Inspection Report Summary
The most recent inspection on May 11, 2022, identified deficiencies related to incomplete and inadequate plans of care for hospice patients, particularly concerning Foley catheter and PEG tube care. Earlier inspections showed a pattern of similar issues with updating comprehensive assessments and plans of care, especially regarding wound care and specific patient needs. A substantiated complaint investigation in early 2019 revealed multiple deficiencies in communication, pain management, wound care, and coordination with an assisted living facility, though follow-up surveys found those issues corrected. Complaint investigations since then were mostly unsubstantiated, and no fines or enforcement actions were listed in the available reports. The facility’s inspection history indicates some recurring documentation and care planning challenges but also shows improvement following corrective actions.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
146 residents
Based on a May 2022 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 146
Deficiencies: 3
Date: May 11, 2022
Visit Reason
The inspection was a licensure survey and recertification survey conducted to assess compliance with state regulations and infection control standards for Columbus Hospice, Inc.
Findings
The facility was found in compliance with criminal background checks and infection control. However, deficiencies were cited related to incomplete and inadequate plans of care for three hospice patients, specifically lacking detailed orders for Foley catheter and PEG tube care.
Deficiencies (3)
The plan of care failed to include specific orders for Foley catheter care including size, balloon inflation solution, and insertion steps for patient #4.
The plan of care lacked specific orders for PEG tube assessment and treatment to identify complications and infections for patient #3.
The plan of care lacked complete Foley catheter orders including insertion steps and balloon inflation details for patient #14.
Report Facts
Current census: 146
IPU census: 7
Number of patients with deficient plans of care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Participated in record review meeting and verbalized deficiencies in plan of care | |
| Administrator | Participated in record review meeting and verbalized deficiencies in plan of care |
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 2
Date: May 11, 2022
Visit Reason
The inspection was a recertification survey of Columbus Hospice, including a Focus Infection Control survey, conducted to assess compliance with hospice regulations.
Findings
The hospice was found to be in substantial compliance overall, but deficiencies were cited related to failure to update comprehensive assessments and plans of care. Specifically, the interdisciplinary group failed to document patient progress and response to wound care, and plans of care lacked specific orders for wound, Foley catheter, and PEG tube care for several patients.
Deficiencies (2)
Failure to update comprehensive assessments to include evaluation and documentation of patient's response to wound care and progress toward desired outcomes for two patients.
Plan of care did not reflect specific problems identified in assessments, goals, interventions, and services necessary to meet assessed needs for three patients.
Report Facts
Current census: 146
IPU census: 7
Patients reviewed for altered skin conditions: 3
Patients reviewed for plan of care deficiencies: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Participated in record review meeting and verbalized deficiencies in plan of care documentation | |
| Director of Nursing (DON) | Participated in record review meeting and verbalized deficiencies in plan of care documentation |
Inspection Report
Routine
Census: 17
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on July 7, 2020 at Columbus Hospice in Columbus, GA.
Findings
The facility was found to be in compliance with 42 CFR part 418.113 related to Emergency Preparedness. No deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2019
Visit Reason
Onsite follow-up survey conducted as a result of a complaint investigation (complaint number GA00194240).
Complaint Details
The follow-up survey was conducted due to complaint number GA00194240. All previously cited deficiencies were placed back in compliance.
Findings
Columbus Hospice was found to be in substantial compliance with applicable hospice regulations, and all previously cited deficiencies were corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2019
Visit Reason
Onsite follow-up survey conducted as a result of complaint number GA00194240 to verify compliance with 42 CFR Part 418, Requirements for Hospices.
Complaint Details
Complaint number GA00194240 triggered the follow-up survey.
Findings
The facility was found to be in compliance with all previously cited condition-level and standard-level deficiencies, which were placed back in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
The inspection was conducted as a complaint investigation for complaint number GA00200132.
Complaint Details
Complaint number GA00200132 was investigated and found not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited. The facility was found to be in compliance with the applicable rules and regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
The inspection was conducted as an onsite complaint investigation for complaint number GA00200132.
