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
111508 A. BUILDING __________
B. WING ______________ 		10/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE ATLANTA 5775 GLENRIDGE DR, SUITE E200, ATLANTA, GA, 30328
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)
L0505      
42460 Based on interviews with staff and family, record reviews, including the policy titled "Complaint Grievance Process", the hospice failed to ensure that the family's complaints were handled based on the agency's policy and with a timely resolution that included follow up notification to the family for one of one (Patient #1) patient receiving hospice services. 1. Patient #1 was admitted to a contracted Inpatient Unit (IPU) on November 26, 2019 for a five day respite stay on November 28, 2019, the Licensed Medical Social Worker (LMSW) visited with P#1 and a family member. During the LMSW visit the family member voiced concerns related to the care provided by the contracted respite facility. The LMSW offered to call a Hospice Clinical Manager, but family member stated they would call later. No further documentation from the LMSW was found in the medical record or in the hospice's "Complaint Report". 2. On December 2, 2019 P #1's caregiver called the hospice and spoke with the Clinical Services Manager. This conversation is documented in the P#1's medical record on December 4, 2019 as a late entry. This complaint was not entered on the Hospice's "Complaint Report". No further documentation was presented. 3. On December 4, 2019 P #1's caregiver called the hospice and spoke with the Director of Hospice Operations. The complainant alleged displeasure with the way she was treated when she called to complain on December 2, 2019. 4. Review of the document titled "Complaint Form, and the policy titled "Complaint Grievance Process" dated April 2020, revealed the hospice failed to follow their policy for complaints. Documentation of the Complaint report was as follows: Description-Complaint was about manner in which complainant was treated by Clinical Services Manager over the phone. Said (the complainant) that the Clinical Services Manager was reacting from personal emotions and not listening to what was going on with P #1's needs. States that the Clinical Services Manager told complainant "'Everybody is not going to satisfy you the way you want". Interventions- "F/U with Client/Caregiver" Prevention- "Other" Follow-up comments-Follow up visit made to home and assessment completed on patient. Continued follow up with respite facility to corroborate care that was provided. The "Complaint Form" was processed on January 12, 2020 at 10:08 a.m. Review of the hospice's policy titled "Complaint Grievance Process" revealed the following: Procedure 1. The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance. The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient's satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. 2. If the grievance cannot be resolved to the patient's satisfaction, the patient or his/her representative is to notify, verbally or in writing, the Executive Director/Administrator. The grievance must state the problem or action alleged and the date the supervisor was notified. The Executive Director/Administrator or designee will then investigate the grievance and contact the patient or his/her representative regarding the grievance in an attempt to resolve the differences. The Executive Director/Administrator will respond to the patient within ten (10) days of notification of failure to resolve the complaint. 3. If the patient feels his/her grievance has not been resolved after working with Visiting Nurse Health System personnel, he/she will be informed of his/her right to notify the state or CHAP via the respective toll-free telephone numbers. 4. Complaints and any action taken will be documented on a complaint form. In a phone interview with the Director of Hospice Operations on October 8, 2020 at 3:10 p.m., the Director stated there was no additional documentation. The complaints received by the LMSW on November 28, 2019 and by the Clinical Services Manager on December 2, 2019 were not documented on the Complaint report or handled based on policy. Furthermore, the Director stated the follow up made to the complainant had not been clearly documented.
L0530      
37796 Based on the clinical record review and staff interview it was determined that the agency failed to ensure that the clinical record included a medication profile that addressed common side effects of medications that are anticipated, and preventive measures for 1 of 3 sampled patients (P#3). Findings include: 1. Review of the clinical record review revealed that P#3 resides in an Assisted Living Facility (ALF) and was admitted to hospice services on January 17, 2020. Review of the plan of care dated July 15, 2020 to September 12, 2020 revealed a medication profile which was electronically signed and dated on October 5, 2020 by the Medical Director of hospice agency. During clinical record review the surveyor, compared the medication profile of the hospice agency with the ALF's medication administration record (MAR). According to the agency medication profile that was given to the surveyor P#3's medications include Famotidine ( H2 blocker, used to treat heart burn) 20 mg, Probiotic blend 2 billion cell (used for upset stomach and to improve digestion) 50 mg and Mucinex (an expectorant to loosen congestion) 600 mg., these medications were not listed on the ALF's MAR. Furthermore, the ALF's MAR revealed that the P#3 is on oxygen 2 liter via nasal cannula as needed for shortness of breath, however, the agency medication profile revealed that P#3 is on oxygen 2 liter via nasal cannula continuously. During a phone interview on October 7, 2020 at approximately 3:15 p.m., with the hospice staff nurse AA, she stated that the patient does not use oxygen continuously. The hospice staff nurse AA stated that the nurse assesses the patient's respiratory status on each visit and pulse oximetry runs between 93 to 95 % with no signs of respiratory distress. During an interview on October 7, 2020 at 4:00 p.m., with the Director of Hospice Operations, it was revealed that that the medications were discontinued on July 15, 2020, and the agency medication profile has not been updated to reflect the current facility MAR. The Director also stated that the patient uses oxygen 2 liters on as needed basis for shortness of breath. On October 7, 2020 at 7:40 p.m., the Director of Hospice Operations provided the surveyor with the updated and revised medication profile which reflect the same medications on the facility MAR. The agency failed to ensure that the plan of care and the clinical record has a medication profile which includes the review of all current medications. During a phone interview on October 8, 2020 at 11:30 a.m., with the Director of Hospice Operations and the Clinical Manager, it was confirmed that the medication profile that was provided to the surveyor on October 6, 2020 did not reflect the current MAR from the facility where the patient currently resides.