Homespun Hospice, LLC

“Based on review of policy titled “Social Work Services,” record reviews, family and staff interview, it was determined the agency failed to ensure a Social Worker (SW) completed an initial and ongoing psychosocial assessment related to patients terminal illness for nine patients (P) (P6, P7, P8, P10, P11, P12, P13, P14, and P15) of nine active patients charts reviewed. Findings included: Review of undated policy titled “Social Work Services,” reveals the following:“Procedure:5. The comprehensive assessment of the patient includes a psychosocial assessment conducted by the Social Worker to evaluate the patient/caregiver’s emotional, social, financial, and environmental resources and identify appropriate psychosocial problems, interventions and goals for the patient’s plan of care.6. A thorough psychosocial assessment is initiated at the time of admission and continued throughout the course of care. Interventions to assist the patient are based on assessment data.” 1. Review of the clinical chart for P6 revealed a start of care (SOC- the official beginning of a patient’s healthcare services) of 02/11/2026 failed to include an initial or ongoing social worker psychosocial assessment. 2. Review of the clinical chart for P7 revealed a SOC of 09/19/2023 failed to include an initial or ongoing social worker psychosocial assessment. 3. Review of the clinical chart for P8 revealed a SOC of 01/29/2025 failed to include an initial or ongoing social worker psychosocial assessment. 4. Review of the clinical chart for P10 revealed a SOC of 10/01/2025 failed to include an initial or ongoing social worker psychosocial assessment. 5. Review of the clinical chart for P11 revealed a SOC of 05/08/2026 failed to include an initial or ongoing social worker psychosocial assessment. 6. Review of the clinical chart for P12 revealed a SOC of 03/04/2025 failed to include an initial or ongoing social worker psychosocial assessment. 7. Review of the clinical chart for P13 revealed a SOC of 03/18/2026 failed to include an initial or ongoing social worker psychosocial assessment. 8. Review of the clinical chart for P14 revealed a SOC of 12/22/2025 failed to include an initial or ongoing social worker psychosocial assessment. 9. Review of the clinical chart for P15 revealed a SOC of 04/15/2025 and failed to include an initial or ongoing social worker psychosocial assessment. On 05/19/2026 at 10:30 AM, during a phone interview, family of P7 confirmed P7 nor the family of P7 had never had a visit or assessment by the agency’s SW. On 05/19/2026 at 1:40 PM, during an office interview, the Assistant Director of Nursing (ADON) confirmed P6, P7, P8, P10, P11, P12, P13, P14, and P15’s clinical chart did not contain an initial or ongoing SW psychosocial assessment.”

“Based on review of policies titled “Hospice Aide/ Personal Care Aide/Personal Care Aide Assignments and Duties,” and “Hospice Plan of Care,” clinical records review, home observation, and staff interviews, it was determined the agency failed to document patient-specific services on Hospice Aide care plans for nine patients (P) (P6, P7, P8, P10, P11, P12, P13, P14, P15) of nine sampled active patients. Findings included: Review of undated policy titled “Hospice Aide/ Personal Care Aide/Personal Care Aide Assignments and Duties,” revealed the following:“Policy:The Hospice Aide/Personal Care Aide/personal care aide functions in a supportive relationship to professional disciplines and may function as an extension of these professional services with written instructions, appropriate supervision and specialized hospice training.Procedure:1. Hospice Aide/Personal Care Aide/personal care aides are assigned to specific patients by a hospice RN that is a member of the interdisciplinary group and follow written patient care instructions in providing care to assigned patients.6. A Hospice Aide/Personal Care Aide/personal care aide provides services that are:a. Ordered by the interdisciplinary group;b. Included in the plan of care;c. Permitted to be performed under State law by Hospice Aide/Personal Care Aide/personal care aides; andd. Consistent with the Hospice Aide/Per sonal Care Aide/personal care aide’s training.” Review of undated policy titled “Hospice Plan of Care” revealed the following:“Policy:The care and services provided/delivered to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patient’s attending physician, the patient and/or his or her representative, and the primary caregiver in accordance with the patient’s needs if any of them so desire.5. The plan of care must detail the scope and frequency of services to be provided to meet the needs of the patient and the patient’s family unit.” 1. Review of document titled “Hospice Certification of Terminal Illness,” for P6, benefit period starting date of 05/12/2026, revealed Hospice Aide (HA) care plan titled “Hospice Aide Visit Task Lists,” effective 02/11/2026. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 2. Review of Plan of Care for P7, effective 02/25/2026, revealed HA care plan, effective 09/19/2023. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 3. Review of Plan of Care for P8, effective 03/25/2026, revealed HA care plan, effective 12/21/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without patient-specific directive. 4. Review of Plan of Care for P10, effective 03/25/2026, revealed HA care plan, effective 10/01/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 5. Review of document “Hospice Certification of Terminal Illness” for P11 with benefit period starting date of 05/06/2026, revealed HA care plan, effective 05/08/2026. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 6. Review of Plan of Care for P12, effective 03/04/2026, revealed HA care plan, effective 10/16/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 7. Review of Plan of Care for P13, effective 03/18/2026, revealed HA care plan, effective 03/20/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 8. Review of Plan of Care for P14, effective 04/08/2026, revealed HA care plan, effective 10/16/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. 9. Review of Plan of Care for P15, effective 04/08/2026, revealed HA care plan, effective 04/17/2025. Bathing method not individualized in care plan. Both bed bath and shower listed without a patient-specific directive. On 05/19/2026 at 11:00 AM, a home observation at the Assisted Living Facility was conducted with P8. Certified Nursing Assistant (CNA) AA was observed giving P8 a bed bath. On 05/19/2026 at 11:30 AM, a home interview was conducted with P8, who revealed taking showers with HA assistance in the past but “not for a while now.” On 05/19/2026 at 11:40 AM, an interview was conducted with CNA AA, who acknowledged the plan of care lists both shower and bed bath, but that P8 no longer gets a shower. On 05/20/2026 at 11:30 AM, an office interview was conducted with the Assistant Director of Nursing, who confirmed the agency’s HA care plans allow for either bed baths or showers but was unaware this was not a patient-specific aide care plan.”

“Based on review of policies and procedures, record review, and staff interview, it was determined the agency failed to use measurable outcomes to document measurable progress achieved with seven active performance improvement projects (PIPs). Findings included: Review of the policy titled “QAPI Benchmarking,” copywritten in 2016, revealed the following:“POLICYTo further the goals of the hospice industry and evidence-based research, [Name] participates in the development, collection and submission of hospice benchmark data.1. The QAPI Committee uses HIS data as well as any other data the committee determines is the most appropriate for tracking the agency services and operations.2. Mechanisms for the collection of appropriate data are developed and implemented.3. Members of the QAPI Committee review and incorporate standardized and validated tools to measure outcomes.”4. The results of internal data are analyzed in order to identify performance improvement opportunities.” Review of the policy titled “QAPI-Performance Improvement Project,” copywritten in 2016, revealed the following:“POLICYAs part of its QAPI program, the hospice develops, implements and evaluates performance improvement projects based upon patient and internet organizational needs.2. In accordance with O.C.G.A. S 31-7-170 et seq, there shall be an ongoing evaluation of the quality management, utilization, and peer review committee to determine its effectiveness, which shall be presented at least annually for review and appropriate action to the medical staff and the governing body. The QAPI committee will record Performance Improvement evaluations in QAPI meeting minutes.7. Each Performance Improvement project will include: a. A description of Indicators(s) to be monitored/activities to be conductedb. Frequency of activitiesc. Designation of who is responsible for conducting the activitiesd. Methods of data collectione. Acceptable limits for findingsf. Programs to re-evaluate if findings fail to meet acceptable limitsg. Any other activities required under state or federal laws or regulations.” Review of seven documents titled “QAPI/PIP,” failed to reveal measurable data for analyzing and tracking compliance. The PIPs failed to reveal a specified time frame of completion, a frequency for monitoring collected data to assess the effectiveness of the project and lacked data collection to identify measurable progress toward identified goal. On 05/19/2026 at 2:07 PM, an in-office interview was conducted with Registered Nurse (RN AA) who revealed no further documentation was available.”

“Based on review of agency’s policies and procedures, record reviews, and staff interviews, it was determined that the governing body and Administrator failed to assume responsibility for the management of the hospice and hospice services. Specifically, the hospice governing body failed to:1. Ensure a Social Worker (SW) completed an initial and ongoing psychosocial assessment related to patients’ terminal illness for 9 patients (P) (P6, P7, P8, P10, P11, P12, P13, P14, and P15) of 9 active patients charts reviewed.2. Include patient specific services and frequencies on Hospice Aide care plans for nine patients (P) (P6, P7, P8, P10, P11, P12, P13, P14, P15) of nine sampled active patients.3. Ensure measurable outcomes were added to document measurable progress achieved with seven active performance improvement projects (PIPs).4. Ensure employees received the required initial hospice orientation training for four employees (Administrator (ADM), Registered Nurse (RN AA), Chaplain (CH BB), Certified Nurse Aide (CNA AA) of eight sampled employees.5. Ensure that entries in the clinical record are legible and appropriately signed for 10 patients (P) (P6, P7, P8, P9, P10, P11, P12, P13, P14, P15) of 15 patients sampled patients. Findings included: Cross Refer to citation L524 for findings related to SW initial and ongoing psychosocial assessment.Cross Refer to citation L547 for findings related to hospice aide care plan.Cross Refer to citation L573 for findings related to measurable outcomes for performance improvement projects (PIPs).Cross Refer to citation L662 for findings related to employees receiving the required initial hospice orientation training.Cross Refer to citation L679 for findings related to authentication of clinical records.”

