Bristol Hospice- East Georgia

“Based on policy titled “INITIAL ASSESSMENT,” record reviews, and staff interviews, it was determined that the facility failed to complete skilled nursing initial assessment within 48 hours for two patients (P) (P6, P14) of 26 sampled patients. The findings included: A review of the policy titled “INITIAL ASSESSMENT,” Policy No. 1-013, dated May 2020, revealed the following:“An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours”. 1. Review of the clinical records for P6 revealed the start of care was done by skilled nurse on 2/13/2026 and completed on 2/17/2026. Review of clinical records failed to reveal that the skilled nurse initial assessment was completed within 48 hours. 2. Review of the clinical records for P14 revealed the start of care was done by skilled nurse on 10/2/2023 and completed on 10/13/2023.Review of clinical records failed to reveal that the skilled nurse initial assessment was completed within 48 hours. There was no documentation in the facility’s electronic medical record system indicating that a physician or the patients’ family requested a delay in services. On 2/24/2026 at 2:30 PM, an interview was conducted with Registered Nurse (RN) AA, by phone at Administrator’s office who said that she did not know why she did not complete P6 initial assessment within 48 hours. On 2/25/2026 at 12:15 PM, an interview was conducted with Registered Nurse (RN) BB, by phone at Administrator’s office. She stated that she did not know why she did not complete P14 initial assessment within 48 hours. On 2/25/2026 at 12:20 PM, an interview was conducted with Executive Director (ED) License Practical Nurse (LPN) DD, at her office. She confirmed that RN AA and RN BB did not complete P6 and P14, initial assessment within 48 hours.”

“Based on review of policies titled “Volunteer Services,” and “Documentation of Volunteer Utilization,” facility documents and staff interview, it was determined that the agency failed to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. Findings included: Review of the policy titled “Volunteer Services,” Policy No. 9-024, dated January 2023 revealed the following:“PROCEDURE:4. The Volunteer coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will meet or exceed 5% of the total patient care hours of paid and contracted hospice personnel.” Review of the policy titled “Documentation of Volunteer Utilization,” Policy No. 1-041 HR, dated April 2025 revealed the following:“POLICY:The hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel.” Review of facility documents titled “Volunteer Coordinator Monthly Report,” dated January 2025 through January 2026, failed to include documentation of volunteers providing day-to-to-day administrative and/or direct patient care services that equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. During an in-office interview with the Registered Nurse (RN) Regional Director of Clinical Operations (RDCO) GG on 02/23/2025 at 3:43 PM, the RN RDCO GG confirmed that the agency had not achieved 5 percent of their total patient care hours in volunteer service hours.”

“Based on review of agency policies and procedures, record reviews and staff interviews was determined the agency’s governing body failed to ensure the nursing services were made available within one hour of notification during after-hours (time when agency office is closed) to meet patients’ needs for three patients (P) (P24, P25, P26) of six sampled patients from agency on-call report. The agency failed to complete Registered Nurse (RN) initial assessments within 48 hours of election of hospice services two patients (P) (P6, P14) of 26 sampled patients reviewed. The agency failed to meet the five percent requirements of volunteers providing day-to-day administrative and/or direct patient care. The agency failed to maintain current competency assessments for two Human Resource (HR) files [Executive Director (ED) RN ED] EE, Certified Nursing Assistant (CNA) FF, of eight HR files reviewed. Findings included: Cross refer to L0522 for findings related to initial assessment requirements.Cross refer to L0647 for findings related to meeting volunteer requirement hours.Cross refer to L0784 for findings related to personnel qualifications.”

“Based on review of policy titled “Competency Assessment,” record review, and staff interview, it was determined the agency failed to ensure that personnel qualifications were maintained and kept current in accordance with applicable Federal, State, and local laws. Specifically, the agency failed to maintain current competency assessments for two HR files [Registered Nurse (RN) Executive Director (ED) RN ED EE], and Certified Nursing Assistant (CNA) FF, of eight HR files reviewed. Findings included: Review of the policy titled “Competency Assessment,” Policy No. 3-0003, dated May 2020 revealed the following:“POLICY:The competence of all hospice clinical personnel (employed, contract, or volunteer) will be assessed during orientation, during the probationary period, periodically throughout the course of the year and during the annual performance evaluation.PROCEDURE:Orientation and Probationary Period2. Using a Competency Skills Performance Checklist, and the Orientation Checklist, the Director of Patient Care Services/Clinical Supervisor or designated preceptor will observe the new personnel performing the required skills and activities.Ongoing Assessments1. Competency assessments will be completed at least (1) time per year.” 1. The HR file for RN ED EE, with a hire date of 10/14/2024, failed to reveal a current annual competency assessment. 2. The HR file for CNA FF, with a hire date of 07/14/2025, failed to reveal an initial competency assessment. During a phone interview with RN ED EE, on 02/25/2026 at 1:02 PM, she revealed that she was not aware that current annual and initial competencies were not in the HR files.”