Every finding on record at Transitions Hospice Care of Georgia, Inc

This standard is NOT MET as evidenced by: Based on record reviews and interview, the hospice failed to ensure that Emergency Drills were accomplished every 2 years. --- The findings are: On 1/18/2024 at 9:00 AM, review of the hospice Emergency Preparedness training records for staff revealed no documentation of staff trainings. The Administrator verified the finding and stated, "They aren't in there as we have not done them."

This standard is NOT MET as evidenced by: Based on review of the hospice's Emergency Preparedness Program and interview, the hospice had no documentation of a community and facility-based risk drill(s). --- The findings are: On 1/18/24 at 10:00 AM, review of the hospice Emergency Preparedness Program revealed the hospice had no documentation of a community and facility-based drills. The finding was confirmed by the Facility Administrator in an interview on 1/18/2024 at 10:30 AM who stated, "They aren't in there as we haven't done them."

Based on record review and interview, the hospice failed to ensure the interdisciplinary group (IDG) collaborated in the development of the patient's comprehensive assessment and plan of care no later than 5 calendar days after the election of hospice care for eight of 14 patient records reviewed .(Patients #1, #4, #8, #9, #10, #11, #13, and #14) --- On 1/16/24 at 2:42 PM, review of Patient #1's record revealed Patient #1 elected hospice care on 6/17/21 with a diagnosis of End Stage Heart Failure. The first IDG meeting was on 6/30/21 which was 13 days after the patient's election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the patient's election of hospice care. On 1/17/24 at 11:52 AM, review of Patient #4's record revealed Patient #4 elected hospice care on 10/9/23 with a diagnosis of Cancer of the head, face, and neck. The first IDG meeting was on 10/17/23 which was eight days after the patient's election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 11:25 AM, review of Patient #8's record revealed Patient #8 elected hospice care on 3/10/23 with a diagnosis of Chronic Lymphocytic Leukemia. The first IDG meeting was on 3/22/23 which was 12 days after the patient's election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 12:54 PM, review of Patient #9's record revealed Patient #9 elected hospice care on 8/12/22 with a diagnosis of Alzheimer (a type of dementia). The first IDG meeting was on 8/23/22 which was 11 days after the patient's election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 2:02 PM, review of Patient #10's record revealed Patient #10 elected hospice care on 8/27/23 with a diagnosis of Alzheimer. The first IDG meeting was on 9/6/23 which was 10 days after the election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 2:58 PM, review of Patient #11's record revealed Patient #11 elected hospice care on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a lung disease). The first IDG meeting was on 5/31/23 which was 13 days after the patient's election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 4:14 PM, review of Patient #13's record revealed Patient #13 elected hospice care on 6/6/23 with a diagnosis of COPD. The first IDG meeting was on 6/14/23 which was eight days after the election of hospice care. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care. On 1/17/24 at 4:42 PM, review of Patient #14's record revealed Patient #14 elected hospice care on 10/6/23 with a diagnosis of Heart Disease and Chronic Kidney Disease. There was no documented evidence the IDG collaborated in the development of the patient's comprehensive assessment and plan of care within 5 calendar days after the election of hospice care.

This standard is NOT MET as evidenced by: Based upon record review and interview, patient medications in the home the patient is currently taking did not match with the facility's medication administration record (MAR). For 3 patients in 3 home visits the medications the patient is actually taking did not match with the list of medications the facility recorded (MAR). (Patients #5, #6, #7) --- The findings are: Record review on 1/17/24 at 9:00 AM is done for Patient #5 with an election date of 8/18/22 and a diagnosis of Chronic Heart Failure. This patient is NOT taking the following medications listed on the medication administration record: Trazadone 100 milligrams, AREDS 14, Ondansetron HCL 4 milligrams, Scopolamine patch, Lorazepam 1milligram, Bisacodyl supp, Ativan 0.5 milligram, Flonase 27.5 micrograms, Omeprazole 40 milligrams. The patient IS taking the following medications not listed on the medication administration record: Calcium 600 milligrams every day, Donepezil HCL 10 milligrams at bedtime, Lisinopril 20 milligrams every day, Lotrisone 1-0.05% twice per day, Meclizine HCL 12.5 milligrams as needed, Vitamin D3 5000 units daily, Eliquis 5 milligrams1/2 tab twice a day, Potassium Chloride 10 milliequivalents daily, Oxygen 3.5 liters nasal cannula. The Nurse in attendance at the home visit agrees on 1/16/24 at 9:30 AM the lists do not match. The Administrator confirmed this information in an interview on 1/18/24 at 9:30 AM. Record review on 1/17/24 at 9:45 AM is done for Patient #6 with an election date of 12/2/2022 and a diagnosis of End Stage Heart Failure. This patient is NOT taking the following medications listed on the medication administration record: Scopolamine patch. The Nurse in attendance at the home visit on 1/16/24 at 11:00 AM agrees that the lists do not match. The Administrator confirmed this information in an interview on 1/18/24 at 9:30 AM. Record review on 1/17/24 at 10:30 AM is done for Patient #7 with an election date of 11/16/2023 and a diagnosis of Chronic Obstructive Pulmonary Disease. This patient is NOT taking the following medications listed on the Medication Administration Record: Gabapentin 300 milligrams 3 times per day. The patient IS taking Tylenol which is not listed on the record. The Nurse in attendance at the home on 1/16/24 at 1:00 PM agrees that the lists do not match. The Administrator confirmed this information in an interview on 1/18/24 at 9:30 AM.

