Every finding on record at Hospice of Fulton County, Inc.

Based on observations and staff interview during a Life Safety Code Standard Survey, on 10/21/2025, required fire resistance-rated construction was not maintained in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Chapter 19.1.3.3 requires that sections of health care facilities classified as other occupancies shall be separated from the health care occupancy by not less than two (2)-hour fire resistance-rated construction in accordance with Chapter 8.  Chapter 8 also requires that penetrations and miscellaneous openings to be sealed with materials equal to the fire resistance rating of the wall assembly.  Specifically, the permitted facility was not separated from the non-permitted administrative space with a 2-hour fire resistance-rated construction due to penetrations not being properly sealed.   This is evidenced as follows:During observations on 10/21/2025 at 12:30PM, an approximately 4-inch by 6-inch penetration in the fire barrier were found above the double fire doors in the main hallway to the resident rooms. During an interview on 10/21/2025 at 2:30 PM, Facilities Director #1 stated that they were unaware and will be sure it is patched and fire protected within next few days. New York Codes Rules and Regulations Title 10 §10NYCRR 415.29(a)(2), 711.2(a) 2012 NFPA 101: 19.1.3.3, 8.3

Based on observations, record review and interviews conducted during a Life Safety Code Standard Survey, on 10/21/2025, the facility did maintain automatic sprinkler components or inspections in accordance with 2012 National Fire Protection Association (NFPA) 101.This is evidenced by:   1)                  During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the dry sprinkler heads have not  been replaced  within the past ten (10) years as is required in accordance with National Fire Protection Association (NFPA) 25.2)                  During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the Quick Response(QR) sprinkler heads have not  been replaced  within the past twenty (20) years as is required in accordance with National Fire Protection Association (NFPA) 25.3)                  During record review on 10/212025 between 12:00pm and 2:00pm it was identified that the sprinkler system components were last inspected on 04/16/2024 which is not within the past one (1) year as is required in accordance with National Fire Protection Association (NFPA) 25.4)                  During record review on 10/212025 between 12:00pm and 2:00pm it was identified that, based on provided documents, the backflow preventors were last inspected on 11/14/2023 which is not within the past one (1) year as is required in accordance with National Fire Protection Association (NFPA) 25.During interview with Administrator #1 on 10/21/2025 at 2:30 pm it was stated that sprinkler company is scheduled for 2nd week this November but will try and push it to earlier. They will discuss with them the changing of the heads and will also be looking into other vendorsNew York Codes Rules and Regulations Title 10 §10NYCRR 415.29(a)(2), 711.2(a) 2012 NFPA 101: 9.752011 NFPA 25: 5.4.1.3,5.4.14,13.7.12010 NFPA 14: 6.4.5.12010 NFPA 13: 8.3.3, 21.4.2

