Survey Report for 111627

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	111627	A. BUILDING __________ B. WING ______________	05/27/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
COMPASSUS-KENNESAW	300 CHASTAIN CENTER BLVD SUITE 345, KENNESAW, GA, 30144
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)
L0500
L0500	37796 Based on interviews, record reviews and review of the agency's policy titled "HIPPA Privacy Rule Policy #3" the agency violated patient's (P#1) rights when they failed to protect health information. The agency communicated P#1's health information to a visitor. This failure resulted in immediate jeopardy in which the agency had caused or had the likelihood to result in violation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) to protect patient health information from being disclosed without the patients/ Power of Attorney consent or knowledge. The immediate jeopardy was related to the agency's noncompliance with the program requirements at 418.52 Condition of Participation: Patient's Rights (L 500), 418.52(b)(1) Exercise of rights and respect for property and person ( L505) , and 418.52(c)(5) Patient right to confidential medical record. (L516). These systemic problems resulted in the hospice agency's inability to ensure and safeguard patients rights, respect of person and right to confidential medical record.
L0505
L0505	37796 Based on interviews, record review and review of the agency's policy titled "HIPPA Privacy Rule Policy #3" the agency failed to protect patients rights and failed to involve the patient's power of attorney (POA) or designee in decisions about their care, treatment and services. The agency's failure created an immediate jeopardy in which the agency violated Health Insurance Portability and Accountability Act of 1996 (HIPPA) to protect patient health information from being disclosed without the patients consent or knowledge. The agency violated patient rights to protect patient's health information for one patient (P#1) out of six patients P#2, P#3, P#4, P#5, P#6 reviewed for patient rights and privacy. Findings include: Review of the plan of care for P#1 with a certification period of 2/25/21 to 5/25/21, revealed P#1 was admitted to hospice with the diagnoses of Dementia and Bullous Pemphigoid (an autoimmune pruritic skin disease). The patients Brief Interview Mental Status Scored 1, (severe cognition impact). Review of the consent and HIPPA forms dated 2/25/21, documented the patient's daughter as the POA. Review of complaint #GA00214534 documented that a nurse at the facility had taken pictures of the patient's (face and bottom) and shared them with a non-family/non-POA person. During a telephone interview on 5/19/21, at 9:30 a.m., with a visitor of P#1 she stated, during her visit on 4/29/21, with the patient a hospice nurse from Compassus showed her the photos she had taken on her personal phone. The nurse also shared verbal information about the patient's health conditions. This visitor was not an authorized POA. During an interview in the agency office on 5/19/21, at 12:30 p.m., the Area Director stated, according to the policy titled " Procedure: C_15 B Wound Management", "the agency does not take photos of the wound but obtains wound measurements on a weekly basis". On 5/20/21, at 9:00 a.m., during a telephone interview with the POA/daughter, it was confirmed that she is the patient's POA and no one else is listed on the form titled, "consent to share health information with designated individuals". During a telephone interview on 5/20/21, at 9:27 a.m., with Registered Nurse AA she confirmed that during a visit on 4/29/21, the patient's health information was shared verbally with her. Review of the agency's policy titled "HIPAA Privacy Rule Policy #3" required the agency to never store patient health information on non-Compassus-owned computers, laptops or computer readable storage media. The agency failed to follow their written policy titled, "HIPAA Privacy Rule Policy #3". Patient #1's privacy rights were violated when RN AA verbally and visually (photos) shared personal health information with a visitor. This practice resulted in the HIPPA violation of respect of property and person. During an interview on 5/20/21, at 1:30 p.m., the Area Director confirmed, P#1's privacy was violated by sharing photos and verbally sharing the patient's health information with the visitor. This practice resulted in failure to protect and safeguard patient's confidential clinical information from unauthorized disclosure without the specific informed consent of the patient or the POA for the patient.
L0516
L0516	37796 Based on staff interviews, record reviews, review of the agency's policy titled "HIPPA Privacy Rule Policy #3" the agency failed to protect and safeguard patient's confidential clinical information from unauthorized disclosure without the specific informed consent of the patient legal representative for one of six patients (P) (P#1), P#2, #3, #4, #5, #6 reviewed for patients rights and privacy. This immediate jeopardy existed in which the agency had caused or had the likelihood to violate patient's right's to a confidential medical record. Findings include : Review of the plan of care for P#1 with a certification period of 2/25/21 to 5/25/21, revealed the patient was admitted to hospice with the diagnoses of Dementia and Bullous Pemphigoid (an autoimmune pruritic skin disease). The patients Brief Interview Mental Status Scored 1, (severe cognition impact). Review of the consent form and Health Insurance Portability and Accountability (HIPPA) form dated 2/25/21, documented the patient's daughter as the Power of Attorney (POA). During a telephone interview on 5/19/21, at 9:30 a.m., with a visitor of P#1 she stated, on 4/29/21, during her visit with the patient a hospice nurse from Compassus showed P#1's photos she had taken of P#1 on her personal phone. The nurse also shared verbal information about the patient's health conditions. This individual was not an authorized POA. During a telephone interview with the POA on 5/20/21, at 9:00 a.m., it was confirmed that she is the POA and no one else was listed on the form titled "consent to share health information with designated individuals". The agency failed to follow their written policy titled "HIPAA Privacy Rule Policy #3". The agency violated P#1's rights to confidential medical record by sharing photos and verbally sharing the patient's health information and findings with the visitor. During an interview in the agency office on 5/20/21, at 1:30 p.m., the Area Director confirmed the agency failed to protect and safeguard patient's confidential clinical information from unauthorized disclosure without the specific informed consent of the patient or legal representative for P#1 which resulted in the violation of patient's right of confidential medical record.
L0545
L0545	37796 Based on clinical record review and staff interviews, it was determined that the interdisciplinary group failed to ensure that the plan of care addressed specific, individualized interventions necessary for the palliation and management of the terminal diagnosis for four of four patients (P#) (P #1, #4, P#5, P#6) with wound care orders. Findings include: 1. Review of the plan of care for P#1 for certification period 2/25/21 to 5/25/21, revealed the patient was admitted with the diagnosis of cellulitis (a common and potentially serious bacterial skin infection) of the right toe. Review of the admission assessment dated 2/25/21, the skilled nurse documented the wound on the right toe. However, the Hospice plan of care dated 2/25/21, did not have orders for wound care/management for the right toe. On 3/5/21 the verbal order for wound care did not specify the location of the wound. The agency failed to ensure that the hospice initial plan of care included the wound care for the patient. During an interview in the agency office on 5/20/21, at 1:30 pm, the Area Director (AD) acknowledged that the plan of care did not contain specific, individualized interventions for wound care necessary for the palliation of and management of the terminal diagnosis. 44327 2. Review of the clinical record for P#4 for certification period 4/13/21 to 6/11/21, revealed an incomplete physician's order for wound care. The physician's order dated 4/25/21, failed to specify the exact the location of wound. 3. Review of P#5's clinical record for certification period 3/31/21 to 6/28/21, revealed an incomplete physician's order for wound care. The physician's order dated 4/12/21, failed to specify the exact location of the wound. 4. Review of P#6 clinical record for certification period 2/15/21 to 4/15/21, revealed an incomplete physician's order for wound care. The physician order dated 2/15/21, failed to specify the exact location of the wound. The clinical record also contained a physician's order for wound care on 2/16/21, the order did not specify the type of dressing to cover the wound. During interview in the agency office on 5/20/21, at 1:30 p.m., the Area Director acknowledged that the plan of care did not contain specific, individualized interventions for wound care necessary for the palliation of and management of the terminal diagnosis.