Every finding on record at Goldencare Hospice & Palliative Care, LLC

Upon patient record review, 1 of 12 (Patient #5) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. #5-Patient was admitted on 08/08/24 for Stage IV lung cancer with metastasis. The record noted that the patient rated pain between 6-9, but no pain medication was ordered. On 08/11/24 the patient was discharged to a non-contracted hospital in respiratory distress and it was noted the patient was actively dying. The administrator stated that the medical director did not want to order pain medication until he could be sure that patient wasn't going to go the ER.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. #1,2,3,4,5,6,7,10,11 All referenced patient charts lack evidence of patient/family's involvement in the development of plan of care.

Upon patient record review 4 of 12 (Patient #2,3,4,10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. #2,3,4-There is no evidence that of a psychosocial assessment as part of the comprehensive assessment. #10-There is not evidence of a psychosocial or spiritual assessment as part of the comprehensive assessment.

Upon patient record review, 5 of 12 (Patient #1,3,4,5,7) 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 #1-The order for O2 2 lpm via NC prn to maintain O2 sats greater than 95% is not included on the medication profile. Remeron is listed twice, once for 7.5 mg q hs and then again for 15 mg tablets, take 7.5 mg q hs. There is a potential for duplication since both medications are listed as active. #3-The order for O2 2 lpm via NC is not included on the medication profile. #4-Albuterol HFA 1 puff q4h prn has no indication. #5-The order for O2 2-3 lpm via NC is not on the medication profile. The following topicals do not list a location for use: Clotrimazole .01mg 1% 1x day, Bacitracin 500u/gm topical 2x day, Triamcinolone 0.1% prn. The triamcinolone order also includes no indication. #7-The order for O2 2 lpm via NC for respiratory distress is not included on the medication profile.

Upon patient record review, 4 of 12 (Patient #4,5,6,10) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. #4- There is no evidence of a plan of care in the patient's chart. #5,6,10-The document titled plan of care only contains visit frequencies.

Upon patient record review, 1 of 12 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. #5-The record lacks evidence that the RN provided continuous assessment. The patient had no visits between admission and discharge. The patient went to the ER in respiratory distress and was admitted to the hospital actively dying per the record. The initial nursing assessment noted a stage 2 pressure ulcer with no specific details and no wound care orders.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. #1,2,3,4,5,6,7,10,11 - All referenced patient charts lack evidence that a plan of care was developed for the hospice to implement/follow.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. #1,2,3,4,5,6,7,10,11 - All referenced patient charts lack evidence of the patient and family had identified responsibilities on the plan of care.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect 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. #1,2,3,4,5,6,7,10,11 All patient charts lack evidence of patient/family goals and interventions based on problems identified in the assessments.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice and is used as part of the Hospice's QAPI program. #1,2,3,4,5,6,7,10,11 All referenced patient charts lack evidence of measurable outcomes.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. #1,2,3,4,6,7,10,11-All referenced patient charts lack evidence of medications listed as part of the plan of care orders. #5-There are no orders for the Stage 2 wound identified on the initial nursing assessment. In addition, there are no medications listed on the plan of care orders.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. #1,2,3,4,5,6,7,10,11- All referenced patient charts lack evidence of equipment and supplies as part of the plan of care.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence that the plan of care included IDG's documentation of the patient's or family's level of understanding, involvement and agreement with the plan of care. #1,2,3,4,5,6,7,10,11 All referenced patient charts lack evidence of the patient/family's level of understanding, involvement and agreement with the plan of care.

Upon patient record review, 9 of 12 (Patient #1,2,3,4,5,6,7,10,11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. #1,2,3,4,5,6,7,10,11 -All referenced patient charts lack a revised plan of care with updates and progress towards goals.

Upon patient record review, 1 of 12 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #1-The nursing frequency from the SOC to present is ordered for 1 x wk. SN visits on 12/1/24, 12/29/24, 02/16/25, 04/13/25, 04/20/25, 06/01/25, 06/08/25 were all made via video call with no telehealth orders. The visits from 2/16 and 6/1 noted a missed visit within the same week for "transportation and weather issues."

Upon observation and home visits, 1 of 1 (Patient #1), there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. #1-Nurse did not perform hand hygiene prior to touching patient or prior to entering her nursing bag to remove equipment.

Upon patient record review, 3 of 12 (Patient #10,11,12) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. #10,11,12-There is no evidence of a bereavement plan of care. There are handwritten monthly reports that state the bereaved declined services.

Upon patient record review 1 of 12 (Patient #7) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training #7-Aide visits are ordered 3x week on plan of care dated 09/11/23. There is no evidence that any aide visits were completed.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency demonstrated a lack of administrative oversight as evidenced by the absence of individualized plans of care for each patient, a failure of the medical director to provide effective oversight and direction of pain and symptom management, incomplete election of benefit forms, and an overall deficiency in organizational supervision and accountability.