Based on clinical record review and staff interview the hospice failed to ensure in six of six records (Patient # 1, 2, 3, 4, 5, and 6) an individualized and complete physician Plan of Care (POC) was developed to meet the needs of the patient. Failure to develop a patient specific individualized and complete plan of care has the potential to result in unmet patient needs and negative patient outcomes. --- Patient # 1 (start of care 07/13/2022) has diagnoses of Huntington's Disease and Complex Regional Pain Syndrome. The Physician's POC for certification period 05/09/2023 through 07/07/2023 contains orders for: Take 5-20 milligrams (mg) of morphine concentrate (100 mg/5 milliliters (mL)) by mouth Every 2 hours (hrs) as needed for pain or dyspnea Maximum Daily Dose (MDD) 12 mLs Dosage Form: solution. The order requires clarification as to how many milliliters of solution to give for each potential dosage of 5-20 mg and Apply 1 mg over 3 days of scopolamine base (Patch) topically Every 72 hours as needed for secretions Dosage Form: patch 3 day. The order requires clarification as to how many mg is in each patch and what dosage form patch 3 day is. Patient # 2 (start of care 04/26/2023) has diagnoses of Chronic Kidney Disease, Stage 4 (Severe). The Physician's POC for certification period 04/26/2023 through 07/24/2023 contains an order for: Take 5-20 mg of morphine concentrate (100mg/5mL (20mg/mL) solution by mouth every 2 hrs as needed for pain/dyspnea Dosage form: solution Medication Indication: Dyspnea, Pain. [MDD 12 mLs}. The order requires clarification as to how many milliliters of solution to give for each potential dosage of 5-20 mg. Also, the Registered Nurse (RN) Admission Assessment (dated 04/26/2023) states the patient has past medical history of Diabetes, Hypertension (HTN), Transient Ischemic Attack (TIA), Chronic Pulmonary Heart Disease and Chronic Obstructive Lung Disease. The POC is incomplete as it does not contain these diagnoses. Patient # 3 (start of care 07/07/2023) has diagnoses of Unspecified Cirrhosis of Liver and Hepatic Failure, Unspecified without Coma. The Physician's POC for certification period 07/07/2023 through 10/04/2023 contains an order for: Give 5-20 mg of morphine concentrate (20mg/mL) by mouth every 2 hrs as needed for pain or shortness of breath. MDD 12 mLs. Dosage Form: solution. The order requires clarification as to how many milliliters of solution to give for each potential dosage of 5-20 mg. Patient # 4 (start of care 06/09/2023) has diagnoses of Unspecified Severe Protein-Calorie Malnutrition. The Physician's POC for certification period 06/09/2023 through 09/06/2023 contains orders for: Apply 1 adhesive patch, medicated of lidocaine (5% patch) topically Daily. Apply to left knee in the morning for Osteoarthritis (OA) pain-remove as scheduled. Dosage form: adhesive patch, medicated. The order is incomplete as it does not direct the patient when to remove the patch and Take 1000 micrograms (mcg) of cyanocobalamin (vitamin B-12) (cyanocobalamin (vit B-12) 100 mcg/mL solution) by injection every 30 days- for vit b 12 deficiency. Dosage Form: solution. The order is incomplete as it does not state what kind of injection to use to deliver the medication: intramuscular, subcutaneous, intravenous or intradermal. Also, the RN Admission Assessment (dated 06/09/2023) states the patient has additional diagnoses of: Coronary Artery Disease (CAD), Hyperlipidemia (HLD), Gastroesophageal Reflux Disease (GERD), Cardiovascular Accident (CVA) without (w/o) residual and TIA's. The POC is incomplete as it does not include these diagnoses. Patient # 5 (start of care 12/28/2022) has diagnoses of Pulmonary Fibrosis and Anxiety Disorder. The Physician's POC for certification period 06/26/2023 through 08/24/2023 contains orders for: Apply 1-2 mg over 3 days of scopolamine base (Patch) topically Every 72 hrs as Needed for terminal secretions-MDD 2 patches over 3 days. Dosage Form: patch 3 day. The order requires clarification as to how many milligrams of medication is in each patch, how many potential patches should be applied, then removed and when; Inhale 1 actuation of fluticasone propionate (50mcg/actuation spray, suspension) into nostril Daily as Needed. for allergy symptoms (sx)-MDD 2 sprays. Dosage Form: spray, suspension. The order requires clarification as to which nostril, or both to apply the medication and whether to give 2 sprays in each nostril or one spray in each nostril and Inhale 1 vial of solution for nebulization Every 4 hrs as Needed for shortness of breath-MDD 6 doses. Dosage Form: solution for nebulization. The order is incomplete as it does not state what medication/solution is to be used for nebulization. Patient # 6 (start of care 03/23/2023) has diagnoses of Other Frontotemporal Neurocognitive Disorder and Insomnia. The Physician's POC for certification period 06/26/2023 through 08/24/2023 contains an order for: Take 5-20 mg of morphine (100 mg/5mL concentrate) by mouth Every 2 hrs as Needed. for pain/dyspnea MDD 12 mL Dosage Form: concentrate. The order requires clarification as to how many milliliters of solution to give for each potential dosage of 5-20 mg. The findings were confirmed on 07/11/2023 10:00 AM with the Chief Operations Officer/President, Clinical Director and Nurse Manager; no additional evidence was provided.

Based on clinical record review and staff interview, the hospice failed to ensure an initial bereavement risk assessment was conducted to identify the needs of the family and caregivers in three of three records reviewed for bereavement only (Bereavement only # 1, 2 and 3). Failure to conduct an initial bereavement risk assessment has the potential to result in unmet family and caregiver needs and may inhibit the hospice's ability to develop a comprehensive bereavement plan of care. --- Bereavement only # 1 (start of care 01/27/2022, date of death 01/28/2022). The record (reviewed on 11/10/2022) lacks documented evidence an initial bereavement risk assessment was conducted. Bereavement only # 2 (start of care 01/24/2022, date of death 03/20/2022). The record (reviewed on 11/10/2022) lacks documented evidence an initial bereavement risk assessment was conducted. Bereavement only # 2 (start of care 06/15/2022, date of death 06/16/2022). The record (reviewed on 11/10/2022) lacks documented evidence an initial bereavement risk assessment was conducted. In an interview conducted with the Clinical Director on 11/09/2022 at 2:30 PM, the Clinical Director stated she thought it was the responsibility of the Medical Social Worker to conduct the bereavement assessment. Further, the on-going bereavement activities do not include all family members, care givers and social support (Bereavement only # 1 - 3) that were identified in the Registered Nurse initial assessment as caring for or providing support to the patients. The findings were confirmed on 11/10/2022 at 8:30 AM with the Clinical Director and the Medical Social Worker; no additional evidence was provided.

