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
111560 A. BUILDING __________
B. WING ______________ 		01/12/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE 700 BROOKSTONE CENTRE PARKWAY, SUITE 100, COLUMBUS, GA, 31904
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)
L0554      
26450 Based on clinical record review and staff interview, it was determined the hospice failed to develop and maintain a system of communication and integration that ensured the interdisciplinary group maintained responsibility for directing, timely coordination, and supervising the care and services provided for 1 of 11 active sampled patients (P#3). The finding include: Review of the clinical record for P#3 revealed the patient was admitted to hospice services on 10/14/21, with a diagnosis of pure hypercholesterolemia. The hospice aide services were ordered three times a week starting 10/16/21. The patient was admitted to services on 10/14/21, with a plan of care that required the hospice aide to provide shower baths to the patient three times a week for twelve weeks. On 10/28/21, the hospice aide reported to supervisor that the patient was not safe with one person transfer to the shower as the patient was combative and reluctant to get in shower. On 10/29/21, the caregiver met with the interdisciplinary team to discuss the patient's safety during the shower bath and to consider bed baths as an option for bathing. The complainant was not in agreement with a bed bath being given and was insistent on a shower bath being given. During the meeting, the Administrator agreed to perform a home visit to observe the shower activity with the aide and patient on 11/2/21. The clinical record did not show evidence that the Administrator performed the home visit on 11/2/21, as stated. On 11/4/21, a physician's order was written for aide services to be placed on hold for 2 weeks until safety issue could be resolved. On 11/11/21, a physician's order was written to obtain a safety risk assessment however, the order was not followed up until 12/7/21, (26 days later). During this time, the patient was not receiving hospice aide services. On 11/23/21, the order was extended to hold aide services for an additional two weeks until a physical therapy (PT) evaluation was completed. An order for a physical therapy evaluation was written 12/7/21, to obtain a safety risk assessment and sent to Kindred Home Health via email and fax. The PT evaluation was completed on 12/14/21, with safety recommendations. A physician's order dated 12/14/21, resumed hospice aide services to visit the patient three times a week. On 12/15/21, the agency was able to notify the complainant that the decision was made to place two aides in the home to provide the shower bath. The complainant was in agreement for the dual aides to start on 12/17/21. During an interview with the Administrator on 1/12/22, at approximately 11:00 a.m., the Administrator acknowledged that the clinical record lacked documentation of timely care coordination efforts with the team to ensure that the safety risk assessment was completed timely to ensure the patient was receiving the care and services needed to meet the needs of the patient.