Every finding on record at John D. Archbold Memorial Hospital, Inc.

Based on review of policies and procedures, and staff interview, it was determined the governing body failed to assume responsibility for all hospice services and continuous quality assessment and performance improvement (QAPI). Specifically, the agency failed to document all complaints/grievances including a grievance/complaint log to review trends, outcomes and performance improvement opportunities. --- Findings included: Review of policy titled, “[Name] ADMINISTRATIVE POLICY MANUAL Customer Concerns and Grievances,” POLICY NUMBER: 101.11 revised March 2023, was related to the hospital customer concerns and grievances, not hospice. Review of policy titled ” Board of Directors,” revised January 2026 revealed the following:“Policy:The [Name] Board of Directors is the Governing body for Hospice of Southwest Georgia.The function of the Board of Directors includes overseeing Archbold Hospice operations, approval of annual budget, review and input into improvement activities.” An in-person interview was conducted on 03/04/2026 at 9:45 AM with the Administrator, and the Administrator revealed when a hospice complaint is received it is entered into the hospital occurrence reporting system (RLDATIX), by the Quality Improvement coordinator, and the risk management at the hospital follows up on the complaints received.The Administrator explained that all hospice complaints/grievances are added to the hospital’s complaints/grievances. The Administrator provided a hospice logbook dated 2021. The Administrator further stated they did not have a current and up-to-date log of hospice complaints with resolutions. The Administrator confirmed they stopped recording complaints in the logbook when the hospital started the online process (RLDATIX). Administrator reported that during the process of trying to compile a list of the hospice complaints for this survey, the conclusion was there was a “glitch” in the system, and the hospice complaints were unable to be provided. A current hospice complaint log with resolutions was requested but not provided at the time of the survey exit conference.

Observed in Record Review. In 3 of 6 patient records reviewed, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. For example, a review of the Hospice Election Form [RRHV#2] revealed no documented evidence that at the time of admission a discussion related to the Hospice Election Statement Addendum and whether or not it was requested was completed. Example #2: A review of the medical record for RRHV#1, revealed that at the time of admission the patient's caregiver requested to receive the form titled Patient Notification of Hospice Non-Covered items, Services, and Drugs. The patient's medication profile revealed that the following medications were not covered by the Hospice benefit: Amlodipine, and Atorvastatin. There was no documented evidence that the patient's caregiver was provided with the document within three days of the request. Example #3: A review of the medical record for HosInpt#2, revealed that at the time of admission the patient's caregiver requested to receive the form titled Patient Notification of Hospice Non-Covered items, Services, and Drugs. The patient's medication profile revealed that the following medications were not covered by the Hospice benefit: Aspirin, Cyanocobalamin, Farxiga, and Finasteride. There was no documented evidence that the patient's caregiver was provided with the document within three days of the request. This observation was reviewed with agency leadership.

Observed in Record Review. In 5 of 16 patient records, it was noted that the organization did not ensure goals were individualized to the patient’s needs and condition. For example, during a review of the medical record for RRHV#2, the following goal statement(s) were noted: “Patient able to identify and avoid fatigue, stressors, and excessive activity; and Patient will be pain free or verbalize an acceptable pain level with current pain management regimen. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. Example #2: During a review of the medical record for RRHV#1, the following goal statement was noted: “Patient/caregiver will verbalize understanding of fall/injury prevention and home safety measures”. The stated timeframe of 12 weeks was not a realistic measurement to assess the patient/caregiver understanding of instruction and education related to maintaining patient safety, and strategies to prevent injury. Example #3: During a review of the medical record for HosInpt#1, the following goal statement related to the patient’s terminal illness diagnosis of End Stage Heart Failure was noted: “Patient's symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow”. The goal statement did not include a method to measure the effectiveness of problem interventions. The stated timeframe of 90 days was not a realistic measurement to assess the management of symptoms related to End Stage Heart Failure. Example #4: During a review of the medical record RRHV#4, the following goal statement was noted: “Patient caregiver can describe measures – maintain adequate nutrition/hydration.” The stated timeframe of 90 days was not a realistic measurement to assess the implementation of measures to maintain adequate nutrition/hydration. Example #5: During a review of the medical record for RRNHV#2, the following goal statement related to the patient’s terminal illness diagnosis of Pneumonitis due to aspiration of food and vomit was noted: “Patient's nutritional needs will be met as patient's condition/comfort allows”. The goal statement did not include a method to measure the effectiveness of problem interventions. The stated timeframe of 90 days was not a realistic measurement to assess the management of nutritional needs. This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 16 patient's records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, during a review of the plan of care for RRHV#2, the following goal statement(s) were noted: “Patient able to identify and avoid fatigue, stressors, and excessive activity; Patient will be pain free or verbalize an acceptable pain level with current pain management regimen; and Patient/caregiver demonstrate proper administration of oxygen”. The plan of care did not include interventions to educate the patient and caregiver on measures to address avoiding fatigue, stressors, and excessive activity; pain management regimen; and oxygen safety. Example #2: During a review of the medical record for RRHV#1, the following goal statements were noted: “Patient able to eat/drink to his/her satisfaction; and “Patient/caregiver will verbalize understanding of fall/injury prevention and home safety measures”. The plan of care did not include interventions to educate the patient and caregiver on measures to address the patient’s nutritional needs; fall/injury prevention, and home safety measures. Example #3: During a review of the medical record RRHV#4, the following goal statement was noted: “Patient caregiver can describe measures – maintain adequate nutrition/hydration.” The plan of care did not include interventions to educate the patient and caregiver on measures to maintain adequate nutrition/hydration. Example #4: During a review of the medical record for RRNHV#2, the following goal statement related to the patient’s terminal illness diagnosis of Pneumonitis due to aspiration of food and vomit was noted: “Patient's nutritional needs will be met as patient's condition/comfort allows”. The plan of care did not include interventions to educate the patient and caregiver on measures to address the patient’s nutritional needs. This observation was reviewed with agency leadership.

Observed in Data Session. It was noted that the goal for the achievement of the Hospice quality measures (ie pain assessment, bowel regimen, etc) was set by the organization to be 97% in 2024; However, no changes were made to the QAPI project after the organization's data collection indicated that the percentage achieved was 85% not meeting the established goal of 97% for this project. This issu was validated with the Hospice QAPI director and Hospice management at the time of the survey.

Observed in Data Session. During review in the QAPI session of the data collected in 2023, the HOSPICE pharmacist surveyor noted that the organization had not developed and documented what performance improvement projects were being conducted, the reasons for conducting these projects, and the measurable progress achieved. This omission was validated with the QAPI cordinator and Hospice management at the time of the survey.

Observed in Building Tour. It was observed in the Hospice electrical room that there was spray on fire proofing missing from the structural beam. This was verified Senior Director of Engineering. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: