Every finding on record at Hearth Healthcare of Georgia, LLC Hearth Healthcare of Georgia, LLC

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the patient chooses a health care provider, including an attending physician Patient #1: Patient admitted 4/30/25. Hospice Election Statement includes patient's choice of physician as Rosewood Facility, not specifying choice.

Upon patient record review, 3 of 19 (Patient #2, 4, 11) 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 #2: Hospice medication profile includes Levothyroxine daily, Nystatin Powder, Ondansetron, Morphine and Ativan, however the SNF medication profile does not. Patient #4: Hospice medication profile includes Aspirin daily for anticoagulation. Patient daughter reports Aspirin is on hold since incident of bleeding There is no indication on hospice medication profile/orders to hold aspirin. Patient # 11: Facility medication profile includes Omeprazole, however hospice medication profile does not.

Upon patient record review, 2 of 19 (Patient #8, 13) 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 #8: Patient admitted 3/26/25 with right side abdominal wound. There were no documented wound measurements for SN visits of right abdominal wound: April 10, 17, 21, 24, 28, May 1, 5, 9, 13. Patient #13: Patient admitted 3/3/25 with Stage 2 Pressure Ulcer rt posterior thigh and SN frequency of 2x/week. The only wound measurement in March was 3/24/25.

Upon patient record review, 3 of 19 (Patient #4, 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. Patient #4: During home visit, patient daughter reports Aspirin is on hold since incident of bleeding. There is no evidence of orders to hold aspirin. Patient #10: 3/18/25 order to change catheter every 30 days and as needed. Circumstances for change are not specified. Patient # 11: Facility medication profile includes Omeprazole, however hospice medication did not have order for this medication.

Upon patient record review, 1 of 19 (Patient #13) 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. Patient #13: Patient admitted 3/3/25 with urinary catheter. Problems, goals and interventions included catheter inserted 3/1/25 with order to change 4/1/25. Catheter was actually changed 3/28/25 and 5/1/25 with no update to interventions. Patient was also treated with antibiotic 4/28/25 related to cellulitis with no updated to problems, goals and interventions.

Upon client record review, 3 of 19 (Patient #5, 11, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: Record includes documented volunteer visits 4/15 and 4/21/25 with no order for service. Patient #11: SC frequency 3/13/25 of 1mo3. No documented visit for April. Patient #13 - Patient admitted with indwelling catheter. Order stated Catheter last changed 3/1/25 with order to change 4/1/25. Catheter was actually changed 3/28/25 and 5/1/25 with no update to orders for those changes.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There is no evidence that 5% threshold is met. The agency has active performance improvement project involving volunteer hours with documented improvement.

Upon patient client record review, 1 of 19 (Patient #1) 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 Patient #1: Patient admitted 4/30/25. Hospice Election Statement includes patient's choice of physician as Rosewood Facility, not specifying facility physician choice.

Upon patient client record review, 1 of 19 (Patient #1) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #1: Patient admitted 4/30/25. Hospice Election Statement includes patient's choice of physician as Rosewood Facility, not specifying which physician for facility . Furthermore, there is no evidence of any facility physician signed CTI for initial benefit period.

Upon patient client record review, 3 of 19 (Patient #3, 11, 12) 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. Patient #3: Record identifies patient advanced directive status as undecided, but there is a documented DNR dated 4/5/25. Patient #11: 5/8/25 SN visit nurse documented unable to obtain INR today d/t lack of adequate specimen. There is no specific documentation as to procedure performed. Patient #12: Patient admitted 2/12/25. Initial comprehensive RN documented aide supervisory visit completed, but, in fact the first aide visit was made 2/27/25.

Upon personnel record review, 1 of 14 (Personnel #14) 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.

Upon personnel record review, 1 of 19 (Personnel #14) 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 # 14: There is no evidence of Criminal Background Check

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. Current Program Director was hired December 2024. The change has reportedly been submitted, but there is no evidence available to surveyor by end of survey, that change was submitted within 30 days.