Every finding on record at Compassionate Care Hospice of Northern Georgia, LLC

Upon patient record review, 1 of 14 (Patient #5) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals, interventions, and other pertinent data, 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 #5: The admission consent reflected that this patient had a Living Will and DPOA-Healthcare. A copy of the DPOA-Healthcare document was on file within the clinical record. However, the IDG POC dated 12/03/25, the initial 90-day POC, and the Aide POC all listed Advance Directives as, "Living Will", and did not include DPOA-Healthcare.

Upon patient record review, 1 of 14 (Patient #6) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #6: A verbal order obtained 11/16/25 listed, "Wound care BID to _________. Cleanse with warm water or equivalent wound cleanser, apply quarter-size Mupirocin ointment. May apply skin barrier to peri-wound." This Physician order was missing the location of the wound care to be provided.

Upon patient record review, 1 of 14 (Patient #1) did not contain a Plan of Care which included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During surveyor-attended home visit on 12/16/25 it was noted that the patient had the following DME: 1) Walker; and 2) Air Mattress. These DME/Supplies were not included on the Plan Of Care.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The POC dated 10/13/25 included, "SN to insert 18F/10cc balloon Foley." The SN visit note dated 10/28/25 documented that the nurse had inserted a 14F Coude catheter. Upon interview of the RN, she reported that she had contacted a physician via phone call during that home visit to obtain this foley-size change order, but had not transcribed that verbal order into a written order. This RN then entered a late entry into the clinical record, at the time of survey, to support this.

Upon patient record review 1 of 14 (Patient #2) did not contain evidence that the Hospice Aide had provided care/services that were: • Ordered by the Interdisciplinary Group • Included in the Plan of Care Patient #2: During surveyor-attended home visit on 12/16/25 the patient's daughter showed surveyor the tube of mupirocin ointment 2% that the hospice aide had applied to the patient's bottom area earlier that morning. The application of this ointment was not assigned on the aide plan of care.

Upon patient record review 1 of 14 (Patient #4) did not contain evidence that the Hospice Aides had reported: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a Registered Nurse, as the changes relate to the Plan of Care and quality assessment and improvement activities • Hospice Aides must also complete appropriate records in compliance with the Hospice's policies and procedures Patient #4: The aide POC assigned, "Date of last BM." The aide visit report dated 12/10/25 responded/documented to this assigned task as, "Not completed. Hasn't had a BM in a while. Taking something for it." There was no documentation located to indicate that the aide had reported this area of concern to the RN Case Manager.

Upon observation, there was not evidence of the annual report documenting the use of Volunteers, providing day to day administrative and/or direct patient care services, in an amount that at a minimum equaled 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. The Hospice's calendar-year 2024 Volunteer Report reflected a percentage of 0.99%.

Upon personnel record review, 1 of 14 (Personnel #8) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel initially during orientation: Personnel #8: DOH 09/03/2024. Her initial Skills Competency Assessment was not conducted until 02/11/2025. This personnel (MSW) had provided independent patient care/services prior to that.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that each patient record contains Advance Directives: Patient #10: The 08/01/25 admission consent reflected that this patient had an Advance Directive of, "D.N.R.". This Advance Directive was not filed within the clinical record.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Hospice had forwarded a Transfer Summary, and a copy of the patient record if requested, to a Medicare/Medicaid-certified facility when transferring the patient to that facility: Patient #11: Revoked on 07/17/25. There was no evidence that the Hospice had forwarded a Transfer Summary/document to the hospital to which the Hospice patient entered to seek aggressive treatment.