Upon personnel record review, 1 of 11 (Personnel #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. #9-The MSW skills assessment dated 6/19/24 is not conducted by a peer, it is a self assessment.

Upon patient record review, 1 of 12 (Patient #2) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness #2-There is no evidence of physician narrative in the patient's chart.

Upon patient record review, 3 of 12 (Patient #3,4,6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 #3-Date of election on EOB is blank. #4-Date of election on EOB is blank and is not signed by the patient/caregiver or hospice representative. #6-Date of election on EOB is blank.

Upon personnel record review, 1 of 11 (Personnel #7) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. #7 There was no OT file for review at survey, unable to verify a licensed Occupational Therapist.

Upon personnel record review, 1 of 11 (Personnel #7) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. #7 There was no OT file for review at survey to provide evidence of a criminal background check being completed.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The administrator on the current organizational chart was not updated with the state of GA between surveys.

Upon observation, there was no evidence the Emergency Preparedness plan: • Was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care

Upon patient record review 1 of 5 (Patient #2) did not have evidence that the hospice Registered Nurse completed an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #2: The patient was admitted on 12/17/2021, however, the RN initial assessment was not completed until 12/20/2021.

Upon patient record review, 5 of 5 (Patients #1 - #5 ) 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 #1: The patient was admitted on 12/1/2021, and the drug review was not conducted until 3/10/2022. On 1/18/2022, the RN documented the use of nebulizers twice a day and on 3/11/2022, the RN documented that "Tylenol had been given by the spouse." Neither the nebulizer or the Tylenol was listed on the Medication Profile. Patient #2: The patient was admitted on 12/17/2021, and the drug review was not conducted until 3/10/2022. During the Surveyor home visit, the medications were reviewed. The medication bottle lists the medication Seroquel as a PRN medication. The instructions on the medication profile state to give 1x day at HS. An updated care plan dated 12/29/2021, listed using Norco, prior to the Aide providing care. Norco was not listed on the Medication Profile. Patient #3: The patient was admitted on 11/3/2021, and the drug review was not conducted until 3/10/2022. During the Surveyor home visits, the following discrepancies were noted: Metformin was listed on the Medication Profile as 1000mg one time a day, however the bottle listed the dose as twice a day. Vitamin D and Hydroxyzine was not listed on the Medication Profile. Levaquin had been used. The medication was not discontinued on the Medication Profile. Lorazepam was scheduled at TID. On the Medication Profile the medication was given "hs and PRN". Patient #4: The patient was admitted on 12/20/2021, and the drug review was not conducted until 3/10/2022. Patient #5: The patient was admitted on 1/20/2022, and the drug review was not conducted until 3/10/2022. On a Nursing note dated 1/25/2022, the Nurse documented in the care coordination with the Aide "the use of mat and nebulizer Rx". There was no nebulizer listed on the Medication Profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 5 (Patient #1, #2 and #4) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: Medications were reviewed on 3/10/2022 with a fax cover sheet from the Pharmacy, listing "Potentially Inappropriate Medication and Drug Interactions" with the "risk of major bleeding" from ASA and Eliquis. On the document the RN Administrator had written "will review in IDG on 3/23/2022. There was no documentation to indicate the RN made the Physician aware of the medication risk nor was it discussed in IDG on 3/23/2022. Patient #2: Although the Aide had documented several times since 12/21/2021 the need for the patient's toenails to be cut, there was no documentation to indicate the RN followed up until 3/23/2022. Patient #4: The Medications were reviewed on 3/10/2022 with a fax cover sheet from the Pharmacy, listing "Potentially Inappropriate Medication and Drug Interactions" with the statement, "Older adults have increased sensitivity to Temazepam, benzodiazepines, increase risk of cognitive impairment, delirium, falls". On the document the RN Administrator had written "will review in IDG on 3/23/2022." Although the patient had several falls, There was no documentation to indicate the RN made the Physician aware of the medication risk nor was it discussed in IDG on 3/23/2022. A nursing note dated 2/14/2022 had documentation that included, ..."complained of pain in right knee upon standing. Unsteady. Doesn't bend the right knee. There was no documentation to indicate the RN informed the Physician of the change in the patient's condition. A PRN (due to fall) Nursing visit dated 2/17/2022, included documentation of ..."pulse ox at 88% on room air. Very lethargic. Dragging left foot today." Under the "Physician contacted" section, the Nurse wrote "will discuss fall at IDG on 2/23/2022". There was no documentation to indicate the Physician was made aware of the change of the patient's status.

