Atlanta Regional Hospice, LLC

“Based on policy titled “Spiritual Services,” record reviews, and staff interview, it was determined that the facility failed to complete initial and comprehensive assessment for five patients, (P) (P3, P8, P9, P11, and P12), and did late initial spiritual assessment for three patients. (P) (P4, P5, and P14) of eighteen sample patients. Findings included:A review of the policy titled “Spiritual Services,” revealed the following:Procedure: 1. “The Chaplain/Spiritual Counselor is a core member of the IDG, and duties include but are not limited to, the following:The initial spiritual assessment will be completed by the SW/Chaplain and/or designated person for all patients within 5 working days from election of the Hospice benefit. This assessment will become part of the comprehensive assessment.” 1. Review of the clinical records for P3 revealed that the start of care was completed by skilled nurse on 02/19/2026, and the initial spiritual assessment was not done. Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. 2. Review of the clinical records for P8 revealed that the start of care was completed by a skilled nurse on 03/24/2026, and the spiritual initial assessment was not done.Review of clinical records failed to reveal that the spiritual initial assessment was completed within five days of start of care. 3. Review of the clinical records for P9 revealed that the start of care was completed by a skilled nurse on 05/12/2025, and the spiritual initial assessment was not done.Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. 4. Review of the clinical records for P11 revealed that the start of care was completed by a skilled nurse on 03/22/2025, and the initial spiritual assessment was not done.Review of clinical records failed to reveal that the spiritual initial assessment was completed within five days of start of care. 5. Review of the clinical records for P12 revealed that the start of care was completed by a skilled nurse on 06/24/2025, and the initial spiritual assessment was not done.Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. Further review failed to show documentation in the facility’s electronic medical record system indicating that a physician or the patients’ family requested a delay in services. On 06/09/2026 at 11:56 AM, an interview was conducted with Dean of Nurses (DON), at her office. She confirmed that Chaplin (CH) CH DD and CH GG did not complete P3, P8, P9, P11, and P12 spiritual initial assessment within five days. She also said that CH GG was fired, and CH DD was not available for interview. Reference:L523, L524”

“Based on policy titled “Spiritual Services,” record reviews, and staff interview, it was determined that the facility failed to complete the initial spiritual assessment within five days, for three patients (P) (P4, P5, and P14) of eighteen sampled patients. Findings included: A review of the policy titled “Spiritual Services,” revealed the following:Procedure: 4.“The Chaplain/Spiritual Counselor is a core member of the IDG, and duties include but are not limited to, the following:The initial spiritual assessment will be completed by the SW/Chaplain and/or designated person for all patients within five working days from election of the Hospice benefit. This assessment will become part of the comprehensive assessment.” 1. Review of the clinical records for P4 revealed that the start of care was completed by skilled nurse on 06/07/2025, and the initial spiritual assessment completed on 08/12/2025.Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. 2. Review of the clinical records for P5 revealed that the start of care was completed by a skilled nurse on 09/10/2025, and the initial spiritual assessment completed on 02/10/2026.Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. 3. Review of the clinical records for P14 revealed that the start of care was completed by a skilled nurse on 05/05/2026, and the initial spiritual assessment completed on 05/16/2026.Review of clinical records failed to reveal that the initial spiritual assessment was completed within five days of start of care. Further review failed to provide documentation in the facility’s electronic medical record system indicating that a physician or the patients’ family requested a delay in services. On 06/09/2026 at 11:56 AM, an interview was conducted with Dean of Nurses (DON), at her office. She confirmed that Chaplin (CH) CHDD and CH GG did not complete P4, P5, and P14 initial spiritual assessment within five days. She also said that CH GG was fired, and CH DD was not available for interview.”

