Every finding on record at Traditions Hospice of Atlanta, LLC

Observed in Record Review. In 1 of 8 active patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured the initial comprehensive assessment was completed within five calendar days of the patient electing the hospice benefit. For example: review of RR# 3's patient record revealed an election of benefit dated approximately 14 days prior to the surveyor review of the record. Further review of RR# 3's patient record revealed no documentation of an initial Medical Social Worker assessment. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 1 of 8 active patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of RR# 3's patient record revealed no documented initial bereavement assessment. This was reviewed, discussed, and validated with the Branch Director.

Observed in Patient Home. In 8 of 8 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, and RR# 5's patient records review it was noted the organization had not ensured the patient's plan of care were based on the patient’s goals and the time frames, required to meet those goals. For example: the plans of care were not individualized for each patient by not including time frames appropriate for each patient. In addition, HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, and RR# 5’s plan of care included the goal “pain managed at current acceptable level of pain” with no indication what each patient’s acceptable level of pain. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 4 of 8 active patient records reviewed, During HV# 1, HV# 2, RR# 4, and RR# 5's patient records review it was noted the organization had not ensured the patient's plan of care included medications and treatment necessary to meet the patient's needs. For example: review of HV# 1's plan of care revealed oxygen at 2lpm as needed. However, review of the recertification RN comprehensive assessment and SN visit notes revealed HV# 1 was on 3lpm continuously. In addition, HV# 1 was observed with continuous oxygen during the home observation at the assisted living facility. Further review of HV# 1's patient record revealed the medication profile with oxycodone 20mg/ml, 1ml every four hours as needed with no indication when to administer the oxycodone. Review of HV# 2's patient record revealed documentation HV# 2 was taking Dilaudid twice a day for pain dated approximately 75 days prior to the surveyor review of the record. During HV# 2's home observation the caregiver shared HV# 2 was now taking Dilaudid once a day for pain. Further review of HV# 2's patient record revealed a recertification Certificate of Terminal Illness (CTI) with documentation that HV# 2 was taking Dilaudid for pain. However, review of HV# 2's plans of care revealed no Dilaudid. Review of RR# 4’s patient record revealed hydromorphone 2mg every 4 hours as needed for moderate/severe pain and hydromorphone 4mg every 4 hours as needed for pain with no indication on what level of pain before taking the hydromorphone 4mg. Further review of RR# 4’s patient record revealed NovoLog insulin – blood sugar minus 100 and divide by 30 to equal the units with no indication when blood sugars were to be assessed for the administration of insulin. Review of RR# 5’s plan of care revealed hydrocodone 1 tab every 4 hours as needed with no indication when it should be given such as pain. Further review of the plan of care revealed Tylenol 325 mg take two tablets every 6 hours as needed with no indication when it should be given such as pain. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 5 of 7 active patient records reviewed with HHA services, During HV# 1, HV# 2, HV# 3, RR# 2, and RR# 3s patient records review it was noted the organization had not ensured the registered nurse prepared written instructions necessary to care for the patient. For example: HV# 1 was oxygen dependent. However, review of the hospice aide written instructions revealed no documentation HV# 1 was dependent on oxygen or if the oxygen could be removed during the task of showering. Review of HV# 2's patient record revealed HV# 2 had oxygen as needed with documentation oxygen had been used intermittently. However, review of the hospice aide written instructions revealed no documentation HV# 2 had oxygen or oxygen precautions. Review of HV# 3's patient record revealed HV# 3 had multiple wounds with dressings on bilateral lower extremities. Review of the hospice aide written instruction included a bed bath twice a week and a shower three times a week. Further review of the hospice aide written instructions revealed no documentation that HV# 3 had wounds or dressings to the lower extremities. Review of RR# 3’s patient record revealed a pressure ulcer to the coccyx with a dressing. Review of RR# 3’s hospice aide written instructions revealed the task of a bed bath. Further review of the hospice aide written instructions revealed no documentation RR# 3 had a wound or a wound dressing. Review of RR# 2’s patient record revealed RR# 2 had oxygen 2lpm as needed. Review of the hospice aide written instructions revealed the task of shower. Further review of the hospice aide written instructions revealed no documentation regarding oxygen or oxygen precautions.