It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document review and interviews. 5 of 13 (38%) records reviewed revealed that this standard was not met as evidence by no goals or interventions for patient or family were documented on the plans of care. Agency policy AA-005 "Plan of Care" states in part, "The plan of care must reflect patient and 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, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care." Clinical Record 1: The patient was admitted to hospice services on 4/20/2021, with a diagnosis of Hypertensive Heart Disease. On the updated plan of care, dated 11/23/2022, a problem list had been identified by the RN, however, there was no evidence of interdisciplinary interventions or goals with measurable outcomes found. Clinical Record 2: The patient was admitted to hospice services on 5/12/2022, with a diagnosis of Cerebral Palsy. On the updated plans of care, dated 10/26/2022, 11/09/2022, 11/23/2022 and 12/07/2022, there was a patient/family problem list identified by the RN. There was no evidence of patient/family goals and interventions to be implemented by the interdisciplinary team. Clinical Record 7: The patient was admitted to hospice services on 11/14/2022, with a diagnosis of Chronic Obstructive Pulmonary Disease. On the updated plan of care, dated 11/23/2022, there was a problem list identified for the patient. There was no evidence of measurable goals and interventions for the patient or family. Clinical Record 5: The patient was admitted to hospice services on 9/16/2022, with a diagnosis of Cerebral Vascular Disease. On the updated plans of care, dated 11/23/22 and 12/7/22, there was a problem list identified by the interdisciplinary team. There was no evidence of measurable goals or intervention for the patient or family. Clinical Record 12: The patient was admitted to hospice services on 4/19/2021. On the updated plans of care, dated 10/26/22, 11/09/22, 11/23/22, and 12/07/22, there was a problem list identified by the interdisciplinary team. There was no evidence on the plans of care of any measurable goals or interventions for the patient or family. In an interview and joint clinical record review with the Area Vice President of Clinical, it was verified that the plans of care, when updated in the interdisciplinary group meetings, were lacking measurable goals and interventions. Agency policy AA-005 Plan of Care states in part, "The plan of care must reflect patient and 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, including the following: Measurable outcomes anticipated from implementing and coordinating the plan of care." In an interview and joint clinical record review with the Area Vice President of Clinical it was verified that the plan of care when updated in the interdisciplinary group meetings was lacking measurable goals and interventions.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records and document review. 1 of 13 (8%) clinical records reviewed revealed that the agency failed to include a service discipline or visit frequency on the patient's plan of care. Agency policy AA-005 "Plan of Care", states in relevant parts, "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions." It also states, "The plan of care shall detail the scope and frequency of services needed to meet the needs of the patient and the patient's family." Clinical Record 2: The patient was admitted on 5/12/22 with a diagnosis of Cerebral Palsy. For the certification periods dated 5/12/22-8/9/22 and 8/10/22-11/7/22, respiratory therapy orders were entered as ordered by the doctor. There was no evidence of respiratory therapy or visit frequency listed on the plan of care Agency policy AA-005 Plan of Care, states in part, "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions." it also states, "The plan of care shall detail the scope and frequency of services needed to meet the needs of the patient and the patient's family."