Upon patient record review, 2 of 5 (Patients #2 and #4) did not have evidence in the patient record that the hospice had developed an individualized written plan of care for each patient. The plan of care must reflect 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 #2: The Gastrointestinal Status problem had been initiated on 1/12/2022 with the goal of "Patients nausea/vomiting will be controlled" There were no interventions listed. The Neurological Status problem had been initiated on 1/12/2022. There were no goals or interventions listed. The Integumentary problem was initiated on 1/12/2022 due to "back had reddened area and decreased skin turgor". There were no goals or interventions listed. The Terminal Care/Impending Death was initiated on 12/20/2021 and again on 1/12/2022. There were no goals listed at either time. Patient #4: The Neurological Status had been initiated on 12/29/2021 with the goals of "seizures will be controlled and patient will remain safe". There were no interventions listed. The Psychological/Mental/Emotional Status was initiated on 12/29/2021 with goals of "caregiver will demonstrate ability to cope, patient be maintained in safe environment and patients agitation will be controlled. There were no interventions listed. The Integumentary Status was initiated on 12/24/2021 with goals of "skin integrity will be maintained". There were no interventions listed.

Upon client record review, 4 of 5 (Patient #1, #2, #3, and #4) did not have evidence that the IDG ensured that the care and services were provided in accordance with the plan of care. Patient #1: The Medical Record contained an order dated 2/4/2022 to add an additional MSW (Medical Social Worker) visit for the month of February." There was no second MSW visit noted.The Medical Record contained an Initial Plan of Care which included orders for weekly Nursing visits. An extra routine Nursing visit was made during the week of 1/1/2022. The Medical Record contained an Initial Plan of Care which included orders for monthly Social Worker visits. There were two additional Social Work visits during the month of January. Patient #2: The Medical Record contained orders for weekly Nursing visits. Two routine visits were made during the week of 12/26/2021. Patient #3: The Medical Record contained orders for monthly Social Work visits. There was no Social Work visit conducted during the month of February. Patient #4: The Medical Record contained an order dated 1/26/2022 to ..."Please do pulse ox at each visit to check respiratory status..." The pulse ox was not assessed on the visit conducted on 4/6/2022.

Condition of Participation: Infection Control.

Upon patient record review, 1 of 5 (Patients #1) did not have evidence in the patient record that spiritual counseling was provided in accordance to the patient/family's desires. Patient #1: was to receive spiritual counseling 1 x month. Missed visit notes dated 1/31/2022 and 2/28/2022 stated ..."Chaplain has Covid. No visit this month. There was no documentation to indicate the Chaplain had attempted visits prior to the last day of each month to ensure the needs of the patient and family were met.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 3 of 5 (Patients #1, #2 and #4) did not have evidence in the patient record that the hospice aide assignments and duties were: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; 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 #1: On 12/1/2021, the Aide Care Plan was based on a visit frequency of 3 x week. The Aide frequency was increased to 5 x week on 3/15/2022. The Aide Care Plan was not updated to provide direction for the other two days. The Aide Care Plan dated 12/1/2021 had Aide visit frequency of 3 x week. The Aide Care Plan directed the Aide to provide both a shower and a bed bath 3 x week. Patient #2: On the Initial Nursing Assessment dated 12/20/2021, the RN documented that the patient has ..."difficulty chewing and swallowing..." Although the Aide had directions which included, "may syringe feed", there was no aspiration precautions listed on the Aide Care Plan. Patient #4: On 12/27/2021, the RN documented, ..."Isolated from HOH (hard of hearing) status. Reads lips. Use clear masks.." There was no documentation on the Aide Care Plan to ensure the Aide had been informed of the patients hard of hearing status, or of the need to wear a clear mask, to ensure the patient was able to communicate.

