Every finding on record at The VI and Milton Weinstein Hospice, Inc

Based on policy titled “ EMERGENCY PREPAREDNESS POLICY LETTER,” facility document review and staff interview, it was determined that the agency failed to maintain documentation of all drills, tabletop exercises, and emergency events after action review and revise the hospice's emergency plan, as needed. --- Findings included: Review of policy titled "Emergency Preparedness Policy Letter," with effective date January 2026 reveals the following:“Purpose:The policy establishes a comprehensive emergency preparedness program to ensure the safety and well-being of hospice patients, staff and volunteers, and to maintain continuity of care during emergencies or disasters affecting operations in Atlanta, Georgia service areaTraining and TestingAll training and exercises are documented and improvements are implemented based on after-action reviews.” Review of the agency's binder titled “Emergency Preparedness.” failed to reveal documentation of the components of the tabletop drills and after action review. The binder failed to reveal a group discussion using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. On 04/14/2026 at 11:30 AM, an office interview was conducted with the Clinical Manager (CM), who acknowledged responsibility for the agency’s disaster plan. The CM stated the agency conducted a tabletop drill on earthquakes on 01/15/2026 and active shooters 10/30/2025. The CM confirmed the agency failed to document the required documents of the table top drills and after action reviews of drills.

Based on record reviews, policy review, and staff interviews, it was determined that the agency Interdisciplinary Group (IDG) team failed to ensure that Master of Social Work (MSW) visits were provided as ordered in the plan of care (POC) for two patients (P) (P1 and P9) of 14 sampled records reviewed. --- Findings included: Review of the policy titled “Missed Visit Policy,” effective date 01/06/2026 revealed the following:“Purpose:To ensure all missed visits are appropriately manager, documented, and communicated in accordance with regulatory requirements, maintaining continuity of care and patient safetyPolicy StatementAll visits ordered on the patient's Plan of Care (POC) must be completed as scheduled. Any missed visits must be:1.         Justified with a valid reason2.         Documented on the same day3.         Communicated to appropriate team members4.         Addressed with a follow-up plan” 1. Review of the POC for P1 revealed the MSW was required to visit P1 two times a month starting 03/04/2026. The MSW failed to visit the patient the month of March. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. 2.  Review of the POC for P9 revealed MSW services were ordered two times a month for two months, two times for one month, then one time a month for one month effective 02/17/2026. The MSW failed to visit the patient the month of March. The clinical record failed to reveal documentation of a missed visit note with physician notification of the missed visits. The clinical record failed to reveal coordination of care with the interdisciplinary team to ensure the missed visits could be rescheduled to provide consistent care and services. During an in-office interview with the clinical manager (CM) on 04/15/2026 at 11:30 AM, who stated the MSW failed to complete the visits as ordered and did not complete a missed visit note as required. The CM confirmed this MSW is no longer employed with the agency and the current MSW is visiting the patients as ordered.

Based on policy titled “Patient Rights and Responsibilities,” record reviews and staff interviews, it was determined that the agency failed to follow physician's order for one patient (P) (P#1) of three patients reviewed. Specifically, Registered Nurse (RN) BB failed to provide the medication as ordered on the plan of care. --- Findings included: Review of the policy titled “Patient Rights and Responsibilities,” effective date September 2015, reveals the following:Purpose:To support and protect patient rights and meet state and regulatory requirements for patient rights.Policy: Hospice ensures that patients and families receive hospice services in a manner that respects and protects their dignity and ensures patients’ rights. Review of “Patient Face Sheet,” reveals P#1 with a start of care date 1/4/2025. Review of the plan of care and medication profile for P#1 revealed medication Morphine 20/mg/1ml oral solution; (an opioid used to treat severe pain) 0.25-1ml by mouth: or under tongue every 20 minutes until comfortable then 2-4 hour as needed for severe pain or SOB (shortness of breath). Review of pharmacy records revealed medications being delivered for P#1 on January 6, 2025, January 7, 2025, and January 9, 2025. Review of P#1 “Patient/Caregiver Communication,” dated 1/10/2025 at 4:55:22 PM reveals RN BB educated P#1 family member and primary care giver (PCG) about discomfort and educated /encouraged to administer Morphine, then gave 0.125 ml of Morphine as initial dose.  On December 15, 2025, during an in-person interview with Executive Director (ED), the ED was unable to provide any information regarding RN BB educating and not administering the correct dosage of Morphine per the physician orders and as noted on P#1 plan of care. However, ED revealed that RN BB was no longer employed with the agency. On December 15, 2025, at approximately 3:00 PM a telephone interview was conducted with pharmacy contracted with the agency, who confirmed that medications were delivered to P#1 on January 6, 2025, January 7, 2025, and January 9, 2025.