“Based on review of agency policies, record review and staff interview, it was determined the agency failed to track and analyze complaints and infections as part of the agency’s Quality Assurance Performance Improvement (QAPI) program. Findings included: Review of the undated policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan,” revealed the following: “OBJECTIVES• To collect and analyze data to improve identified processes and outcomes of care.• To collect and analyze data to improve identified processes of patient care/services as well as outcomes of patient care, leadership and managerial processes, as indicated.• To create and maintain information systems (manual and/ or computer} to support the collecting, managing and analyzing of data needed to facilitate ongoing QAPI.” Review of the undated policy titled, “Grievance Process” revealed the following: “PROCEDURE11. The Performance Improvement Coordinator will prepare a quarterly report summarizing all complaints received that quarter.12. Reports may include:Number of complaints receivedTypes of complaints receivedAction and resolution of complaints 13. The Performance Improvement Committee will review patient grievance trends on a quarterly basis. Identified trends will be followed through the established performance improvement process.” Review of the undated policy titled, “Infection Control Surveillance System: Prioritized Risks Defined,” revealed the following: “PROCEDURE3. At least quarterly, the Director and infection control and QAPI committees will review and assess the infection control logs. Data will be aggregated and analyzed on the Infection Control Quarterly Data Aggregation and Analysis: Patients and Employees form.4. Problems and/or undesirable trends in infections will be identified, including potential significant Hospice acquired and/or community acquired infections. If such problems or undesirable trends are identified, the infection control and QAPI committees will identify any common factors that could have led to the transmission of the infection(s).” Review of document “QAPI Committee Meeting Agenda,” dated 01/08/2026, failed to reveal infections or complaints for October, November and December 2025. Review of documents “Infection Identification- Patient Report” revealed patient infections on 10/06/2025, 11/19/2025, 11/30/2025, and 12/11/2025. Review of document titled “Incident Report” revealed a complaint dated 12/30/2025. On 06/09/2026 at 1:00 PM, an office interview was conducted with the Administrator, who confirmed the meeting minutes failed to include an accurate account of complaints and infections, “I must have missed those.” The Administrator further confirmed that all QAPI documentation had been provided.”

“Based on review of the policy titled “Performance Improvement Committee,” record review, and staff interview, it was determined the agency failed to document reasons for conducting performance improvement projects (PIPs) and failed to include measurable outcomes for monitoring ongoing progress. Findings included: Review of the undated policy titled, “Performance Improvement Committee,” revealed the following: “l. The Performance Improvement Committee is responsible for the identification and resolution of problems and for identifying opportunities to improve patient care, service and performance throughout the organization.2. The PI Committee may serve as the Performance Improvement Team or may appoint a team to plan and implement a specific improvement project. The Performance Improvement Team will report all results in the form of minutes to the PIC.The PI Committee shall ensure that ongoing monitoring includes: (a) at least one important aspect related to service provided and (2) one related to an administrative aspect of function or servicePLAN:Benchmarks or thresholds that trigger further assessment and evaluation are established. Undesirable patterns or trends in performance are analyzed. Further analysis may he conducted when the levels of performance, patterns or trends vary significantly from those expected.” Review of document titled “Quality Assurance Performance Improvement Log” revealed the following: For dates 07/05/2025, 10/01/2026, 01/03/2026, and 04/01/2026, “Issue/Problem: HR files.” Date 05/01/2026, “Issue/Problem: IDT documentation visit notes.” Review of document “Performance Improvement Project Activity,” dated 11/05/2025, revealed the following: “Project Data- compliance of personnel files.How is it measured: 100% complianceCurrent Status: 100% complianceBenchmark: 100% compliance” Further review failed to reveal reasons for initiating PIP or documentation of personnel file audits. QAPI and PIP documents failed to reveal reasons for initiating PIP “IDT documentation visit notes” or include measurable data and thresholds for monitoring progress. On 06/09/2026 at 1:00 PM, an office interview was conducted with the Administrator, who revealed having two active PIPs- one for incomplete personnel files and one addressing documentation. Administrator explained the documentation for the PIP was because of late or missed documentation, but had not been written up, as it had only started on 05/01/2026. Administrator acknowledged that the PIPs failed to document the reasons for the PIPs or measurable data to measure progress achieved.”

“Based on record reviews, and staff interview, it was determined that the agency failed to document and transfer the infection’s information into Quality Assurance Performance Improvement (QAPI). Review of infection control meeting logs revealed that the infection control for October 1st, November 2nd, and December 1st was not transferred to QAPI report. On 6/8/2026 at 1:00pm an interview was conducted with the Administrator at conference room who stated that she thought the infection control documentation is supposed to be done once a year. The Administrator also confirmed that she failed to document the infection control information for the above months into QAPI.”

“Based on review of the policy titled “Bereavement Services,” clinical record review, and staff interview, it was determined the agency failed to establish a bereavement plan of care to reflect the needs of the bereaved for two patients (P) (P11, P12) of two sampled bereavement charts. Findings included: Review of the policy titled “Bereavement Services” revealed the following: “PROCEDURE5. Unless Bereavement Services have been refused, a Bereavement Counselor, Chaplain or Social Worker will call designated bereaved to continue bereavement supportive or counseling services. A bereavement plan of care will be initiated, which may include telephone support, individual or family counseling and bereavement groups. The plan of care will note the kind of bereavement services to be offered and frequency of service delivery.” Record reviews revealed the date of death for P11 as 05/21/2026. The clinical record failed to reveal a bereavement plan of care. Record reviews revealed the date of death for P12 as 09/06/2025. The clinical record failed to reveal a bereavement plan of care. On 06/09/2026 at 1:30 PM, an in-office interview was conducted with Licensed Medical Social Worker (LMSW) LMSW CC, who revealed responsibility for performing and documenting bereavement care. LMSW CC was not aware of the requirement for bereavement plans of care.”

