Every finding on record at Regency Hospice of Georgia, LLC

Upon observation, and record review (Patient #16) did not have evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #16: The record indicated that the patient's son had complaints about the DME company related to delivery time and the conversation with a staff member of the DME company. There was not evidence of a grievance report. Corrected on site.

Upon patient record review 3 of 23 records (Patient #9,#17,#19) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #9: The patient was admitted on 1/27/23. The record indicated that the spiritual assessment was completed on 2/3/23. Patient #17: The patient was admitted on 2/14/23. The record indicated that the spiritual assessment was completed on 2/21/23. Patient #19: The patient was admitted on 3/22/23. The record indicated that the spiritual assessment was completed on 3/28/23.

Upon patient record review, 6 of 23 records (Patient #2,#3,#5,#6,#12,#15) 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 • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: The medication profile contained Acetaminophen 325mg, 2 caps q6h prn pain/fever. There was not evidence of a parameter for the fever. Corrected on site. Patient #3: The record indicated that the patient was on Bactrim 800mg-160mg, 1 tab bid X10 days starting 6/27/23. The medication profile still contained the drug, Bactrim. Corrected on site. Patient #5: Nurse documentation dated 7/9/23 indicated that oxygen was ordered to be delivered. The record indicated that the patient had oxygen on at 5L/min. There was not evidence of oxygen in the medication profile. Patient #6: The medication profile included several Seroquel orders, one which read Seroquel 25 mg, 1-2 tabs every am. There was not clear evidence of when to administer 1 tablet or 2 tablets. Corrected on site. Patient #12: The medication profile indicated oxygen via nasal cannula at 2-4L/min continuously. An IDG dated 7/5/23, in the nurse narrative documentation revealed that the patient was wearing oxygen via nasal cannula at 3L/min intermittently. There was not evidence in the record that the order was changed/revised to prn. Corrected on site. Patient #15:The medication profile contained Aspirin 81mg, 1 daily. Maximum dose 4000mg/24h from all sources. Corrected on site.

Upon patient record review, 1 of 23 records (Patient #3) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3:The patient was admitted on 5/9/23. The record indicated that the bereavement assessment was completed on 5/16/23.

Upon patient record review, 2 of 23 records (Patient #6,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #6: The record indicated that the patient had a G-tube. There was not evidence of care plan problems with goals and interventions related to the G-tube. Corrected on site. Patient #10: The patient was admitted with a diagnosis of Alzheimer's Disease, late onset. The patient was total care for all ADLs, bedbound, 7A on the FAST scale and was unable to understand or participate in care. There was not evidence that the plan of care reflected patient/family goals and interventions related to the patient's neurological disease. Corrected on site.

Upon patient record review, 5 of 23 records (Patient #2,#5,#6,#12,#15) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: The record contained an order for Acetaminophen 325mg, 2 caps q6h prn pain/fever. There was not evidence tin the order of a parameter for the fever. Corrected on site. Patient #5: Nurse documentation dated 7/9/23 indicated that oxygen was ordered to be delivered. The record indicated that the patient had oxygen on at 5L/min. There was not evidence of an order for oxygen. Patient #6: The record contained several Seroquel orders, one which read Seroquel 25 mg, 1-2 tabs every am. There was not clear evidence of when to administer 1 tablet or 2 tablets. Corrected on site. Patient #12: The record indicated an order for oxygen via nasal cannula at 2-4L/min continuously. An IDG dated 7/5/23, in the nurse narrative documentation revealed that the patient was wearing oxygen via nasal cannula at 3L/min intermittently. There was not evidence in the record that the order was changed/revised to prn. Corrected on site. Patient #15:The record contained an order for Aspirin 81mg, 1 daily. Maximum rec dose 4000mg from all sources. Corrected on site.