Observed in Record Review. In 3 of 7 active patient records reviewed with HHA services, During HV# 2, HV# 3, and RR# 5's patient records review it was noted the organization had not ensured the hospice aide provided services as ordered. For example: review of HV# 2's hospice aide written instructions revealed the task of documenting the last BM. Review of HV# 2's patient record revealed documentation of Y in four of four hospice aide visit notes. Review of HV# 3's hospice aide written instructions revealed the task of documenting the last BM. Review of HV# 3's patient record revealed documentation of Y in the hospice aide visit notes. Review of RR# 5’s hospice aide written instructions revealed the task of documenting the last “BM. Review of RR# 5’s patient record revealed documentation of “not required this visit” in the hospice aide visit notes for the current certification period. This was reviewed, discussed, and validated with the Branch Director.

Observed in Patient Home. In 4 of 7 patient records reviewed with HHA services, During HV# 2, HV# 3, RR# 1, and RR# 2's patient records review it was noted the organization had not ensured staff were supervised effectively, as there was no documentation indicating that the registered nurse had conducted supervisory visits on the hospice aides every14 days as required by regulation. For example: review of HV# 2's patient record revealed no documented hospice aide supervisory visit for 75 days prior to the surveyor review of the record. Review of HV# 3's patient record revealed no documented aide supervisory visits for 38 days prior to the surveyor review of the record. Review of RR# 1's patient record revealed no documented hospice aide supervisory visits for 45 day prior to the surveyor review of the record. Review of RR# 2's patient record revealed no documented hospice aide supervisory visits for 70 day prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Branch Director.

Observed in HR File Review. In 4 of 12 HR files reviewed, During HR# 4, HR# 9, HR# 12, and contracted staff HR# 5's HR files review, staff did not participate in training required by regulation. This is evidenced by the following: the staff members have potential to be in contact with infectious material from patients, and would therefore need to take annual bloodborne pathogen training per OSHA. However, the organization was unable to produce information on bloodborne pathogen training for the employees within the past year. This was reviewed, discussed, and validated with the Branch Manager,

Observed in Patient Home. In 3 of 3 home visits conducted, During HV# 1, HV# 2, and HV# 3's home observation it was noted the organization had not ensured the patient record contained information that reflected the patient's care treatment, or services. For example: HV# 1 medication profile revealed oxycodone 20mg/ml take 1ml every four hours. However, review of the assisted living facility medication administration record revealed oxycodone 20mg/ml take 1 ml two times a day as needed for pain. Review of HV# 2's medication profile revealed duloxetine 60mg capsule, delayed release 1 capsule daily. However, review of the medication bottle in the home revealed Duloxetine 50 mg 1 capsule daily. Review of HV# 3's assisted living facility medication administration record revealed haloperidol 1mg tablet take 1 tablet every 4 hours as needed for agitation/anxiety. However, review of HV# 3's medication profile revealed no haloperidol listed. In addition, during HV# 3's home observation the registered nurse (RN) was observed providing wound care to the left lower leg venous stasis ulcer and wound care to three open areas on the right leg. HV# 3 shared the venous statis ulcer had been present prior to admission to hospice and HV# 3's spouse was a wound nurse that had been providing wound care. However, review of HV# 3's patient record revealed documentation that the right leg had the venous stasis ulcer and the left leg had blisters and all documentation in the SN visit notes included this inaccurate wound location documentation. This was observed, reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 2 of 2 discharged patient records reviewed due to extended prognosis, During RR# 6 and RR# 8's patient records review it was noted the organization had not ensured the Medicare Notice of Non-Coverage (NOMNC) was signed within 2 days of discharge. For example: review of RR# 6's patient record revealed RR# 6 was discharged due to no longer being eligible for the hospice benefit. Review of the record revealed documentation to start discharge planning four days prior to discharge by the MSW. Further review of the record revealed a copy of a U.S. mail address dated four days after discharge with a hand written note stating the POA had not returned phone calls and unable to notify POA regarding discharge due to ineligibility. However, there was no copy of the NOMNC with the discharge date and information on how to appeal the decision. Further review of RR# 6's patient record revealed documentation nine days after discharge by the Medical Director indicating the patient was discharged. Review of RR# 8's record review revealed a discharge planning documentation form dated 14 days prior to discharge with documentation RR# 8's son signed the form. Further review of the record revealed a blank NOMNC with the son's signature dated approximately two months prior to discharge or one month prior to the Medical Director documenting RR# 8 was no longer meeting the hospice criteria for terminal illness. However, there was no documentation the daughter/POA was given a NOMNC with information on how to appeal the decision. This was reviewed, discussed, and validated with the Branch Director.