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
111577 A. BUILDING __________
B. WING ______________ 		06/06/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
WEINSTEIN HOSPICE: YAD V'LEV 3150 HOWELL MILL ROAD, NW, ATLANTA, GA, 30327
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)
L0555      
38989 Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to have complete documentation of nursing visits in the clinical record for 1 of 1 (#3) sampled patients. Findings were: 1. Patient # 1(P#1) was admitted by the hospice on November 26, 2022 with a terminal diagnosis of malignant carcinoid of ileum. The patient wife revoked hospice on 1/21/2022. 2. The interdisciplinary plan of care for P #1 specified that the nurse would visit the patient 2-3 times per week. The patient's clinical record lacked documentation of nursing visits from 12/31/2021 until discharged on 1/21/2022. 3.. In an interview on June 9, 2022 at 9:00 a.m., the Administrator stated the nurse did make the visits to patient #1; however failed to document the visits. The Administrator acknowledged the state regulation that all documentation should be incorporated into the clinical record within 7 days of the service provided. The Administrator stated she had no documentation regarding any visits by the registered nurse.
L0604      
38989 Based on record review and staff interview it was determined that the agency failed to provide physical therapy (PT) to 1 of 3 (#) patients reviewed. The census at time of survey was 44. Findings include: 1. Review of patient # 1 medical record revealed a request from patient's wife for a physical therapy consult to help with weakness. The agency failed to arrange for physical therapy consult. 2. Review of contracts revealed the agency did not have a current contract for PT services. 3. Interview with the DON and Administrator on June 2, 2022 at 11:00 a. m. revealed the Administrator had called two agencies and stated they were not able to provide the service. The Administrator notified the patient's wife of the difficulty with obtaining the physical therapy assessment. The DON and the Administrator stated that no further action was taken regarding the PT consult.
L0672      
38989 Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to have complete documentation of nursing visits in the clinical record for 1 of 1 (#3) sampled patients. Findings were: 1. Patient # 1(P#1) was admitted by the hospice on November 26, 2022 with a terminal diagnosis of malignant carcinoid of ileum. The patient wife revoked hospice on 1/21/2022. 2.The interdisciplinary plan of care for P #1 specified that the nurse would visit the patient 2-3 times per week. The patient's clinical record lacked documentation of nursing visits from 12/31/2021 until discharged on 1/21/2022. 3.. In an interview on June 9, 2022 at 9:00 a.m.in the agency boardroom, the Administrator stated the nurse did make the visits to patient #1; however failed to document the visits. The Administrator acknowledged the state regulation that all documentation should be incorporated into the clinical record within 7 days of the service provided. The Administrator stated she had no documentation regarding any visits by the registered nurse.
L0678      
38989 Based on clinical record review and interview with the Administrator, it was determined that the hospice failed to document an order for foley catheter on patient # 1 (P # 1). Findings include: 1. Review of patient records revealed the agency failed to ensure all orders were written on 1 of 3 patients reviewed. The visit note for P # 1 dated 12/3/2021 documented 'having difficulty voiding, obtained order for Foley,Procedure tolerated well.' No order for foley documented. 2. Interview on June 9, 2022 at 9:45 a. m. with the DON revealed there was no order written for an indwelling Foley catheter.
L0784      
38989 Based on record review and staff interview it was determined that the agency failed to maintain the human resource file for 1 of 4 personnel files reviewed. The census at time of survey was 44. Findings include: 1. Review of personnel files revealed the agency failed to maintain the human resource file for one of four employees. The file for employee # 1 did not contain the person's application, employment history, emergency contact information, evidence of qualifications, job description, evidence of initial and annual health screening, yearly skills competency assessments, evidence of verified licensure or certification, and evidence of orientation, education, and training. 2. Group interview with the DON, Human Resources Manager,and Administrator on June 2, 2022 at 10:30 a. m. in the boardroom of the agency revealed the employee file was incomplete. The DON stated she wasn't sure if she had to keep a file on the nurse practitioner. The Administrator stated the agency did not have a complete file on the nurse practitioner. The Administrator did verify the nurse practitioner was a full-time employee of the agency.