Upon client record review, 4 of 23 records (Patient #1,#3,#8,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Documentation by the nurse dated 7/6/23 indicated that the nurse massaged the leg to help facilitate drainage, wrapped the patient's legs with gauze directly on her skin then applied light compression with Coban. There was not evidence that this treatment was a part of the plan of care. Corrected on site Patient #3: The record indicated a visit by the bereavement coordinator on 5/18/23. There was not evidence of a visit frequency for this service. Patient #8: The visit frequency for the spiritual care counselor was for an evaluation then 2m1, 1m1. The patient was admitted on 4/13/23. The record indicated 2 visits during the month of June, on 6/6/23 and 6/12/23. Corrected on site. In addition, the social worker visit frequency was for an evaluation then 1m1. The patient was admitted on 4/13/23. The record indicated a visit on 6/16/23 without evidence of an order. Corrected on site. Patient #12: The record indicated volunteer visits 1x/week for the benefit periods beginning 4/8/23 and 6/7/23. There was not evidence of visits by the volunteer. Corrected on site.

Upon patient record review, 4 of 23 records (Patient #4,#5,#6,#16) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4: The record indicated the task of shampoo weekly and when soiled. Corrected on site. Patient #5: The record indicated the task of shave weekly and if visible beard growth. Patient #6: The record indicated the task of shampoo weekly and as indicated for soiling. Also to shave weekly and if visible beard growth. Patient #16:The record indicated for nail care weekly and if soiled. Also shave weekly and if patient requests. Corrected on site.

Upon patient record review 2 of 23 records (Patient #2,#9) 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 #2: The record contained an order dated 5/22/23 for the aide visit indicating that due to the holiday it was OK to miss 1 aide visit for the week of 5/29. There was not evidence of the patient's or families level of understanding, involvement and agreement with the plan of care regarding the deleted visit. Patient #9: The record contained an order dated 5/29/23 for the aide visit indicating that due to the holiday it was OK to miss 1 aide visit for the week of 5/29. There was not evidence of the patient's or families level of understanding, involvement and agreement with the plan of care regarding the deleted visit. In addition, the aide plan of care indicated to provide nail care weekly. The record indicated that nail care was provided at every visit from 6/1/23 to current.

Upon patient client record review, 4 of 23 records (Patient #1,#2,#14,#17) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: The patient was admitted on 5/18/23. The aide visit frequency indicated 1w12 effective 5/12/23 (Date prior to admission date). Patient #2: The record contained a missed visit document entered by the nurse and entered on 5/23/23, that was completely blank. Patient #14: An IDG dated 6/21/23, under the social worker narrative comments indicated that the patient was a full code. The Advance Directive section indicated that the patient was a DNR. The entries were conflicting Patient #17: There was a missed visit document in the record, entry date by the RN was 6/16/23. The document was blank with no evidence of the date the visit was missed or the reason it was missed.

Upon client record review, 4 of 23 records (Patient #2,#4,#7,#13) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The record indicated a visit by the bereavement coordinator on 5/18/23. There was not evidence of a visit frequency for this service. Patient #4: The visit frequency for the social worker for the benefit period 4/6/23-7/4/23 was 2/week and 2 prn. The record indicated visits were conducted on 4/19/23, 5/3/23, 5/17/23, 6/12/23, and 6/21/23 which is not in compliance with the ordered frequency. Patient #7: The spiritual care counselor visit frequency was 1x/week. There was not evidence of a visit for the week of 7/2/23-7/8/23. Corrected on site. In addition the social work visit frequency was for an evaluation, then 3x/week and on 5/10/23 changed to 1m1, 2m2. Visits were conducted on 5/4/23, 5/8/23, and 6/6/23. Corrected on site. Patient #13: The social work visit frequency was for an evaluation then 3m1, 5m1 and 2 prn. The routine visit pattern was followed however the record revealed 4 prn visits on 5/4/23, 5/5/23, 5/6/23, and 6/2/23. There was not evidence that the visit order for prn visits was revised. Corrected on site.

Upon client record review, 1 of 23 records (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #2: The record contained orders for wound care dated 5/12/23 indicating to cleans the right scapula wound with NS. Pat dry. Apply Dakins soaked gauze and cover with ABD pad daily and prn soiling. Can be performed by RN/CG/FS. The second wound on the patient's sacral area contained the same order with the exception that the sacral wound would be treated BID. There was not clear evidence as to which provider was to perform the wound care. Corrected on site.