The Weinstein Hospice

“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”