Complaint Details
Complaint number GA00200132 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with 42 CFR Part 418 Requirements for Hospices.
Inspection Report
Renewal
Deficiencies: 0
Date: Jul 18, 2019
Visit Reason
The visit was a recertification survey to assess compliance with 42 CFR Part 418, including Emergency Preparedness for Hospices.
Findings
Columbus Hospice, Inc. was found to be in compliance with emergency preparedness requirements and in substantial compliance with hospice requirements. No deficiencies were cited during this recertification survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 7, 2019
Visit Reason
An unannounced survey was initiated on May 7, 2019 to investigate complaint #GA00195786 regarding improper medication disposal.
Complaint Details
Complaint #GA00195786 regarding improper medication disposal was investigated and found to be unsubstantiated.
Findings
The survey revealed that Columbus Hospice, Inc. was in substantial compliance with 42 C.F.R., Part 418, Requirements for Hospices. The allegation of improper medication disposal was unsubstantiated based on review of three closed records, medication reconciliation forms, drug disposal policy and procedure, and staff interview.
Report Facts
Records reviewed: 3
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 12, 2019
Visit Reason
The inspection was conducted as a complaint investigation for complaint number GA00194240 regarding Columbus Hospice, Inc.
Complaint Details
The complaint was substantiated. The investigation revealed multiple failures including untimely communication with family members, inadequate pain management documentation, lack of wound care documentation, and failure to provide coordinated care plans with the assisted living facility.
Findings
The hospice was found non-compliant with multiple regulatory requirements including failure to ensure effective communication among hospice staff, patients, and families; failure to provide hospice care without physical or emotional abuse or neglect; inadequate documentation and involvement in the plan of care; and lack of coordination with the assisted living facility regarding patient care responsibilities.
Deficiencies (5)
Failure to ensure effective communication among hospice staff, care team, patients, and family members.
Failure to provide hospice care in a manner that neither physically nor emotionally abuses or neglects the patient.
Failure to develop the plan of care with input from the patient, family, caregivers, or representatives.
Failure to review and update the plan of care at required intervals with documentation of patient's progress.
Failure to ensure written communication and coordinated plan of care with the licensed assisted living facility, specifying responsibilities for care tasks.
Report Facts
Complaint call dates: 3
Date of patient death: Nov 23, 2018
Plan of care review interval: 15
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 12, 2019
Visit Reason
The inspection was conducted as an onsite complaint investigation for complaint number GA00194240 regarding Columbus Hospice, Inc.
Complaint Details
The complaint was substantiated based on findings of inadequate pain management, communication failures, lack of wound care, and failure to provide coordinated care and training to ALF staff.
Findings
The hospice failed to ensure adequate pain management, communication, wound care, and coordination with the assisted living facility (ALF). There was no documentation of medication teaching, pain assessment, wound care, or caregiver education on end-of-life care. Communication failures included lack of timely response to the ALF's calls and no coordinated plan of care provided to the ALF. The hospice also failed to provide training to ALF staff on hospice philosophy and care.
Deficiencies (9)
Failure to ensure patient and family received hospice care without physical or emotional abuse or neglect, including lack of pain medication teaching and communication with facility.
Failure to provide effective pain management and symptom control related to the terminal illness.
Failure to be free from mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of patient property.
Failure of interdisciplinary group to document patient's progress toward goals in plan of care.
Failure to include interventions to manage pain and symptoms in the plan of care.
Failure to maintain professional management of patient's hospice services including communication and coordination with ALF.
Failure to include in written agreement the manner of communication and documentation between hospice and facility to meet patient needs 24/7.
Failure to ensure hospice plan of care reflected participation and coordination with facility staff and designation of responsible providers for each task.
Failure to provide orientation and training to facility staff on hospice philosophy, policies, symptom management, and when to contact hospice.
Report Facts
Date of inspection: Feb 12, 2019
Patient admission date: Aug 31, 2018
Patient death date: Nov 23, 2018
Medication dosage: 7.5
Medication dosage: 2.5
Call time: 2300
Call time: 334
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