Every finding on record at Traditions Hospice of Lawrenceville, LLC

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not assess the risk related to oxygen tank storage. Observed in RRHV#2, the patient had two E-Oxygen cylinders and one M size portable oxygen cylinder standing upright and not within storage racks. This was validated with the Director of Patient Clinical Services who was present during the home visits.

Observed in Patient Home. In 2 of 2 home visits conducted, with a Skilled Nurse, the organization did not conduct a comprehensive physical reassessment to address individualized needs and ensure appropriate care was included in the care plan in accordance with organizational policy #PE.5, IX which states The patient will be reassessed throughout the course of care in order to identify and deliver the right care, treatment or services. The process includes: A. Collecting information about the patient's health history as well as physical, functional, and psychosocial status . . .. Observed in RRHV#1, and RRHV#2 the Registered Nurse did not complete a full skin assessment on both of the patients who were nutritionally compromised, had limited mobility, spent the majority of each day in bed and who were both incontinent. This was validated with the Director of Patient Clinical Services following the home visits.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization did not develop a written plan of care based on the patients' goals and timeframes. Identified during the record review session all goals in the nursing plans of care were without target dates. This was validated by the Administrator/Area Director of Operations who was present during the record review session.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization did not ensure that the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. For example, in the record review for RRHV#1, the patient had a diagnosis of CHF and Acute Respiratory Failure yet there was no care plan developed for Pulmonary or Respiratory. In RRHV#2 the patient had a diagnosis of COPD, yet there was no care plan developed for Pulmonary or Respiratory. In RRNHV#1, the patient had active symptoms of agitation and nausea & vomiting to which she was receiving medications for treatment, yet there was no care plan developed for agitation or GI symptom management. In RRNHV#3, the patient had a history of seizures and was being treated with anti-seizure medication yet there was no care plan developed for seizure or neurological symptoms. In RRNHV#4, the patient had a diagnosis of end-stage Alzheimer's Disease, was documented to be pocketing food/medications and choking, yet there was no care plan developed for Swallowing Difficulties/Choking or Aspiration Risk. In RRNHV#5 the patient had a diagnosis of Metastatic Colon Cancer and Traumatic Brain Injury with paraplegia, and was being treated with multiple Opioid pain medications, yet there was no care plan developed for Pain or Risk to Skin Integrity. In RRNHV#6 the patient was on multiple opioid pain medications, yet there was no care plan developed for Pain. In RRNHV#7 the patient had a diagnosis of Sequelae of Stoke with active seizures, yet there was no care plan developed for Seizure or Neurological Symptom Management. This was validated with the Administrator/Area Director of Operations who was present for the record review session.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not provide detailed and specific interventions to manage pain and symptoms. Identified during the record review for RRNHV#5 and RRNHV#6 the patients were each prescribed multiple pain medications without indicating a hierarchy of use. For example, in RRNHV#5, the patient was on Oxycodone HCL 5mg every 8 hours prn, and Morphine Sulfate 20 mg/1ml, 0.25 - 1 ml every 2 hours prn with no indication of which to use for what level of pain or which to administer first or second. In RRNHV#6, the patient was on Hydrocodone 5/325, 1 table 3 times daily as needed, and Morphine Sulfate 20mg/1 ml, 0.25 - 1 ml every 2 hours as needed without indication of which to use for what level of pain or to administer first or second. This was validated by the Administrator/Area Director of Operations who was present during the record review session.

Observed in Record Review. In 2 of 5 patient records reviewed, where the patient had Hospice Aide Services, appropriate instructions and precautions were not included on the Hospice Aide care plan. For example, in RRNHV#5 and RRNHV#6, the patients had active seizures yet there were no instructions or precautions regarding the risk of seizures on the Hospice Aide Plans. This was validated with the Administrator/Area Director of Operations who was present during the record review session.

Observed in Patient Home. In 1 of 3 home visits conducted, the patient record did not contain information that reflected the patient's care and treatment. Identified during the medication reconciliation process conducted during RRHV#2, the medication profile was inaccurate. The medication record did not include Isosorbide 60mg tablet daily, and Morphine Sulfate 20mg/ml oral solution. This was validated with the Director of Patient Clinical Services following the home visits conducted.

