DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
111507 A. BUILDING __________
B. WING ______________ 		09/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
WELLSTAR COMMUNITY HOSPICE 4040 HOSPITAL WEST DRIVE, AUSTELL, GA, 30106
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0530      
37796 Based on interviews with staff, review of clinical records, care plans, drug profiles and the interdisciplinary group (IDG) it was determined that the agency failed to review patient's prescription drugs, for the effectiveness of drug therapy, side effects, actual or potential drug interactions and possible duplicate drug therapy for 1 of 2 patients (P#1) who were hospice beneficiaries. Findings include: Review of P#1's initial care plan dated 8/12/20 and follow up care plan dated 8/27/20, revealed that patient was taking lorazepam (sedative) 1 mg every 4 hours as needed for anxiety, agitations, seizures, Haldol (antipsychotic) 1 mg as needed for agitation, hallucinations, nausea/vomiting and Clonazepam (sedative) 0.5 mg every 12 hours for anxiety. Review of the skilled nurse visit notes dated 8/20, 8/23, 8/27, 9/2, 9/5, and 9/10/20 lacked evidence of teaching and monitoring of the effectiveness or side effects of these medications. There was no evidence in the clinical records to address the duplication of medications to treat the same symptoms nor evidence that non-pharmacological interventions that are noted in the care plan were implemented. During an interview with the Administrator, Director of Nursing and nursing's staff on 9/16/2020 at 4:30 p.m., it was confirmed that the skilled visit notes dates mentioned above did not include teaching and monitoring of the specific medications related to anxiety. Refer to L0533
L0533      
37796 Based on interviews with staff, review of skilled nurse visit notes, interdisciplinary group (IDG) notes and the plan of care, it was determined that the agency failed to develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures titled ( DPP-23 Interdisciplinary Plan of Care). The agency also failed to ensure that the plan of care review process included documentation of the patient's progress toward desired outcomes, as well as a reassessment of the patient's response for 1of 2 (Pt#1)) patients who were current hospice beneficiaries. Findings Include : Review of the plan of care and IDG meeting notes dated 8/12/20 and 8/27/20, revealed interventions for P#1 when experiencing anxiety, discuss methods to reduce anxiety with patient and family, provide ideas such as relaxation techniques, periods of rest, talking through emotions. Review of the skilled nurse visit notes dated 8/20/20, 8/23/20, 8/27/20, 9/2/20, 9/5/20, and 9/10/20 lacked evidence that the specific interventions such as relaxation techniques were implemented for P#1 when experiencing anxiety. Further review of visit notes did not contain documentation that non-pharmacological interventions noted on the care plan nor the patient's response to any of the interventions if implemented. The IDG failed to ensure that the specific interventions for patient's anxiety were implemented in accordance with the plan of care. Review of the plan of care dated 8/12/20 and 8/27/20 also revealed that the goals for this patient experiencing anxiety is that patient will express decrease in anxiety as evidenced by a reported decrease in the Edmonton's scale anxiety score from 5 to 2 within the next 2 weeks. However, the review of the skilled nurse visit notes dated 8/20/20, 8/23/20, 8/27/20, 9/2/20, 9/5/20, and 9/10/20 lacked documentation of patients' progress or lack of progress towards the specific goals related to anxiety reflected in the plan of care. The agency also failed to follow their own policies and procedures, titled ( DPP-23 Interdisciplinary Plan of Care) to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided to the patient and that the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group(IDG) in collaboration with the individual's attending physician, and evaluate the changes that have taken place since the initial assessment. During an interview on 9/16/20 at 4:30 p.m.,with the Director of Nursing (DON) and the agency nursing staff, it was confirmed that the progress towards specific goals related to anxiety were not documented on the plan of care review. This DON and agency staff also confirmed that the nursing visits did not contain documentation that the non-pharmacological interventions noted on the care plan nor the patient's response to any of the interventions if implemented.