Hospice of South Georgia, Inc.

“Based on review of the Hospice of South Georgia’s Emergency Preparedness Program and interviews with staff it was determined that the facilities plan was not in substantial compliance set forth in Appendix Z. This could place all residents at risk in the event of an emergency.The findings include:During a review of the facilities Emergency Preparedness Program on 05/27/2025 between 12:00 pm and 2:45 pm it was noted that the facility failed to provide all required components of the Emergency Preparedness Program, therefore it did not meet the requirements of Appendix Z.These findings were confirmed by Staff M at the time of discovery.”

“Based on observation and staff interviews it was determined the facility failed to ensure the fire alarm power circuit was not labeled with the breaker location and fire alarm breaker was not locked.This could affect staff and residents in the facility. 1) The findings include:During a tour of the facility with Staff M on 05/27/2025 between 12:00 PM and 2:45 PM observation revealed that the fire alarm power circuit was not labeled on the circuit box.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 3.4.1, 9.6, 9.6.1.3 and 2010 NFPA 72, Chapter 10, Section 5.5.2 2) During a tour of the facility with Staff M on 05/27/2025 between 12:00 PM and 2:45 PM observation revealed that the fire alarm breaker was not locked in the breaker panel.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 5.1.1, 9.1.2 and 2011 NFPA 70, 760.41(A)(B)2012 NFPA 101, Chapter 19, Section 3.4.1, 9.6.1.3, 2010 NFPA 72, 10.5.5.2.1 thru 10.5.5.2.4”

“Based on observation and staff interviews it was determined the facility failed to ensure fire pull stations were unobstructed and accessible.This could affect staff and residents in the lobby area. The findings include:During a tour of the facility with Staff M on 05/27/2025 between 12:00 PM and 2:45 PM observation revealed that the fire pull station in the lobby was blocked by a chair.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101 Chapter 19, Section 3.4.1, 3.4.3.1, 3.4.2.2, Chapter 9, Section 6.1.3, 6.2.7, 2010 NFPA 72, Chapter 1, Section 14.5”

“Based on observation and staff interviews it was determined the facility failed to ensure the storage height was not at least 18 inches from the sprinkler heads and failed to ensure that escutcheon plates were properly attached to the sprinkler heads.This could affect staff and residents in the upstairs area and staff and residents in Room 3. 1) During a tour of the facility with Staff M on 05/27/2025 between 12:00 PM and 2:45 PM observation revealed that the storage height upstairs was not 18 inches from the bottom of the sprinkler heads.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Section 19.3.5.1, Chapter 9, Section 9.7.1.1.(1) and 2010 NFPA 13, Chapter 8, Sections 8.5.6, 8.5.6.12) During a tour of the facility with Staff M on 05/27/2025 between 12:00 PM and 2:45 PM observation revealed that the escutcheon plate was missing from the sprinkler head in Room 3.These findings were confirmed by Staff M at the time of discovery.Reference: 2012 NFPA 101, Chapter 19, Sections 19.1.6.1, 19.3.5.1, 19.3.5.3, 19.3.5.4, Chapter 9, Sections, 9.7.5, 9.7.6, 9.7.1.1 and 2011 NFPA 25. Chapter 5, Sections; 5.2.1.1.2 & 5.2.1.1.4, (explanation in Annex E, E.1, Table E.1), and 2010 NFPA 13, Chapter 6, Section 6.2.7”

“Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” record reviews, and staff interviews, it was determined the hospice failed to document progress of performance improvement projects (PIPs) by failing to include measurable data elements in three of three active PIPs. Findings include:Review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised June 2018, reveals the following:Data Collection3. Data collection includes developing indicators, criteria or performance levels for each process determined to be improved. Data collection will be ongoing and frequency will be determined by the process improvement activity and approved by the Governing Body. Data collected will be used to monitor the effectiveness and safety of services and the quality of care. Review of a binder labeled “QAPI” revealed 15 dividers identifying performance improvement projects (PIPs) and labeled from one to fifteen. PIPs numbered 2, 14, and 15 were identified by the QAPI Coordinator and Inpatient Unit (IPU) Director as active PIPs. Further review of active PIPs failed to reveal specific data indicators used to measure the need for the PIP, thresholds for improvement, or measures of progress achieved by PIP activities. On 5/6/2025 at approximately 12:25 p.m., an interview was conducted at the hospice agency with the Administrator, the IPU Unit Manager, and QAPI Coordinator. They agreed the PIPs failed to include measurable data elements. The IPU Manager further revealed she recently added two active PIPS to the QAPI binder but did not have specific data elements included in the PIP’s development or ongoing evaluation.”

“Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” record reviews, and staff interviews, the hospice governing body failed to ensure the agency evaluates performance improvement projects (PIPs) for effectiveness by failing to ensure measurable outcome data was included in three of three active PIPs. Findings include: Review of the policy titled “Quality Assessment and Performance Improvement (QAPI) Plan”, revised June 2018, reveals the following:Responsibility/ Accountability1. The Governing Body is ultimately responsible for QAPI and implementation of the QAPI plan. Review of a binder labeled “QAPI” revealed 15 dividers identifying performance improvement projects (PIPs) labeled number one to fifteen. PIPs numbered 2, 14, and 15 were identified as active PIPs.Further review failed to reveal specific data indicators used to measure the need for the PIPs, thresholds for improvement, or measures of progress achieved by PIP activities. On 5/6/2025 at approximately 12:25 p.m., an interview was conducted at the hospice agency with the Administrator and QAPI Coordinator. The QAPI Coordinator stated she is responsible for QAPI activities for the home care team only. The Administrator revealed that the QAPI Coordinator is responsible for all QAPI activities for the hospice agency and further agreed that the PIPs failed to include measurable data elements.”

“Based on observation of inpatient unit (IPU), review of policy titled “Infection Control Plan”, and staff interviews, it was determined that the hospice failed to maintain infection control by placing a dirty biohazard blood borne pathogens medical waste (a red bag inside a large red container filled with used dirty intravenous bags and trash) under clean medication refrigerator in the medication room IPU. The findings include: Review of policy titled “Infection Control Plan,” revised June 2018 reveals the following:Second page 4. Goals for the infection control program include:• To minimize the risk of transmitting infections associated with the use of procedures, medical equipment, and medical devices. On 5/5/25 at 2:00 p.m., observed IPU medication room with Unit Manager (UM), revealed hospice staff placed a dirty biohazard blood borne pathogens medical waste (a red bag inside a large red container filled with used intravenous bags and trash) under clean medication refrigerator in the medication room IPU. Additionally, during the observation in the laundry room, clean linens were observed in the same room with patients soiled clothes. On 5/5/25 at 2:58 p.m., an interview conducted with the UM in the conference room, she confirmed the above information was true. UM stated she did not know they must separate the dirty biohazard red container from clean medication room, and clean linens from soiled clothes. On 5/5/25 at 3:15 p.m., an interview was conducted with the Administrator who said she was not aware of the dirty biohazard red container placed with clean medication refrigerator in medication room at IPU, and clean linens placed in the same place with patients soiled clothes at laundry room.”

“Based on review of patients’ admission record, review of policy titled “Patient Admission Criteria,” and staff interviews, it was determined the hospice failed to obtain admission order for three patients (P) (P#1, P#2, P#20), of 22 sampled patients. The findings include: Review of policy titled “Patient Admission Criteria,” revised June 2018 reveals the following:10. During the initial assessment, the RN will:• provide information relevant to physicians’ orders and services to be provided so that patient/caregiver can give consent.• Obtain and implement the physician’s orders. 1. Review of admission record revealed that P#1 was admitted to hospice on 2/16/2025, without physician’s order. 2. Review of admission record revealed that P#2 was admitted to hospice on 2/7/2025, without physician’s order. 3. Review of admission record revealed that P#20 was admitted to hospice on 8/31/2024, without physician’s order. On 5/5/25 at 3:34 p.m., an interview was conducted with Registered Nurse (RN) CC, in the conference room, who said there were no physician’s orders to admit patients. On 5/5/25 at 3:42 p.m., an interview was conducted with the Administrator at the conference room who confirmed that there were no physician’s orders to admit patients.”

“Based on observation of the inpatient unit (IPU), review of policy titled “Controlled Substances in the Inpatient Unit,” and staff interviews, it was determined that the agency failed to remove two bottles of Morphine Sulfate (an opioid pain-relieving medication) injection 10 milligrams (MG), expired on 4/2025, in the emergency kits in the IPU medication room. The findings include: Review of policy titled “Controlled Substances in the Inpatient Unit,” revised March 2013 reveals the following:Disposal of controlled substances: Take unused, unneeded, or expired prescription drugs out of their original container and dispose of in an approved waste site or in an undesirable substance as described below. Observation of the IPU medication room on 5/5/2025 at 2:00 p.m., with Unit Manager (UM) revealed two bottles of Morphine Sulfate injection 10 milligrams (mg) lot 043095 with an expiration date of 4/2025 in the emergency kit. The agency failed to remove two bottles of expired medications from the emergency kit located in the IPU medication room. On 5/5/25 at 2:20 p.m., an interview was conducted with the Unit Manager (UM), in the conference room. UM said the pharmacist comes every month to inspect IPU medications, but the last time they saw him was February 2025. On 5/5/25 at 3:12 p.m., an interview was conducted with the pharmacist on the phone who confirmed that the last time he visited IPU was February 2025. On 5/5/25 at 3:27 p.m., an interview was conducted with the Administrator in conference room who confirmed that two bottles of Morphine Sulfate 10 mg injections were expired on 4/2025, also confirmed that the last time she saw the pharmacist was February 2025.”