Based on record review and interview, the hospice failed to ensure an initial bereavement risk assessment was completed and incorporated into the plan of care for one of 14 patient records reviewed. (Patient #9) --- Findings: On 1/17/24 at 1:00 PM, review of Patient #9's record revealed Patient #9 was admitted on 8/12/22 with a diagnosis of Alzheimer. There was no documented evidence of an initial bereavement risk assessment. During an interview with the Administrator on 1/18/24 at 10:17 AM, he/she confirmed the findings.

Based on record review and interview, the hospice failed to ensure the plan of care included a detailed statement of the scope and frequency of services necessary to meet the specific patient and family need for six of 14 patient records reviewed (Patients #5, #6, #7, #12, #13, and #14). --- Record review is done on 1/16/24 at 2 PM for Patient #5 who has an election date of 8/18/22 and a diagnosis of Chronic Heart Failure. The visit frequencies are not defined at election of hospice or in initial Interdisciplinary Group meeting. Frequencies for the current period listed in the patient chart include a Home Health Aide (HHA) to visit twice a week (order dated 12/10/23), yet the Home Health Aide visited 3 times a week in weeks 2 & 5 without seeking additional orders from the physician or nurse. Record review is done on 1/16/24 at 2:30 PM for Patient #6 with an election date of 12/2/2022 and a diagnosis of End Stage Heart Failure. The visit frequencies are not defined at election of hospice or in initial Interdisciplinary Group meeting. Frequencies for the current period listed in the patient chart include Registered Nurse to visit once a week (order dated 12/4/23) yet the Registered Nurse visited 2 times a week in week 6 without seeking additional orders from the physician. Record review is done on 1/16/24 at 3:00 PM PM for Patient #7 with an election date of 11/16/2023 and a diagnosis of Chronic Obstructive Pulmonary Disease. The visit frequencies are not defined at election of hospice or in initial Interdisciplinary Group meeting. Frequencies for the current period listed in the patient chart include a Home Health Aide (HHA) to visit twice a week (order dated 12/13/23) yet the HHA made 0 visits in week 3 without missed visit notes or notification to the physician. The Registered Nurse (RN) is to visit twice a week yet visited only 1 time in week 1, 3 times in Week 4 and 4 times in week 5 without seeking additional orders from the physician. Findings: On 1/17/24 at 3:45 PM Patient #12's record was reviewed. Patient #12 was admitted to hospice care on 9/19/23 with a diagnosis of Cerebrovascular Accident (Stroke). The admission plan of care dated 9/19/23 did not include visit frequencies for the nurse, the social worker, the chaplain or the hospice aide. During an interview with the Administrator (ADM) on 1/18/24 at 10:53 AM he/she confirmed the findings. On 1/17/24 at 4:14 PM Patient #13's record was reviewed. Patient #13 was admitted to hospice care on 6/6/23 with a diagnosis of Chronic Obstructive Pulmonary Disease (disease of the lungs). The admission plan of care dated 6/6/23 did not include visit frequencies for the nurse, the social worker, the chaplain, or the hospice aide. During an interview with the ADM on 1/18/24 at 11:13 AM he/she confirmed the findings. On 1/17/24 at 4:42 PM Patient #14's record was reviewed. Patient #14 was admitted to hospice care on 10/6/23 with a diagnosis of Heart Disease and Chronic Kidney Disease. The admission plan of care dated 10/6/23 did not include visit frequencies for the nurse, the social worker or the hospice aide. During an interview with the ADM on 1/18/24 at 11:30 AM he/she confirmed the findings. On 1/18/24 review of the hospice's policy titled, "INTERDISCIPLINARY TEAM PLAN OF CARE" revealed, "...The Plan of Care will Contain...A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..."