“Based on review of policy titled “Orientation Program,” review of the personnel files and staff interview, it was determined that the hospice failed to ensure four employees (Administrator (ADM), Registered Nurse (RN AA), Chaplain (CH BB), Certified Nurse Aide (CNA AA) received the required initial hospice orientation training of eight of eight sampled employees. Specifically, the orientation training failed to include Hospice Concept/Philosophy, Disaster preparedness, Fire safety, and Emergency evacuations. Findings included: Review of the undated policy titled “Orientation Program,” revealed the following:“POLICYAll persons providing services for a hospice must receive an orientation to the hospice to include, but not be limited to:(a)Hospice concepts and philosophy;(b)Patient rights including abuse reporting requirements; and(c)Hospice policies and procedures, including, but not limited to, disaster preparedness , fire safety and emergency evacuations, and reporting abuse and neglect.PROCEDURE1.All newly hired employees participate in an orientation program prior to providing patient care or assuming administrative responsibilities.6. Documentation of the successful completion of the orientation program is retained in the employee’s personnel record.” 1. Review of the personnel file for ADM failed to reveal documentation of the required hospice orientation training. 2. Review of the personnel file for RN AA failed to reveal documentation of the required hospice orientation training. 3. Review of the personnel file for CH BB failed to reveal documentation of the required hospice orientation training. 4. Review of the personnel file for CNA AA failed to reveal documentation of the required hospice orientation training. On 05/20/2026 at 9:30 AM, an in-office interview was conducted with the Chief Executive Officer (CEO), who confirmed that the personnel files lacked documentation of the required orientation training.”

“Based on review of policy titled “Documentation Requirements,” record reviews, and staff interviews, it was determined the agency failed to ensure that entries in the clinical record are legible and authenticated with the signature of the individual making the entry for 10 patients (P) (P6, P7, P8, P9, P10, P11, P12, P13, P14, P15) of 15 sampled patients. Findings included: Review of undated policy titled “Documentation Requirements,” revealed the following:“Policy:Members of the interdisciplinary group document the interventions provided to the patient/caregiver, their response to care, services provided and the goals or outcomes achieved .Procedure:6. All documentation contains complete, factual, essential, and accurate information.” 1. Clinical record for P6 revealed Hospice Aide (HA) notes, dated 05/12/2026 and 05/14/2026, Registered Nurse (RN) notes dated 04/28/2026 and 05/12/2026, and chaplain notes dated 02/13/2026 and 03/09/2026. The notes failed to reveal the clinician’s signatures. 2. Clinical record for P7 revealed document titled “Hospice Certification of Terminal Illness,” for benefit period beginning 03/07/2026. The Medical Director’s handwritten physician narrative was illegible.Further review of P7’s clinical record revealed HA notes dated 05/15/2026 and 05/18/2026, RN notes dated 05/11/2026 and 05/19/2026, and chaplain notes dated 04/06/2026 and 05/13/2026. The notes failed to reveal the clinician’s signatures. 3. Clinical record for P8 revealed document titled “Hospice Certification of Terminal Illness,” for benefit period beginning 03/25/2026. The Medical Director’s handwritten physician narrative was illegible.Further review of P8’s clinical record revealed HA visit notes dated 05/15/2026 and 05/18/2026, RN note dated 05/11/2026, and chaplain notes dated 04/06/2026 and 05/13/2026. The notes failed to reveal the clinician’s signatures. 4. Clinical record for P9 revealed document titled “Hospice Certification of Terminal Illness,” for benefit period beginning 02/06/2026. The Medical Director’s handwritten physician narrative was illegible. 5. Clinical record for P10 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 03/30/2026. The Medical Director’s handwritten physician narrative was illegible. 6. Clinical record for P11 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 05/06/2026. The Medical Director’s handwritten physician narrative was illegible. 7. Clinical record for P12 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 04/28/2026. The Medical Director’s handwritten physician narrative was illegible. 8. Clinical record for P13 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 04/07/2026. The Medical Director’s handwritten physician narrative was illegible. 9. Clinical record for P14 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 04/21/2026. The Medical Director’s handwritten physician narrative was illegible.Further review of P14’s clinical record revealed HA visit notes dated 05/14/2026 and 05/19/2026, Registered Nurse (RN) notes dated 05/05/2026 and 05/18/2026, and chaplain notes dated 03/04/2026 and 05/14/2026. The notes failed to reveal the clinician’s signatures. 10. Clinical record for P15 revealed document titled “Hospice Certification of Terminal Illness”, for benefit period beginning 04/10/2026. The Medical Director’s handwritten physician narrative was illegible. On 05/19/2026 at 1:00 PM, an office interview was conducted with the Assistant Director of Nursing (ADON) and Chief Executive Officer (CEO), who acknowledged that the Medical Director’s handwritten documentation is illegible. The ADON and CEO revealed a new dictation system has been implemented for the Medical Director but were unable to provide clinical documentation using the new dictation system. On 05/19/2026 at 1:30 PM, an office interview was conducted with the Medical Director, who confirmed learning a new dictation system to improve documentation clarity, but has only used it in the past week or two.”