Based on review of policy titled “Complaint/Grievance Process,” record reviews, complaint log, and staff interview, it was determined that the agency failed to document a complaint/grievance for one patient (P) (P#1) of three sampled patients. --- Findings included: Review of policy titled "Grievance and Complaints,” revised September 2022, reveals the following:Purpose: To assure all patient-related grievances and complaints are resolved in a consistent and timely method.Policy: Patients and their representatives have the right to voice complaints and grievances regarding treatment or careIn the event of a patient related complaint, hospice identifies and resolves problems and uses the opportunity to improve patient care. All complaints are processed in a uniform and timely manner.Procedure:7. Complaints and any action taken are documented. Review of “Patient Face Sheet,” reveals P#1 start of care date 1/4/2025. Review of the complaint logs failed to reveal complaints related to P#1. On December 15, 2025, at approximately 10:30 a.m. during an in-office interview, the Executive Director (ED) of the agency acknowledged she is aware of a complaint. The ED stated that she received the complaint via certified mail. The ED revealed that P#1 mentioned in the complaint was no longer on services with the agency and had expired several months prior to receiving the complaint. Furthermore, the ED revealed that the complainant was not power of attorney (POA) of P#1 nor the family of P#1 and did not have legal authorization to act on behalf of the patient and family. The ED stated that due to the complainant not having the legal authority to act on behalf of P#1 and family and the P#1 no longer being on services with the agency and being expired, the ED was advised to not respond to the complaint.

Based on review of policy titled ”Governing Body and Administrator,” record reviews and staff interviews, it was determined that the agency failed to ensure that a governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice. Specifically, the agency failed to ensure that the governing body is responsible for the day-to-day operations of the hospice. --- Findings included: Review of Policy titled ”Governing Body and Administrator,” revised September 2022, reveals:Purpose: To define legal authority and responsibility for the management of Hospice.Policy: The Governing body (or designated persons so functioning) assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations and, and continuous quality assessment and performance improvement. Cross refer to L0508: EXERCISE OF RIGHTS/RESPECT FOR PROPERTY/PERSONCross refer to L0500: EXERCISE OF PATIENT RIGHTS/ RESPECT FOR PROPERTY/PERSON

