Survey Report for 111633

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	111633	A. BUILDING __________ B. WING ______________	07/28/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
DYNAMIC HOSPICE	2799 LAWRENCEVILLE HWY, SUITE 106, DECATUR, GA, 30033
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
L0554	26450 Based on clinical record review and staff interviews, it was determined the hospice failed to develop and maintain a system of communication and integration, in accordance with the hospice's written policy titled, "Management Staff Functions" dated 5/17/04 to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided for 1 of 4 sampled patients (P#2). Finding were: 1. Review of clinical record for P#2 revealed the patient was admitted to hospice on 2/14/20 and hospice aide services were requested to assist with the P#2 personal needs. During the time frame of 2/14 - 3/6/20 the clinical record lacked documentation to indicate the agency provided aide visits to assist the caregiver with the patient's personal needs. The clinical record also lacked documentation of coordination of care with team members to ensure the patient/caregiver received the services needed to ensure proper care and safety of the patient. Additionally, the clinical record indicated that respite care was requested for the week of 2/29/20 however, the agency never provided the respite care as requested. The clinical record lacked any documentation of coordination of care with team members to arrange respite care for the patient and caregiver. 2. During an interview with Employee #1 ( Clinical Director) on 7/28/20 at approximately 11:00 a.m., Employee #1 did acknowledge that the clinical record lacked documentation of care coordination efforts for aide visits and respite care to provide services for the identified needs of the patient.