Opuscare of Georgia

“Based on policy titled “Symptom Management,” record reviews, and staff interviews, it was determined that the facility failed to implement initial spiritual assessments for the two patients (P) (P#5, P#15) of 15 patients reviewed. The findings include: Review of the policy titled “Symptom Management,” revised 3/2025 reveals the following:IV. Policy a) It is our policy that the care team assesses a patient within five days of admission, develops a written, individualized care plan before services begin, involves the patient and family in planning, specifies the type and frequency of services, and requires regular review and updates to ensure care remains appropriate to the patient’s changing needs. 1. Review of the clinical records for P#5 revealed the start of care was completed by skilled nurse on 1/17/2025.The clinical record failed to reveal an initial spiritual assessment. 2. Review of the clinical records for P#15 revealed that the start of care was completed by skilled nurse on 4/9/2025. The initial spiritual assessment was completed on 4/15/2025, six days after the start of care, and the psychosocial assessment was completed on 4/16/2025, seven days after start of care. On 9/16/2025 at 1:30 p.m., an interview was conducted with Chaplain (CP), who said he did not know why he skipped P#5, assessment and he had no reason as to why P#15 spiritual assessment was done late. On 9/16/2025 at 1:50 p.m., an interview conducted with the Administrator, who confirmed that the hospice staff failed to implement initial spiritual assessments for P#5 and completed late spiritual and psychosocial assessments for P#15.”

“Based on review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” Quality Assessment Performance Improvement (QAPI) binder and staff interview, it was determined that the agency failed to develop, implement and evaluate Performance Improvement Projects (PIP) for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025. Findings include: Review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised 5/2023, revealed the following:Performance Expectation1. For each process identified to be improved, mechanisms to identify levels, patterns or trends in that process that will trigger further evaluation of the process will be identified.Sample size will be determined.2. For each established process to be improved, the performance expectation will be determined. The frequency of the data collection and analysis will be specified for each process. The QAPI committee, and/or those involved in patient care, will analyze the data collected to pursue opportunities for improvement and identify important problems.3. A summary of data collection, analysis, recommendations for improvement and report of cumulative findings will be prepared by the QAPI committee. The reports are forwarded to the Governing body. Failure to achieve levels of performance will be documented and an explanation delineated to identify opportunities for improvement. Review of the agency’s Quality Assessment Performance Improvement (QAPI) binder revealed the agency failed to include in the committee meeting minutes, a Performance Improvement Project (PIP) for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025. On 9/17/2025 at 9:30 a.m., during an office interview, The Administrator admitted the agency failed to include a PIP in the committee meeting minutes for Quarter four of 2024, Quarter one, Quarter two and Quarter three of 2025.”

“Based on review of agency policies and procedures, Quality Assessment Performance Improvement (QAPI) binder, review of agency’s emergency preparedness binder, and staff interview, it was determined the agency’s governing body failed to ensure the quality improvement program was maintained and evaluated to include a Performance Improvement Plan (PIP) for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025 and failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. Findings include: Review of policy titled “Quality Assessment and Performance Improvement (QAPI) Plan,” revised 5/2023, revealed the following:Achieved and Sustained Improvement1. The Administrator/Director is responsible for taking appropriate action. Aggregate measures of performance for each process will be compared to pre-establish performance expectations to determine if additional evaluation is required.Performance Expectation7. OpusCare will document what performance improvement projects are being conducted, the reasons for conducting these projects and the measurable progress achieved on them.8. The QAPI program will be evaluated annually by the Governing Body as a part of the annual program evaluation. Review of agency policy titled “Emergency Operations Plan,” revised 6/2024, revealed the following:Procedure:1. OpusCare complies with all applicable federal, state, and local emergency preparedness requirements.Policy2. OpusCare has established and maintains an emergency preparedness program that meets all requirements. Review of the agency’s Quality Assessment Performance Improvement (QAPI) binder revealed the agency failed to identify and document an ongoing performance improvement project (PIP), with assessment and evaluation, in the committee meeting minutes for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025. Review of agency’s 2024 and 2025 emergency preparedness binder revealed the agency failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. On 9/17/2025 at 9:30 a.m., during an office interview, The Administrator acknowledged that the governing body failed to identify and document an ongoing performance improvement project (PIP), with an assessment and evaluation, in the committee meeting minutes for Quarter four of 2024 and Quarter one, Quarter two and Quarter three of 2025 and additionally acknowledged that the agency failed to document an annual rehearsed disaster preparedness plan with participants, summary of problems identified, and effectiveness of rehearsal for the years 2024 and 2025. The Administrator revealed he was not aware he had to conduct and document an annual rehearsed disaster preparedness plan since the agency no longer had an inpatient unit (IPU).”

“Based on policy titled “Volunteers Services,” record reviews, and staff interview, it was determined the facility failed to document cost saving achieved through the use of volunteers. The findings include: Review of the policy titled “Volunteers Services,” Policy: No.-V001, revised 5/2025 reveals the following:PROCEDURE:1. OpusCare will document active and ongoing efforts to recruit and retain volunteers.2. OpusCare will document the cost savings achieved through the use of volunteers and will include:· Identification of each position occupied by volunteers.· The work time spent by volunteers occupied by those positions.· Estimate of the dollar cost that OpusCare would have incurred if paid employees occupied positions identified.· OpusCare will document and maintain a volunteer staff sufficient to provide administrative and/or direct patient care in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid OpusCare employees and contract staff. OpusCare will document a continuing level of volunteer activity. OpusCare will maintain records on the use of volunteer for patient care and administrative services, including the type of services and time worked. Review of facility documents failed to reveal documentation of cost savings achieved through the use of volunteers. On 9/16/2025 at 1:45 p.m., an interview was conducted with the Administrator who acknowledged that records of cost savings were not documented or computed according to the Volunteer-Services policy.”

“Based on review of facility documents and staff interview, it was determined the facility failed to provide day to day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. The Findings include: Review of facility document “Cost Saving through Use of Volunteers,” revealed that the document was blank. The agency failed to document from January through September 2025, the Monthly Service percentage that was less than 5%. The hospice agency failed to provide day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. On 9/16/2025 at 1:45 p.m. an interview was conducted with the Administrator who acknowledged that the record of day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total care hours of all paid hospice employees and contract staff, were not met, and were not documented. The Administrator also confirmed there was no documentation from January to September 2025 recorded for the volunteer’s services percentage.”