It is required that the hospice provides nursing care under the supervision of a registered nurse. (L591) This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 13 (8%) clinical records reviewed revealed the agency failed to provide supervision of a licensed practical nurse in accordance with policy. Agency policy AA-015(a) "Supervision of Disciplines-RN/LPN" states in part, "The registered nurse must supervise the LPN/LVN every 30 days." Clinical Record 6: The patient was admitted on 7/7/22 with Senile Degeneration of the Brain. There was a visit made by an LPN on 8/16/2022. There was no documented evidence of a supervisory visit by a RN until after 9/27/2022. In an interview with the Area Vice President of Clinical, she verified that it is a requirement of the hospice for the RN to do a supervisory visit of the LPN every 30 days. Agency policy AA-015(a) Supervision of Disciplines-RN/LPN states in part, "the registered nurse must supervise the LPN/LVN every 30 days." in an interview with the Area Vice President of Clinical she verified that it is a requirement of the hospice for the RN to do a supervisory visit of the LPN every 30 days.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records, document review and interview. 2 of 13 (15%) records reviewed revealed that the agency failed to provide aide services when ordered by the interdisciplinary group. Agency policy TX0-16 "Non-Core Services-Hospice Aide and Homemaker Services" states in part, "The hospice shall provide hospice aide services that are ordered by the IDT, under the direction and supervision of a registered nurse." Clinical Record 2: During the initial certification period dated 5/12/2022-8/9/2022, the hospice aide visit frequency orders were 3 times a week for 12 weeks. There were missed aide visits on 6/24/2022 and 7/5/2022 with no documentation explaining why the visits were missed. In an interview with the Clinical Manger, it is the agency process to fill out a communication note in the patient's record that includes discipline, why the visit was missed, who it was reported to, and if it can be rescheduled. The communication notes written by aide on 6/24/2022 and 7/5/2022 did not include any of this information. Clinical Record 5: The patient was admitted to hospice services on 9/16/2022. In the clinical record, the aide documented missed visits on 10/27/2022 and 11/14/2022; there was no documented reason why the visits were missed and no evidence that the RN had been notified. In an interview with the Area VP of Clinical, she stated that the aides were required to put in a note that specifically states the reason why the visit was missed and who was notified. Agency policy TX0-16 Non-Core Services-Hospice Aide and Homemaker Services states in part, "The hospice shall provide hospice aide services that are ordered by the IDT, under the direction and supervision of a registered nurse." In an interview with the Area VP of Clinical she stated that the aides were required to put in a note that specifically states the reason way the visit was missed and who was notified.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records, document review and interview. 6 of 13 (46%) clinical records reviewed revealed that the hospice aides failed to report changes in the plan of care to registered nurse case manager. Agency policy TX-016 states in part, "Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities." Clinical Record 8: The patient was admitted on 11/01/2022 with a diagnosis of Cerebrovascular Disease. A shampoo for the patient and vital signs were assigned on the aide plan of care. A visit made on 11/07/22 documented the shampoo was not completed. A visit made on 11/25/22 documented that vital signs were not completed. There was no evidence in the clinical record that the registered nurse (RN) was notified of these uncompleted tasks on either visit. Clinical Record 7: During an aide visit on 11/22/2022, the aide documented "No assist with bath, shampoo, or skin and back care". On a visit made on 11/30/2022, the aide documented "no bath, oral care, shampoo, skin care or peri care done". On a visit completed on 12/6/2022, the aide documented "No bath or skin and back care". On the aide visit, made on 12/8/2022, the aide documented "no bath, oral care, shampoo, skin care or peri care done". On the aide visit made on 12/13/2022, the aide documented "No vital signs were done, no shampoo, skin care, peri care or barrier cream done". On the aide plan of care initiated by the RN, these tasks are assigned for every visit. There is no documentation in the patient record that the aide updated the RN that the tasks were not completed. Clinical Record 4: The patient was admitted on 11/23/2021 with a diagnosis of Malignant Neoplasm of the Left Breast. Hospice aide visits were ordered by the Interdisciplinary Team at a visit frequency of 2 times a week. The aide plan of care assigned vital signs, oral care, shampoo, and record last bowel movement every visit. For the aide visit made on 7/19/22 there was no heart rate recorded, no oral care completed, and no shampoo completed. There was no documentation that the RN was notified of uncompleted tasks. For the aide visit on 12/12/22 no oral care was completed. For the visit on 12/1/22 no temperature, blood pressure, heart rate, last bowel movement or shampoo was completed. For the visit on 11/1/22 no oral care or shampoo was completed. In the clinical record, there was no evidence found that the RN case manager was notified of the uncompleted tasks. Clinical Record 5: The patient was admitted on 9/16/2022 with a diagnosis of Cerebrovascular Disease. Aide visits were ordered on the plan of care at a visit frequency of 2 times a week. The aide plan of care assigned the tasks of vital signs, shave and oral care to be done every visit. On the visit made on 12/9/22 no shave was completed. On the visit on 12/6/22, no temperature, blood pressure respiration, or heart rate was documented. On the visit on 12/2/22, no shave was completed. And on the visit 12/13/22, no temperature, blood pressure, heart rate, shave or oral care were documented. There was no evidence found in the clinical record that the RN case manager was notified of uncompleted tasks. Clinical Record 10: The patient was admitted on 2/17/2022. Aide visits were ordered on the plan of care at a visit frequency of 1 time a week. Assigned on the aide plan of care was barrier cream, oral care, and nail care to be done every visit. On the visits made 5/17/22 and 5/10/22, no barrier cream was documented. On the visit made 6/16/22, no oral care or nail care were completed. And on the visit made on 6/7/22, no oral care or barrier cream were completed. There was no evidence in the clinical record that the uncompleted tasks had been reported to the RN case manager. In an interview and joint review of clinical records with the Area Vice President of Clinical, she verified that the aide is required to report any tasks not completed on the plan of care to the RN case manager. Agency policy TX-016 states in part, "Hospice aides must report changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities. In an interview and joint review of clinical records with the Area Vice President of Clinical she verified that the aide is required to report any tasks not completed on the plan of care should be reported to the RN case manager.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: 1. A copy of the hospice discharge summary; 2. The patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document review and interview. 1 of 3 (33%) applicable clinical records of discharged patients reviewed, revealed that the agency failed to send required documents to the community doctor upon discharge of patient from hospice services. Agency policy AA-013A states in relevant parts, "A copy of the discharge summary and the clinical record, if requested by the attending physician or receiving facility." Also, "When the patient is discharged to another organization, relevant medical information is provided to that agency and /or patient when requested." Clinical Record 10: The patient was admitted to hospice services on 2/17/2022. On 6/21/2022 the patient was discharged due to no longer being terminally ill. In a note dated 6/20/22 the social worker documented "The patient does have a relationship with her primary care doctor and this physician will be following the patient post-hospice discharge." There was no evidence found that the discharge summary or clinical record were sent to the primary care physician post-discharge of this patient. In an interview with the Office Manager and the Area Vice President of Clinical it was verified that the agency requires the discharge summary be sent to the new agency or community attending physician. Agency policy AA-013A states in part, "A copy of the discharge summary and the clinical record, if requested by the attending physician or receiving facility." Also, "When the patient is discharged to another organization, relevant medical information is provided to that agency and /or patient when requested." In an interview with the office manager and the Area Vice President of Clincical it was verified that the agency requires the discharge summary be sent to the new agency or community attending physician.