Based on record review and staff interviews, it was determined that the agency failed to ensure the initial comprehensive assessment was completed within 48 hours after the election of hospice care for 11 patients (P), (P#1, P#2, P#3, P#4, P#5, P#7, P#8, P#9, P#10, P#11, and P#12), of 14 sampled patients (P#1, P#2, P#3, P#4, P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#6, P#13, P#14). The Findings Include: --- 1. Review of the clinical record for P#1, with a diagnosis of senile degeneration of brain (mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), revealed the admission was on 4/4/2023, and the initial skilled nurse assessment was completed on 4/12/2023, (eight days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 2. Review of the clinical record for P#2, with a diagnosis of hemiplegia (one-sided muscle paralysis or weakness), revealed admission was done on 1/11/2023, and the initial skilled nurse assessment was completed on 1/15/2023, (four days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 3. Review of the clinical record for P#3, with a diagnosis of acute and chronic respiratory failure with hypoxia (when you do not have enough oxygen in your blood), revealed admission was done on 4/6/2023, and the initial skilled nurse assessment was completed on 4/13/2023, (seven days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 4. Review of the clinical record for P#4, with a diagnosis of malignant neoplasm of upper lobe right lung (cancerous tumor), revealed admission was done on 2/2/2023, and the initial skilled nurse assessment was completed on 3/7/2023, (35 days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 5. Review of the clinical record for P#5, with a diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), revealed admission was done on 2/8/2023, and the initial skilled nurse assessment was completed on 2/15/2023, (seven days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 6. Review of the clinical record for P#7, with a diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure), revealed that the admission was done on 12/7/2022, and the initial skilled nurse assessment was completed on 12/20/2022, (13days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 7. Review of the clinical record for P#8, with a diagnosis of acute respiratory failure (when your lungs cannot release enough oxygen into your blood), revealed admission was done on 9/8/2022, and the initial skilled nurse assessment was completed on 9/15/2022, (seven days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 8. Review of the clinical record for P#9, with a diagnosis of acute and chronic respiratory failure (when you do not have enough oxygen in your blood), type 2 diabetes, depression, revealed that the admission was done on 3/27/2023, and the initial skilled nurse assessment was completed on 4/2/2023, (six days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 9. Review of the clinical record for P#10, with a diagnosis of hypertensive heart chronic kidney disease (high blood pressure caused by the narrowing of your arteries that carry blood to your kidneys), revealed admission was done on 1/18/2023, and the initial skilled nurse assessment was completed on 1/23/2023, (five days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 10. Review of the clinical record for P#11, with a diagnosis of breast cancer (cancer that develops in the breast cells and progresses in stages), revealed admission was done on 11/1920/21, and the initial skilled nurse assessment was completed on 12/6/2021, (17days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 11. Review of the clinical record for P#12, with a diagnosis of traumatic subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain), revealed admission was done on 2/17/2023, and the initial skilled nurse assessment was completed on 3/6/2023, (17days) after the election of hospice care. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 4/25/2023 at 3:55 p.m., with Registered Nurse (RN) AA, who is also the Executive Director (ED), stated that she thought that what the regulation says was to complete the admission within seven days. The ED also confirmed that the surveyor has been provided with all available documentation for the patients records. On 4/25/2023 at 4:00 p.m., an interview was conducted with RN BB, who stated that she was not aware that the initial assessment must be completed within 48hours.

Based on review of records, staff interviews, and review of agency policy, it was determined the interdisciplinary group failed to ensure that the bereavement plan of care was done after patient death for three patients (P) (P#10, P#11, and P#12) of 14 sampled patients (P#1, P#2, P#3, P#4, P#5, P#7, P#8, P#9, P#10, P#11, P#12, P#6, P#13, P#14). The Findings Include: --- 1. Review of the clinical record for P#10, admitted on 11/12/2021 with a diagnosis of severe protein calorie malnutrition (form of malnutrition that is defined as a range of conditions arising from coincident lack of dietary protein and/or energy (calories) in varying proportions), revealed P#10 expired on 2/2/2023, and the bereavement plan of care was not completed. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 2. Review of the clinical record for P#11, admitted on 11/23/2021, with a diagnosis of malignant neoplasm of intrahepatic bile duct (cancer that forms in the slender tubes (bile ducts) that carry the digestive fluid bile), revealed P#11 expired on 12/18/2021, and the bereavement plan of care was done almost two months late on 2/1/2022. The clinical record lacked documentation regarding the staff's delay in completing the assessments. 3. Review of the clinical record for (P#12), who was admitted on 2/17/23, with a diagnosis of traumatic subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissue covering the brain), revealed P#12 expired on 2/26/2023, and the bereavement plan of care was not done. The clinical record lacked documentation regarding the staff's delay in completing the assessments. In an interview on 4/20/2022 at 3:15 p.m., the Administrator revealed she did not know how they missed it. The Administrator also confirmed that the surveyor has been provided with all available documentation for the patients records. On 4/25/2023 at 11:25 a.m., an interview was conducted with Chaplain (CH) DD, revealed that she was out on Family Medical Leave of Absent (FMLA) from 10/30/2022 to 02/15/2023 and ";No one was delegated to do my job while I was out on FMLA." On 4/25/2023 at 12:10 p.m., an interview was conducted with Master Social Worker (MSW) EE revealed, ";I dont know if anyone was in charge of bereavement while CH DD, was out." On 4/25/2023 at 12:14 p.m., during a phone interview with MSW FF revealed, ";I did not know that I was supposed to do a bereavement care plan on anyone while CH DD, was out". Hospice agency policy was not available.