Observed in Tracer Activities. During the review of the patient Admission Booklet and supplemental documents, the Surveyor noted that there was no evidence that the organization's drug disposal policy was provided to the patients prior to controlled substances being added into the plan of care. According to the organization's policy PC.140, page 2, I. Upon admission the hospice will: A. Provide a copy of the written policies and procedures on the management and disposal of controlled to the patient or representative. This was validated with the Area Director of Operations.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR# 1 and RR# 3's patient records review it was noted the organization had not ensured the patients were reassessed as needed and per organizational policy Pain & Symptom Management PC134 that included pain will be reassessed by a nurse within a timely manner following initiation of a pain intervention. For example: review of RR# 1's plan of care revealed a wound care order for daily wound care to be performed by the skilled nursing facility nurses and monitored weekly by the hospice nurse. Further review of the plan of care revealed a Skilled Nurse (SN) frequency of weekly. Review of RR# 1's patient record revealed six out of seven SN visit notes with no wound monitoring documentation. Review of RR# 3’s patient record revealed a Skilled Nurse (SN) visit note with documentation RR# 3 had a pain level of 8/10 and the worst pain during the last 24 hours had been 10/10. Further review of the SN visit note revealed RR# 3 was instructed to increase the Tramadol to four times a day PRN as RR# 3 was using Tramadol two times a day PRN. Further review of the patient record revealed a new order for Norco 5/325mg PRN two days later. Further review of RR# 3’s patient record revealed the next SN visit note seven days after reporting a pain level of 8/10 and five days after initiating a pain intervention. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 7 of 7 active patient records review, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, and RR# 4's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and time frames required to meet those goals. For example: review of the seven of seven patient records revealed no time frames or inappropriate time frames to include 11 years to four months prior to the surveyor review of the record. Review of HV# 1, RR# 3, RR# 4,and RR# 2's plans of care revealed the same goal pain currently managed at a level acceptable to patient with no documentation of what an acceptable level is for each patient. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 3 of 11 patient records reviewed, During HV# 2's home observation, and RR# 4 and RR# 8’s patient records review it was noted the organization had not ensured the plans of care included medications and treatment necessary to meet the patient's needs. For example: during HV# 2's home observation an oxygen concentrator and portable E-tank were observed in the home. Review of the plan of care and medication profile revealed no documentation of oxygen. HV# 2's spouse stated it had been necessary for use on two occasions since admission to hospice. Review of RR# 8’s patient record revealed a Licensed Vocational Nurse (LVN) SN visit note with documentation the LVN attempted to place an indwelling foley catheter and was unsuccessful. Further review of RR# 8’s patient record revealed no physician order for an indwelling foley catheter. Review of RR# 4’s patient record revealed a physician order for oxygen at 2L with no indication on route such as face mask or nasal cannula. This was observed, discussed, and validated with the Branch Director.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 8's patient record review it was note the organization had not ensured the physician was notified when RR# 8 had a change in condition. For example: review of RR# 8's patient record revealed RR# 8 had sat on the toilet for over 24 hours and suffered swelling to the scrotum and a tear in the scrotum with bleeding. Further review of RR# 8's record revealed a SN visit note by the Licensed Vocational Nurse (LVN) the following day with documentation that an attempt to place a foley catheter was unsuccessful and Emergency Medical Services were called to assist with transferring so RR# 8 could stand up to urinate with no documentation the registered nurse (RN) or physician was notified. Review of the RN SN visit note dated and timed after the LVN visit note revealed documentation that RR# 8's family called to notify the RN of a fall and pressure wound on the buttock with no documentation the physician was notified. Further review of RR# 8's record revealed RR# 8 was transferred to the hospital three days after being found on the toilet and completed a revocation of hospice services. This was reviewed, discussed, and validated with the Branch Director

Observed in Patient Home. In 2 of 2 home visits conducted with vital sign equipment, During HV# 1 and HV# 3's home observations it was noted the organization had not ensured it implemented infection prevention and control activities when performing disinfection of medical devices. For example: during HV# 1's home observation the registered nurse (RN) was observed cleaning the B/P cuff, thermometer, and pulse oximetry with a Sani-cloth and placing the items immediately into a smaller bag with out following the contact/wet time as specified by the Sani-cloth manufacturers IFU. During HV# 3's home observation the RN was observed not following the organization's Bag Technique policy IC.60 that included disinfecting the equipment prior to returning the equipment in the bag. For example: the RN was observed placing the B/P cuff, pulse oximetry, and stethoscope into the nurse bag without disinfecting prior to placing them in the bag. This was observed, discussed, and validated with the Branch Director. Observed in Patient Home. In 2 of 3 home visits conducted, During HV# 1 and HV# 3's home observations it was noted the organization had not ensured staff performed hand hygiene consistent with the organization's policy Bag Technique IC.60 that included hand hygiene to be performed prior to entering the bag. For example: during HV# 1's home observation the registered nurse (RN) was observed cleaning the vital sign equipment with gloves and placing the equipment into the bag without removing gloves and performing hand hygiene. During HV# 3's home observation the RN was observed placing the vital sign equipment into the bag without performing hand hygiene prior to entering the bag. This was observed, discussed, and validated with the Branch Director.

