Deficiencies per Year
4
3
2
1
0
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Routine
Census: 8
Deficiencies: 0
Jul 6, 2020
Visit Reason
An onsite COVID-19 Focused Infection Control Survey was conducted by the State Agency at Heritage Hospice in Marietta, Georgia.
Findings
The agency was found to be in compliance with 42 CFR part 418.113 related to Emergency Preparedness. No deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 23, 2020
Visit Reason
The inspection was conducted as a complaint investigation for complaints GA00201813 and GA00201795. Complaint GA00201813 was unsubstantiated, while complaint GA00201795 was partially substantiated and resulted in cited deficiencies.
Findings
The facility failed to ensure that direct care staff hired after October 1, 2019 had the required criminal background check prior to employment, and the hospice failed to maintain clear and complete on-call logs for calls received after normal business hours during March and April 2019.
Complaint Details
Complaint # GA00201813 was unsubstantiated. Complaint # GA00201795 was partially substantiated and resulted in cited deficiencies related to background checks and on-call log documentation.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position. | SS= D |
| Failure to maintain a clear and complete on-call log for all calls received after normal business hours, including missing documentation of RN taking the call, time, response, and interventions. | SS= D |
Report Facts
Number of staff members hired after 10/1/2019 without required background check: 1
Months with incomplete on-call logs: 2
Inspection Report
Follow-Up
Deficiencies: 0
Jun 29, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 11, 2017
Visit Reason
The inspection was conducted as a complaint investigation for complaint number GA00172481 regarding the hospice's response to a patient's change in condition.
Findings
The hospice was found to have failed to respond in a timely manner to meet the needs of one sampled hospice patient who had a change in condition, resulting in substantiated complaint findings. The governing body also failed to provide oversight to ensure timely palliative care and symptom management.
Complaint Details
The complaint was substantiated. The hospice failed to respond timely from the initial call by the social worker on 1/21/17 at 4:15 PM until the RN arrived approximately 4 hours later at 8:05 PM on 1/21/17.
Severity Breakdown
standard-level: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to respond in a timely manner to meet the needs of a hospice patient who had a change in condition. | standard-level |
| Failure of the governing body to provide oversight to ensure timely palliative care and symptom management for a hospice patient with a change in condition. | standard-level |
Report Facts
Complaint number: GA00172481
Dates of patient visits: Patient admitted 12/29/16; nurse visits on 1/6/17, 1/12/17, 1/21/17; patient pronounced deceased 1/22/17
Time delay: 4
Inspection Report
Census: 12
Deficiencies: 3
Jan 19, 2017
Visit Reason
The survey was conducted to determine compliance with Federal regulations related to fire safety and building code requirements at Heritage Hospice, Inc.
Findings
The facility failed to maintain smoke resistance by holding a rated door open with a rubber wedge, failed to assure smoke/fire wall continuity due to a penetration hole above the ceiling, and allowed a portable space heater in a staff area, placing residents and staff at risk in the event of fire.
Deficiencies (3)
| Description |
|---|
| Facility failed to assure smoke resistance in compartment by holding a rated door with a door closer open with a rubber wedge device. |
| Facility failed to assure smoke/fire wall continuity due to a 2x2" penetration hole above the ceiling at the smoke compartment doors. |
| Facility failed to assure safety by allowing a portable space heater under a desk in the Marketing / Admissions office. |
Report Facts
Number of residents and staff at risk: 6
Number of residents and staff at risk: 12
Number of staff at risk: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during tour of the facility |
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