Based on clinical record review and staff interview the hospice failed to ensure in five of thirteen records (Patient # 1, 2, 5, 7, and 11) an individualized and complete physician Plan of Care (POC) was developed to meet the needs of the patient. Failure to develop a patient specific individualized and complete plan of care has the potential to result in unmet patient needs and negative patient outcomes. --- Patient # 1 (start of care 12/21/2021) has diagnoses of Malignant Neoplasm of Prostate and Secondary Malignant Neoplasm of Bone. The Physician's POC for certification period 10/17/2022 through 12/15/2022 contains orders for: -Oxygen: Start Oxygen Concentrator at 2 liters to 5 liters per minute continuously and an order for Oxygen 2-4 liters via nasal cannula or mask per concentrator or back up tank; Dyspnea. The orders require clarification as to which liters per minute order is correct: 2-5 liters per minute or 2-4 liters per minute. Also, the POC is incomplete as it is lacking Oxygen precautions. Patient # 2 (start of care 10/06/2022) has diagnosis of Secondary Malignant Neoplasm of Brain. The Physician's POC for certification period 10/06/2022 through 01/03/2023 that contains an order: Take 81 milligrams (mg) of Aspirin (81 mg tablet) by mouth daily. The POC is incomplete as it is lacking bleeding precautions. Patient # 5 (start of care 10/13/2022) has diagnoses of Malignant Neoplasm of Cecum and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. The POC for certification period 10/13/2022 through 01/10/2023 contains the following orders: Take 5 mg of Eliquis (5mg tablet) by mouth every 12 hours. The POC is incomplete as it is lacking Bleeding Precautions, and Oxygen: Start Oxygen nasal cannula at 2 liters to 4 liters per minute as needed (PRN). The POC is incomplete as it is lacking Oxygen Precautions. Patient # 7 (start of care 05/19/2022 and discharged on 09/14/2022) has diagnoses of Unspecified Protein-Calorie Malnutrition and Urinary Tract Infection, Site Not Specified. The POC for certification period 08/17/2022 through 11/14/2022 contains an order for: Oxygen 2-4 liters via nasal cannula or mask as needed per concentrator or back up tank. The POC is incomplete as it is lacking Oxygen Precautions. Patient # 11 (start of care 09/19/2022) has diagnoses of Chronic Obstructive Pulmonary Disease, Unspecified and Other Nonspecific Abnormal Finding of Lung Field. The record contains a POC for certification period 09/19/2022 through 12/17/2022 and a RN Admission Assessment dated 09/19/2022. The RN assessment documents the patient has "Dysphagia", "becomes very fatigued very easily" and has "weakness". The POC is incomplete as it is lacking Aspiration and Fall Precautions. The findings were confirmed on 11/08/2022 at 1:40 PM and 3:20 PM, at 11/09/2022 at 11:00 AM and 3:50 PM, and at 11/10/2022 at 11:05 AM with the Clinical Director; no additional evidence was provided.

Based on review of the hospice's infection control policies and procedures and interview with the hospice President/Chief Executive Officer (CEO), evidence is lacking the hospice has ensured the development of a comprehensive infection control program that protects patients, families, visitors and hospice personnel by preventing and controlling infections and communicable disease. Failure to develop a comprehensive infection control program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes and adversely affect hospice operations. --- The hospice's infection control policies and procedures were reviewed on 11/07/2022. The policies and procedures fail to include specific guidelines on caring for patients with Multi-drug resistant organisms The finding was confirmed on 11/07/2020 at 12:50 pm with the President/Chief Executive Officer; no additional evidence was provided.

Based on clinical record review and staff interview the hospice failed to ensure in one out of thirteen records (Patient # 1) care and services are provided in accordance with the aide Plan Of Care (POC). Failure to provide care in accordance with the patient's established plan of care has the potential to result in inappropriate care, unmet patient needs and negative patient outcomes. --- Findings: Patient # 1 (start of care 12/21/2021) has diagnoses of Malignant Neoplasm of Prostate and Secondary Malignant Neoplasm of Bone. The Plan of Care (POC) for certification period 10/17/2022 through 12/15/2022 states the patient is to have a Home Health Aide (HHA) visit daily. The record contains a HHA Care Note (aide plan of care) dated 09/19/2022 that states the patient is to receive assistance with the following tasks every visit: Bed bath/partial bed bath/chair bath/shower; Foot Care; Dressing and Documentation of any Durable Medical Equipment (DME) used: Beside Commode, Hospital Bed, Side Rails, Wheelchair, Shower Chair/Bench. The record is lacking documented evidence these tasks were completed on the following dates: 10/09/2022, 10/17/2022, 10/29/2022 and 11/06/2022. The finding was confirmed on 11/08/2022 at 1:40 PM with the Clinical Director; no additional evidence was provided.