physician order for left foot shin wound care. On 2/14/2023 at 12:30 p.m., an interview was conducted with RN BB, who stated that she did not follow the Hospice Agency Policy and Procedures to obtain physicians order for left foot shin wound care for P#3. During an interview on 2/14/2023, at 4:50 p.m., the Director of Nursing (DON), confirmed that RN BB, did not follow the Hospice Agency Policy and Procedures to obtain a physicians order before performing P#3s left foot shin wound care.

Based on observation, record review, staff interview and patient interview, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on patients hospice plan of care. The agency failed to provide the needed medications related to the co morbidities for two Patients (P) (P#3, and P#9) of 13 sampled patients (P#1, P#2, P#4, P#5, P#6, P#7, P#8, P#10, P#11, P#12, and P#13). --- 1. Record review of plan of care (POC) for P#3 revealed admitted to hospice services on 8/25/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD), with acute exacerbation including the following co morbidities (a disease or medical condition that is simultaneously present with another or others in a patient): acute respiratory failure with hypoxia, pneumonia, acute kidney failure, hypertensive chronic kidney disease, and hyperkalemia. Record review of the Registered Nurse (RN) Initial Assessment with visit date of 8/25/2022 revealed the co morbidity of acute respiratory failure with hypoxia ";related to terminal diagnosis". The record showed the agency was not providing coverage for payment for the following medications used to manage the co morbidities: Flovent Diskus (Fluticasone propionate) was used to treat COPD by decreasing inflammation in the lungs. In a home visit with P#3 on 2/14/2023 at 11 a.m., P#3 revealed he was taking the medications, but that the Flovent inhaler was not ordered or paid for by the hospice agency. 2. Record review of POC for P#9 reveals admitted to hospice services on 1/19/2023 with a primary diagnosis of neurocognitive disorder with Lewy bodies. Co-morbidities include but not all inclusive of dementia and abnormal weight loss. Record review of the RN Initial Assessment with visit date of 1/19/2023 reveals co-morbidity of dementia and abnormal weight loss being ";related to terminal diagnosis". The record showed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of dementia, and abnormal weight loss: Megestrol Acetate oral suspension 40 milligrams/ milliliters (MG/ML), give one ml oral twice daily for appetite stimulant related to weight loss. In an interview at the agencys office on 2/15/2023, at 10:30 a.m., the Director of Nursing (DON), revealed that she was unaware that it was a requirement for the agency to pay for medication related to the listed co morbidities on the patients plan of care.