Based on record review, staff interview, and review of agencys policy, it was determined that the agency failed to provide drugs and biologicals related to the management and palliation of the terminal illness and related conditions identified on patients hospice plan of care. The agency failed to provide the needed medications related to the co morbidities in seven patients (P) (P#1, P#4, P#5, P#6, P#7, P#8, P#9) of 14 sampled patients (P#2, P#3, P#10, P#11, P#12, P#13, P#14). The findings include: --- 1. Clinical records for P#1 were reviewed for certification period, 4/4/2023 to 7/2/2023. Plan of care revealed patient was admitted to hospice services on 4/4/2023, with a primary diagnosis of senile degeneration of brain (mental deterioration (loss of intellectual ability)) with the following co morbidity (the simultaneous presence of two or more diseases or medical conditions in a patient): benign prostatic hyperplasia (BPH) (enlarged prostate), with lower urinary tract symptoms. The record revealed the agency was not providing coverage for payment for the following medications used to manage the co morbidities of BPH: Flomax (Tamsulosin) (used by men to treat the symptoms of an enlarged prostate) 0.4 milligrams (MG), take one capsule oral daily treatment of BPH; Dutasteride (Avodart) (used in men to treat the symptoms of an enlarged prostate) 0.5mg take one capsule daily used for treatment of BPH, urinary retention. 2. Clinical records for P#4 were reviewed for certification period, 2/2/2023 to 5/2/2023. Review of the patient's plan of care revealed the patient was admitted to hospice services on 2/2/2023 with a primary diagnosis of malignant neoplasm of upper lobe right lung (cancerous tumor). The record revealed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of phlebitis (inflammation of veins) and thrombophlebitis (condition where an inflammation in a vein is caused by a blood clot) of left vein: Xarelto (Rivaroxaban) (used to prevent blood clots from forming) 20 mg take one tablet oral daily use to prevent blood clots. 3. Clinical records for P#5 were reviewed for certification period, 2/8/2023 to 5/8/2023. Review of the patient's plan of care revealed patient was admitted to hospice services on 2/8/2023 with a primary diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure). The record revealed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and depression (mood disorder): Eliquis (Apixaban) 5mg take one tablet oral twice daily used for blood thinner; Bupropion (Wellbutrin SR) 150mg take one tablet oral daily used for depression. 4. Clinical records for P#6 were reviewed for certification period, 3/2/2023 to 5/30/2023. Review of the patient's plan of care revealed patient was admitted to hospice services on 3/2/2023 with a primary diagnosis of embolism (blockage in the arterial (oxygen rich blood which flows from the heart to rest of the body) or venous (which carry deoxygenated blood from the organs to the heart) blood flow due to a blood clot) and thrombosis (formation or presence of a blood clot in a blood vessel) of lower extremities. The record revealed agency was not providing coverage for payment for the following medication used to manage the co morbidities of hypertension (high blood pressure), hyperlipidemia imbalance of cholesterol in your blood), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat): Eliquis (Apixaban) 5mg take one tablet oral twice daily used for blood thinner; Metoprolol succinate ER (Toprol XL) 100mg take one tablet oral daily to lower blood pressure; Norvasc (amlodipine) 2.5mg take one tablet oral daily used to lower blood pressure; Rosuvastatin Calcium (Crestor) 5mg take one tablet oral at bedtime to lower cholesterol. 5. Clinical records for P#7 were reviewed for certification period, 3/7/2023 to 6/4/2023. Review of patient's plan of care revealed patient was admitted to hospice services on 12/7/2022 with a primary diagnosis of hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure). The record revealed agency was not providing coverage for payment for the following medication used to manage the co morbidities of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), and congestive heart failure (progressive heart disease that affects pumping action of the heart muscles): Clopidogrel (Plavix) 75mg take one tablet oral daily use to prevent blood clots; Propranolol (Inderal), take one tablet oral twice daily as needed use to manage tremor and blood pressure. 6. Clinical records for P#8 were reviewed for certification period, 9/8/2022 to 12/6/2022. Review of patient plan of care revealed patient was admitted to hospice services on 9/8/2022 with a primary diagnosis of acute respiratory failure (occurs when the air sacs of the lungs cannot release enough oxygen into the blood). The record revealed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of hypertension (high blood pressure), hypoosmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (the sodium level in the blood is below normal): Sodium Chloride 1gram take one tablet oral daily use for hyponatremia. 7. Clinical records for P#9 were reviewed for certification period, 3/27/2023 to 6/24/2023. Review of the patient's plan of care revealed patient was admitted to hospice services on 3/27/2023 with a primary diagnosis of acute chronic respiratory failure (occurs when there is a sudden decrease in the ability to exchange oxygen and carbon dioxide between the lungs and bloodstream). The record revealed the agency was not providing coverage for payment for the following medication used to manage the co morbidities of type 2 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), and depression (mood disorder): Metformin 500mg take half tablet oral daily use to lower blood sugar; and Lexapro (Escitalopram) 20mg take one tablet oral daily to manage depression. In an interview at the agencys office on 4/25/2023, at 11:30 a.m., the Executive Director (ED), revealed that she was unaware that it was a requirement for the agency to pay for medications related to the listed co morbidities on the patients plan of care. Hospice policy was not available.

Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to have complete documentation of nursing visits in the clinical record for 1 of 1 (#3) sampled patients. Findings were: 1. Patient # 1(P#1) was admitted by the hospice on November 26, 2022 with a terminal diagnosis of malignant carcinoid of ileum. The patient wife revoked hospice on 1/21/2022. 2. The interdisciplinary plan of care for P #1 specified that the nurse would visit the patient 2-3 times per week. The patient's clinical record lacked documentation of nursing visits from 12/31/2021 until discharged on 1/21/2022. 3.. In an interview on June 9, 2022 at 9:00 a.m., the Administrator stated the nurse did make the visits to patient #1; however failed to document the visits. The Administrator acknowledged the state regulation that all documentation should be incorporated into the clinical record within 7 days of the service provided. The Administrator stated she had no documentation regarding any visits by the registered nurse.

Based on record review and staff interview it was determined that the agency failed to provide physical therapy (PT) to 1 of 3 (#) patients reviewed. The census at time of survey was 44. Findings include: 1. Review of patient # 1 medical record revealed a request from patient's wife for a physical therapy consult to help with weakness. The agency failed to arrange for physical therapy consult. 2. Review of contracts revealed the agency did not have a current contract for PT services. 3. Interview with the DON and Administrator on June 2, 2022 at 11:00 a. m. revealed the Administrator had called two agencies and stated they were not able to provide the service. The Administrator notified the patient's wife of the difficulty with obtaining the physical therapy assessment. The DON and the Administrator stated that no further action was taken regarding the PT consult.

Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to have complete documentation of nursing visits in the clinical record for 1 of 1 (#3) sampled patients. Findings were: 1. Patient # 1(P#1) was admitted by the hospice on November 26, 2022 with a terminal diagnosis of malignant carcinoid of ileum. The patient wife revoked hospice on 1/21/2022. 2.The interdisciplinary plan of care for P #1 specified that the nurse would visit the patient 2-3 times per week. The patient's clinical record lacked documentation of nursing visits from 12/31/2021 until discharged on 1/21/2022. 3.. In an interview on June 9, 2022 at 9:00 a.m.in the agency boardroom, the Administrator stated the nurse did make the visits to patient #1; however failed to document the visits. The Administrator acknowledged the state regulation that all documentation should be incorporated into the clinical record within 7 days of the service provided. The Administrator stated she had no documentation regarding any visits by the registered nurse.

Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to document an order for foley catheter on patient # 1 (P # 1). Findings include: 1. Review of patient records revealed the agency failed to ensure all orders were written on 1 of 3 patients reviewed. The visit note for P # 1 dated 12/3/2021 documented 'having difficulty voiding, obtained order for Foley,Procedure tolerated well.' No order for foley documented. 2. Interview on June 9, 2022 at 9:45 a. m. with the DON revealed there was no order written for an indwelling Foley catheter.

Based on record review and staff interview it was determined that the agency failed to maintain the human resource file for 1 of 4 personnel files reviewed. The census at time of survey was 44. Findings include: 1. Review of personnel files revealed the agency failed to maintain the human resource file for one of four employees. The file for employee # 1 did not contain the person's application, employment history, emergency contact information, evidence of qualifications, job description, evidence of initial and annual health screening, yearly skills competency assessments, evidence of verified licensure or certification, and evidence of orientation, education, and training. 2. Group interview with the DON, Human Resources Manager,and Administrator on June 2, 2022 at 10:30 a. m. in the boardroom of the agency revealed the employee file was incomplete. The DON stated she wasn't sure if she had to keep a file on the nurse practitioner. The Administrator stated the agency did not have a complete file on the nurse practitioner. The Administrator did verify the nurse practitioner was a full-time employee of the agency.