Bristol Hospice Georgia, LLC

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed of patients who accepted spiritual services on admission revealed that the agency did not ensure that the chaplain completed an initial assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 9: The patient elected hospice care on 02/17/2026 with a Primary diagnosis of Progressive Multiple Sclerosis. The Chaplain’s initial assessment was not completed until 02/26/2026, 9 days after the election of Hospice. The clinical record did not have documented evidence of the reason why the initial spiritual assessment was not completed by the Chaplain no later than 5 calendar days. During an interview and joint clinical record review on 07/01/2026, the Administrator confirmed and agreed that the Chaplain did not complete the initial Spiritual Assessment in the required 5-day timeframe. No further information was provided.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by the document review and interview. In review of the Volunteer Program documents, it was revealed that the agency did not provide volunteer services in an amount that equaled five percent or more of the total patient care hours of all paid hospice employees and contract staff. DOCUMENT 1: A joint review of the agency QAPI Report revealed that the Volunteer utilization for the period 01/01/2025-12/31/2025 was 3.4%, which fell below the requirement for volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. Volunteer utilization for the year 2026, up to date from 01/01/2026-05/31/2026, was 1.35%. During an interview on 07/01/2026, the Volunteer Coordinator stated, “We had challenges recruiting Volunteers last year. The agency has started a performance improvement plan to recruit more Volunteers. The Volunteer Coordinator provided documentation of the active Volunteer recruitment and retention program. No further information was provided. The agency did not ensure that hospice Volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum equaled five oercent (5%) of total patient care hours of all paid hospice patient care hours and contracted staff.”

“Based on record reviews, review of the facility policy titled “;Missed Visits,” and staff interviews, it was determined the agency failed to ensure hospice aide and nursing services were provided as ordered in the plan of care for five patients (P) (P#1, P#2, P#3, P#6, P#7) of ten sampled patients. Findings include: Review of the policy titled, “;Missed Visits,” Policy No. 1-027, dated May 2020 reveals the following: Policy Missed visits will be documented in the clinical record. Procedure 2. If a visit is missed and not rescheduled the clinician will: B. Document in the patients clinical record the following information: 1. Patient name 2. Date and type of visit that was missed 3. Reason for the missed visit 4. Description of any unmet needs and how the patients needs were met 5. Any other follow-up needed 6. Other person(s) notified of the missed visit 7. Signature of staff member reporting the information 1. Review of the clinical record for P1 revealed the patient was admitted to hospice services on 4/29/2024. Review of the document titled “;Clinical Summary” revealed skilled nursing visits were ordered 3 times a week for the week of 4/29/2024 and one time a week beginning 5/6/2024. The clinical record revealed one visit was made on 4/29/2024 and failed to reveal further nursing visits before the patient transferred to another hospice on 5/6/2024. The clinical record failed to reveal skilled nursing missed visit notes for the weeks of 4/29/2024 – 5/4/2024 or 5/5/2024 until 5/6/2024. 2. Review of the clinical record for P2 revealed the patient was admitted to hospice services on 1/28/2024. The clinical record revealed skilled nursing visits were ordered once per week for 13 weeks. P2 received a nursing visit 3/15/2024 and no further visits until 3/29/2024. The clinical record failed to reveal skilled nursing missed visit notes for the week of 3/17/2024- 3/22/2024. 3. Review of the clinical record for P3 revealed patient was admitted to hospice services on 2/28/2024. Review of the clinical record revealed skilled nursing visits were ordered three times per week for 14 weeks. The clinical record revealed: 2 nursing visits from 3/3/2024 to 3/9/2024, 2 nursing visits from 3/10/2024 to 3/16/2024, 1 nursing visit for the week of 3/24/2024 to 3/30/2024, 2 nursing visits from 3/31/2024 to 4/6/2024, The clinical record failed to reveal missed skilled nursing visit notes for the dates 3/3/2024- 3/16/2024 or 3/24/2024- 4/6/2024. 4. A review of the clinical record for P6 revealed the patient was admitted on 3/28/2024. Review of the document titled “;Clinical Summary” revealed hospice aide visits were ordered three times each week beginning 3/31/2024. P6 received two hospice aide visits the week of 4/14/2024 to 4/20/2024. The clinical record failed to reveal hospice aide missed visit notes. 5. A review of the clinical record for P7 revealed the patient was admitted on 12/20/2022. Review of the document titled “;Clinical Summary” revealed nursing visits were ordered two times a week beginning 5/6/2024. The clinical record revealed a nursing visit on 5/2/2024 with no other nursing visits until the patient transferred to another hospice on 5/14/2024. The clinical record failed to reveal missed nursing visit notes for the week of 5/6/2024- 5/11/2024 and the week of 5/12/2024- 5/14/2024. During an office interview on 7/31/2024 at 11:00 am, the Executive Director (ED) did not provide any documentation of the missed visits. During a telephone interview on 7/31/2024 at 11:25 am with the Regional Vice President of Operations (RVPO) revealed daily morning meetings are utilized to report missed visits. He was not aware of any issues with missed visits.”

“Based on record review and staff interview, it was determined the hospice failed to assess the skills and competency of all individuals providing care for two employee files (RN AA, RN CC) of six employee files sampled. Specifically, employee files failed to reveal skills competency check-offs. Findings include: 1. Registered Nurse (RN) AA was hired on 3/4/2024. A review of the personnel file for RN AA failed to reveal a competency skills checklist to assure competency in performing required skills. 2. RN CC was hired on 7/19/2021. A review of the personnel file for RN CC failed to reveal a competency skills checklist to assure competency in performing required skills. During an interview with the Executive Director (ED) and Regional Vice President of Operations (RVPO) on 7/31/2024 at 1:30 pm revealed that the ED and RVPO confirmed missing competency assessments.”