“Based on the review of policies and procedures, records review, and staff interviews, it was determined 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, and the provision of all hospice services to include the following: 1. failure to complete initial and comprehensive assessment for five patients, (P) (P3, P8, P9, P11, and P12), and did late initial spiritual assessment for three patients. (P) (P4, P5, and P14) of 18 sample patients. 2. failure to complete the initial spiritual assessment within five days, for three patients (P) (P4, P5, and P14) of 18 sampled patients. 3. failure to complete the initial spiritual assessment for five patients (P) (P3, P8, P9, P11, and P12) of 18 sampled patients. 4. . failure to track and analyze complaints and infections as part of the facility’s Quality Assurance Performance Improvement (QAPI) program. 5. failure to document reasons for conducting performance improvement projects (PIPs) and failed to include measurable outcomes for monitoring ongoing progress. 6. failure to document and transfer the infection’s information into Quality Assurance Performance Improvement (QAPI). 7. failure to establish a bereavement plan of care to reflect the needs of the bereaved for two patients (P) (P11, P12) of two sampled bereavement charts. 8. failure to assess the skills and competence of all individuals that provide care. Findings included: Review of policy titled “GOVERNING BODY,” POLICY #4-004.1, REVISED APRIL 2020, revealed the following: POLICYThe governing body will assume full legal authority and responsibility for the operation of Primecare Hospice and Palliative Care. The governing body of Atlanta Regional Hospice will serve as the governing authority for the hospice program, which will function according to Atlanta Regional Hospice bylaws. PROCEDUREThe Governing Body must ensure that the QAPI program: D. Focuses on indicators related to improved palliative outcomes E. Takes action to demonstrate improvement in hospice performance Cross reference to L0520 relating to INITIAL & COMPREHENSIVE ASSESSMENT OF PATIENT. Cross reference to L0523 relating to TIMEFRAME FOR COMPLETION OF ASSESSMENT. Cross reference to L0524 relating to CONTENT OF COMPREHENSIVE ASSESSMENT. Cross reference to L0569 relating to PROGRAM ACTIVITIES. Cross reference to L0573 relating to PERFORMANCE IMPROVEMENT PROJECTS. Cross reference to L0580 relating to CONTROL. Cross reference to L0596 relating to COUNSELING SERVICES. Cross reference to L0663 relating to TRAINING.”

“Based on review of undated policy titled “EDUCATION & COMPLIANCE ANNUAL REVIEW WORKSHOP,” human resource (HR) files, and staff interview, it was determined that the agency failed to assess the skills and competence of all individuals that provide care. Specifically, the facility failed to provide evidence of completed competency assessments for four individuals, Register Nurse (RN) FF, Chaplain (CH) GG, Registered Nurse (RN) AA, and Dean of Nursing (DON), of eight HR files reviewed. Findings included: Review of the facility’s undated policy titled “EDUCATION & COMPLIANCE ANNUAL REVIEW WORKSHOP,” revealed the following: POLICYAtlanta Regional Hospice holds an Annual Review Workshop yearly to educate existing staff on the mandatory policies as outlined by The State of Georgia Hospice Rules and Regulations. Topics covered include:Patients RightsInfection ControlFoley Catheter Insertion & carePalliative CareAbuse and Neglect Review of the HR file for RN FF revealed a hire date of 03/02/2026. Further review of the HR file revealed an incomplete initial competency assessment dated 02/27/2026. The competency assessment did not document that all required job specific skills were assessed in accordance with the facility’s policy. Specifically, the competency assessment lacked evidence of the assessment of foley catheter insertion and care. Review of the HR file for CH GG revealed a hire date of 07/15/2025. Further review of the HR file revealed an incomplete competency assessment dated 12/29/2025 with the letters “N/A” written across the document. Review of the HR file for RN AA revealed a hire date of 04/22/2025. Further review of the HR file revealed an outdated competency assessment dated 04/22/2025. Review of the HR file for DON revealed a hire date of 08/14/2021. Further review of the HR file revealed an outdated competency assessment dated 08/14/2021. On 06/10/2026 at 12:10 PM, an in-office interview was conducted with the Administrator, who confirmed that all documentation had been provided for competency assessments. The administrator acknowledged that the facility provides foley catheter training during the initial orientation and annual training. The administrator stated, “we take care of condom caths all the time.””