Based on review of the hospice quality assessment and performance improvement (QAPI) documentation and interview, the hospice's governing body failed to provide oversight and approve the frequency and detail of the data collection. --- Findings: On 1/18/24 at 11:30 AM, the hospice QAPI documentation and a concurrent interview with the Administrator (ADM) that the ADM stated the Chief of Administration (COA) was the Governing Body (GB) oversight. There was no documented evidence the COA/GB provided oversight and approved the frequency and detail of the quality data collected. The ADM confirmed the findings. On 1/18/24, during review of the hospice policy, titled, "QUALITY MANAGEMENT, UTILIZATION AND PEER REVIEW," revealed, "...The Governing Body will appoint a Quality Assurance Coordinator to head this committee and to take responsibility for the quality management, utilization and peer review committee. The Quality Assurance Coordinator will insure the monitoring and evaluating the quality and level of patient care on an ongoing basis..."

Based on review of the hospice's documentation and interview, the hospice failed to track staff infections and failed to review and analyze staff and patient infections as part of the hospice's quality assessment and performance improvement program (QAPI). --- Findings: On 1/18/24 at 11:40 AM, the hospice QAPI documentation revealed there was no documented evidence of tracking patient or staff infections. During a concurrent interview with the Administrator (ADM) and the Assistant Administrator (AA), the AA stated the electronic medical record (EMR) software had a report of patient infections available. The report was viewed electronically with the AA. There was no documented evidence the patient infection report had been reviewed. During a concurrent interview with the ADM, he/she confirmed the patient infections report was not reviewed and the hospice did not track staff infections. The ADM confirmed the hospice did not review or analyze patient and staff infections or include any resulting findings in the hospice QAPI program. On 1/18/24, review of the hospice's policy, titled, "QUALITY MANAGEMENT, UTILIZATION AND PEER REVIEW," revealed, "...The following areas will be reviewed...Infection control practices and surveillance data..."

Based on record reviews and interview, the hospice failed to provide bereavement services for one of two bereavement patient records reviewed. (Patient #3) --- Findings: On 1/17/24 at 10:20 AM, review of Patient #3's record revealed Patient #3 was admitted on 11/10/22 with a diagnosis of End Stage Heart Failure and died on 1/19/23. There was no documented evidence the bereaved received bereavement services. During an interview with the Administrator on 1/18/24 at 9:36 AM, he/she confirmed the findings. On 1/18/24, review of the hospice's policy, titled, "BEREAVEMENT SERVICES," revealed, "...Within two (2) weeks of patient's death...Write sympathy card to those to be followed in bereavement...Complete bereavement assessment, establish the plan of care and create bereavement file...Within first month...Send condolence letter to each person identified on the bereavement assessment...Three months after date of death call/visit as appropriate. Send adjustment level letter...Nine months after date of death call/visit as appropriate. Send adjustment level letter...Twelve Months after date of death call/visit as appropriate. Send closure letter..."

Based on record reviews and interview, the hospice failed to ensure each patient's record included physician orders for four of 14 patient records reviewed. (Patient #1, #3, #9, and #10) --- Findings: On 1/16/24 at 2:42 PM, review of Patient #1's record revealed Patient #1 was admitted on 6/17/21 with a diagnosis of End Stage Heart Failure (ESHF). There was no documented evidence of physician orders at the time of admission including a physician order to admit, a diagnosis, the level of care the patient needed, which staff were to visit the patient, or the frequency of visits. During an interview with the Administrator (ADM) on 1/18/24 at 9:17 AM, he/she confirmed the findings. On 1/17/24 at 10:20 AM, review of Patient #3's record revealed Patient #3 was admitted on 11/10/22 with a diagnosis of ESHF. There was no documented evidence of physician orders at the time of admission, including an order to admit, a diagnosis, the level of care the patient needed, which staff were to visit the patient, or the frequency of visits. During an interview with the Administrator (ADM) on 1/18/24 at 9:36 AM, he/she confirmed the findings. On 1/17/24 at 12:54 PM, review of Patient #9's record revealed Patient #9 was admitted on 8/12/22 with a diagnosis of Alzheimer. There was no documented evidence of physician'orders at the time of admission, including an order to admit, a diagnosis, the level of care the patient needed, which staff were to visit the patient, or the frequency of visits. During an interview with the Administrator (ADM) on 1/18/24 at 10:10 AM, he/she confirmed the findings. On 1/17/24 at 2:02 PM, review of Patient #10's record revealed Patient #10 was admitted on 8/27/23 with a diagnosis of Alzheimer. There was no documented evidence of physician orders at the time of admission, including an order to admit, a diagnosis, the level of care the patient needed, which staff were to visit the patient, or the frequency of visits. During an interview with the Administrator (ADM) on 1/18/24 at 10:21 AM, he/she confirmed the findings. On 1/18/24, review of the hospice's policy, titled, "Medical Records", revealed, "...Each medical/clinical record will contain at least the following...Physician orders..."