Upon patient record review 5 of 5 (Patients #1, #2, #3, #4 and #5) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: The Aide frequency was ordered at 3 x week. There was no documentation to indicate the Aide made any visits for the first two weeks. There was direction on the Aide Care Plan for ..."no lotion". The Aide documented the application of lotion on the visits conducted on 12/15/2021, 12/16/2021, 12/17/2021, 12/22/2021 and 12/23/2021. On the visits conducted on 12/29/2021, 12/30/2021 and 12/31/2021, the Aide documented the "provision of catheter care, measure catheter output and empty drainage bag and shaving". The patient had no catheter noted and the RN had not instructed the Aide to shave the patient. (d) On the visits conducted on 12/22/2021, 12/23/2021 and 12/24/2021, the Aide documented "preparing meals, laundry and shopping" The Nurse had not instructed the Aide to do those tasks. Patient #2: The Aide care plan dated 12/21/2021 directed the Aide to shampoo the patient's hair 2 x week. There was no documentation to indicate the task had been completed on the visits conducted on 12/21/2021, 12/28/2021, 1/4/2022, 1/11/2022 and 1/25/2022. On the visits conducted on 12/28/2021, 1/4/2022, 1/11/2022 and 1/25/2022, the Aide documented soaking the patient's feet. The RN had not directed the Aide to perform that task. Patient #3: The Aide care plan dated 11/3/2021, instructed the Aide to provide a shower 3 x week. There was no documentation to indicate a shower was given on the visits conducted on 4/4/2022, 4/6/2022 and 4/8/2022. On the visits conducted on 3/28/2022, 3/30/2022, and 4/1/2022, the Aide documented providing "passive range of motion." The RN had not directed the Aide to perform that task. Patient #4: The Aide Care Plan dated 12/20/2021, directed the Aide to perform tasks which included, ..."file and clean nails every visit." There was no nail care on the visits conducted on 12/28/2021, 1/11/2022, 1/18/2022, 1/25/2022, 2/1/2022 and 2/8/2022. Patient #5: The Aide frequency was ordered at 2 x week starting 1/20/2022. There was no documentation to indicate the Aide made any visits during the first week. There was direction on the Aide Care Plan for ..."shower every visit". The Aide documented that the patient "washes up on the toilet" on the Tuesday and Thursday visits.

Upon patient record review 2 of 5 (Patients #2 and #4) did not have evidence in the patient record that the hospice aides 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 • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #2: On the visits conducted on 2/1/2022, 2/3/2022, 2/8/2022, 2/10/2022 and 2/15/2022, the Aide documented a rash on the back. There was no documentation to indicate the Aide notified the RN. Patient #4: On 2/12/2022, the Aide documented, ..."ice to knee. Had a fall on 2/12/2022." There was no documentation to indicate the Aide notified the RN.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5: Had a start of care of 1/20/2022. There was no indication the Attending Physician provided verbal certification of terminal illness within 2 days of the patient electing hospice care. A fax cover sheet was sent to the Patient's Attending Physician, with the following statement ..."Please date form for start of Hospice 1/20/2022 and return to us asap." The fax cover sheet had been dated by the sender with a date of 2/1/2022.

Upon patient record review, 1 of 4 applicable (Patient #3) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #3: The Certification period of 3/2/2022-5/1/2022 contained no written documentation of the anticipated life expectancy of 6 months or less.

Upon patient client record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patients #1-#5: Had an Initial Bereavement Assessment in the record, however, the assessment was not dated nor signed in any record. Patient #3: Within the record, there were noted extra copies of the CNA notes that were already completed with the tasks the Aide was directed to complete based on the Aide Plan of Care. The only thing left for the Aide to fill out was the date she went and her signature. #4, Review of clinical record revealed several Aide notes that had been dated in advance of the visit being completed, including the dates of 4/12/2022, 4/19/2022, 4/26/2022, 5/3/2022, 5/10/2022 and 5/12/2022. The notes included checkmarks indicating tasks that were completed and each note was approved by the RN Administrator with a signature and date of 5/17/2022.

Upon personnel record review, 3 of 9 (Personnel # 6, 7, 8 ) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. #6, 7, 8 - these personnel were contract PT, OT,ST. The agency was not able to obtain credentialing information from the contracted agency.

Upon personnel record review, 1 of 1 applicable (Personnel #8) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #8: The agency was not able to obtain a personnel record from the contracted agency in order to determine the availability of a qualified Speech Therapist should a Physician order Therapy Services.

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #7: The agency was not able to obtain a personnel record from the contracted agency to evidence that a qualified Occupational Therapist was licensed in the State of Georgia was available should a Physician order Therapy Services.

Upon personnel record review, 1 of 1 applicable (Personnel #6) did not have evidence that all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #6: The agency was not able to obtain documentation from the contracted agency in order to determine qualifications of a Physical Therapist that was licensed in the State of Georgia should a Physician order Therapy Services.

Upon personnel record review, 3 of 4 applicable (Personnel #6, #7 and #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #6, #7 and #8: There was no evidence that a criminal background check had been conducted on at least one individual who could perform Physical, Occupational and Speech Therapy, should a Physician order therapy services to ensure the needs of the patient were met. The agency could not get a personnel file from the contracted agency.

Upon personnel record review, 3 of 11 (Personnel #6, #7 and #8) did not have documentation that all personnel had been fully vaccinated for the Covid-19. Personnel #6, #7 and #8: Failed to have documented proof that the COVID vaccination had been obtained on at least one individual who could perform Physical, Occupational and Speech Therapy, should a Physician order therapy services to ensure the needs of the patient were met. These staff were contract and the agency was unable to obtain a personnel record from the contracting agency. In addition, total percentage of all employees and contracted direct care employees remaining unvaccinated or without an approved exemption is 29%, which creates a likelihood of serious harm.