Observed in HR File Review. In 2 of 2 Hospice Aide HR files reviewed, During HR# 3 and HR# 4's HR files review it was noted the organization had not ensured the Hospice Aides completed a competence evaluation of Hoyer lift transfer. For example: during HV# 3's home observation it was noted a Hoyer lift was present and HV# 3's spouse shared the Hoyer was used to transfer HV# 3 out of the bed. Review of HV# 3's patient record revealed both HR# 3 and HR# 4 provided Hospice aide services to include a shower. Review of both HR# 3 and HR# 4's HR file revealed no documentation of a Hoyer lift transfer competency evaluation. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 6 of 6 active patient records reviewed with hospice aide services, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 4's patient record review it was noted the organization had not ensured the registered nurse (RN) prepared complete written patient care instructions for the hospice aide. For example: review of RR# 1's patient record revealed RR# 1 had a stage IV pressure ulcer to the sacrum with a dressing. Review of RR# 1's hospice aide instructions revealed the task of shower. However, further review of RR# 1's written instructions revealed no documentation the patient had a wound dressing or what to do if the dressing got wet. Review of HV# 3's patient record revealed HV# 3 needed the use of a Hoyer lift for transfers. Review of HV# 3's hospice aide written instructions revealed the task of a shower. However, review of the hospice aide instructions revealed no documentation HV# 3 used a Hoyer lift. Review of HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 4's patient record revealed the use of oxygen as need or continuous. Review of the hospice aide written instructions revealed no documentation the patient used oxygen or oxygen precautions. This was reviewed, discussed, and validated with the Branch Director.

Observed in Record Review. In 2 of 6 active patient records reviewed with hospice aide services, During HV# 1 and HV# 3's patient records review it was noted the organization had not ensured the hospice aide provided services as ordered. For example: review of HV# 3's hospice aide written instructions revealed the task of documenting the date of the last BM. Review of HV# 3's patient record revealed no documentation of the date of the last BM in seven out of eight Hospice aide visit notes. During HV# 1's home observation HV# 1 shared she/he used oxygen continuously and only took it off during her shower with the hospice aide. Review of HV# 1's hospice aide written instructions revealed no documentation regarding if the oxygen could be removed. This was reviewed, discussed, and validated with the Branch Director

Observed in Patient Home. In 2 of 2 home visits conducted with Medication Review, During HV# 1 and HV# 3's home observation's it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: during HV# 1's medication review it was noted HV# 1 was receiving Chlorthalidone 25mg with potassium chloride ER 20 MEQ daily, vitamin D3, vitamin C, and vitamin B12. However, the medication profile did not have those medications. Review of HV# 1's patient record revealed Chlorthalidone and potassium chloride ER had been discontinued on start of care. HV# 1 shared she had taken both medications for shortness of breath and it had been effective. During HV# 3's medication review it was noted HV# 3 had an order for Dilaudid 1mg/mL liquid solution to administer 0.25 to 1 mL every 2 hours PRN for SOB or pain. However, review of the medications in the home revealed Morphine Sulfate 100mg/5mL solution to administer 0.25 mL every two hours for pain/SOB and no Dilaudid was in the home.This was observed, discussed, and validated with the Branch Director.

Based on record review and staff interview, it revealed Traditions Health failed to provide the required license for the Social Worker (SW) employed by the facility and licensure required by law to perform social work for hospice patients. --- Review of records revealed the agency employed a SW who did not have a license to perform social work for hospice patients as required by the state of Georgia. During an interview on 2/21/2023 at 11:00 a.m., the Clinical Supervisor confirmed the employed SW at the agency did not have a license for social work. During a phone interview on 2/22/2023 at 10:00 a.m. with the agency SW revealed she had a certification stating she was eligible to practice social work, although no document was produced for verification. The SW confirmed she did not have a license to perform social work for hospice patients as required by the state of Georgia.