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
111640 A. BUILDING __________
B. WING ______________ 		12/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ACCENT CARE HOSPICE & PALLIATIVE CARE OF GEORGIA 11675 GREAT OAKS WAY, SUITE 310, ALPHARETTA, GA, 30022
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)
L0523      
37796 Based on clinical record review and staff interview, it was determined that the hospice failed to ensure the hospice social worker completed the initial comprehensive psychosocial assessment to assess the patient's psychosocial status and needs within five days of admission to hospice services for one of nine (#1) patients who currently receive hospice services. Findings: 1. Review of the clinical record for Patient #1 revealed that the patient was admitted on 11/14/19. Documentation reflected that the initial psychosocial assessment was completed on 11/23/19, 9 days after the patient was admitted. The clinical record lacked documentation regarding the staff's delay in completing the psychosocial assessment. 2. During an interview on 12/18/19 at 11:00 a.m. the executive director and the acting director of nursing verified that the surveyor had been provided with all available documentation for the clinical records.
L0536      
37796 Based on review of clinical records; IDG care plan, plan of treatment and staff interview, it was determined the hospice failed to ensure that the requirements for the interdisciplinary group, care planning and coordination of services were not met. The hospice failed to ensure that the initial plan of care was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician , (Refer to L537); failed to ensure that hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire , (Refer to L543); failed to ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care , (Refer to L544); failed to ensure that the plan of care reflected all disciplines and interventions necessary to address the patient's assessed problems and needs , (Refer to L545); failed to ensure that the plan of care reviews/updates included a specific frequency of visits for the nurse, aide, social worker, chaplain and volunteer (Refer to L547); and failed to ensure that the plan of care included the interdisciplinary group's documentation of the patient's or representative's understanding, involvement and agreement with the plan of care ,(Refer to L551), failed to ensure that the plan of care review process included documentation of the patient's progress toward the specific goals and outcomes reflected in the plan of care (Refer to L553). The cumulative effects of these systemic problems resulted in the hospice's inability to ensure the provision and availability of all services that effectively met the patients' and their caregivers' needs
L0537      
37796 Based on clinical record review and staff interview, it was determined that the hospice failed to ensure that the initial plan of care was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician for 1 of 9 ( #9) sampled patients. Findings: Review of the clinical record for patient #9 revealed that the patient was admitted on 12/13/19, however, the clinical record documentation lacked a written plan of care for the patient. During an interview on 12/18/19 at 11:00 a.m., the executive director and the acting director of nursing confirmed the plan of care was not available for the hospice surveyor to review at the time of the survey.
L0543      
37796 Based on clinical record review and staff interview, it was determined that the hospice failed to ensure that hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire for 3 of 9 sampled patients (#1 #5 and #6) sampled patients. Findings were: 1. Review of the initial assessment summary dated 11/23/19 for patient #6 revealed that patient is thin, fragile and has generalized bruising with bruises to the left forehead and right thigh. However, the initial Plan of Care did not reflect assessment of skin integrity and the assessment and prevention of the bruises. Furthermore, the patient has foley catheter that needs to be changed on monthly basis, however, the foley catheter order does not specify the type of solution to inflate the balloon and the plan of care lack assessment and prevention of complications with foley catheters such as infections and blockage of urinary output. Additionally , the plan of care revealed an order to access the following line : INT/SC, (peripheral, subcutaneus, intravenous, PICC, epidural, etc.). During an interview on 12/17/19 at 1:00 p.m., the executive director verbalized that the order for access is in error and the patient does not have any intervenous line. The plan of care also did not reflect social worker evaluation to address and/ or meet the patient's psychosocial problems/needs, and a chaplain consult to address the initial and ongoing spiritual and bereavement needs. During an interview on 12/18/19 at 11:00 a.m., the acting director of nursing and the executive director confirmed that the plan of care lacked identified clinical nursing assessments/needs and social worker and chaplain evaluation for psychosocial and spiritual problems. 2.. Review of the clinical record for patient # 1 revealed that patient was admitted to the inpatient unit on 11/14/19 with the diagnosis of stage 2 pressure ulcer of sacral region. The wound care order dated 11/16/19 reads wound care twice daily. Review of the medication administration record (MAR) revealed the wound care order as follows: cleanse wound with wound cleanser. , apply barrier cream and gauze. During an interview with the registered nurse at the facility on 12/17/19 at approximately 4:00 p.m., the nurse confirmed that the nurse has been performing wound care as follows: cleanse wound with wound cleanser, apply barrier cream and gauze. However, the plan of care lacks such wound care order. During an interview on 12/18/19 at 11:00 a.m., the acting director of nursing and the executive director confirmed that the plan of care lacked a complete wound care order to treat patient's specific wound. 3. Review of clinical records for patient #5, revealed that patient was admitted to hospice on 7/20/19 with a diagnosis of acute myeloblastic leukemia. According to the plan of care patient has a life port to the right upper chest area and requires a nurse to flush with normal saline once monthly. the order reads as follows : skilled nurse to access lifeport to right upper chest monthly and flush with saline. However, the order lacks a complete step by step order clean the life port site and the amount of solution to flush the line. During an interview,on 12/18/19 at 11.00 a.m., the executive director and the acting director of nursing acknowledged that order for lifeport care is incomplete.
L0544      
37796 Based on clinical record review and staff interview, it was determined the hospice failed to ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care for 2 of 9 (#5 and #6) sampled current hospice beneficiaries. Finding were: 1. Review of clinical records for patient #5, revealed that patient was admitted to hospice on 7/20/19 with a diagnosis of acute myeloblastic leukemia. According to the plan of care patient has a life port to the right upper chest area and requires a nurse to flush with normal saline once monthly. However, the clinical record lacked documentation of education provided to the patient /family on the complications of life port. The agency failed to ensure that the pt/family received education by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. During an interview on 12/18/19 at 11:00 a.m. , the executive director and the acting director of nursing acknowledged that the patient/family were not given education on the complications of life port. 2. Review of the plan of care dated 11/23/19 for patient #6 revealed that patient has foley catheter that needs to be changed on monthly basis, however, the clinical record lacks education provided to the patient/caregiver on the complications of foley catheter; signs and symptoms of urinary tract infection or retention During an interview, on 12/18/19 at 11.00 a.m., the executive director and the acting director of nursing acknowledged that the patient/family were not given education on the complications of foley catheter; signs and symptoms of urinary tract infection or retention.
L0545      
37796 Based on review of clinical records and staff interview, it was determined that the hospice failed to ensure that an interdisciplinary plan of care was developed for each patient that reflected the specific problems identified in the assessments, goals and interventions, and services necessary to meet the assessed needs of the patient for 9 of 9 (#1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled patients who were current hospice beneficiaries. Findings were: 1. Review of the clinical record for patients #1, #2, #3, #4, #5, #6, #7, #8, and #9 revealed that each clinical record lacked a comprehensive interdisciplinary plan of care that included patient-specific problems and needs identified during the initial and updated comprehensive assessments, patient and family goals, interventions/tasks necessary to address the problems/needs, and the disciplines responsible and accountable for each intervention/task. During interview on 12/18/19 at 11:00 a.m., the executive director and the acting director of nursing confirmed that the plan of care lacked patient specific problems /needs and interventions specific to each discipline.
L0547      
37796 Based on clinical record review, it was determined that the interdisciplinary group failed to ensure that the plan of care reviews/updates included a specific frequency of visits for the nurse, aide, social worker, chaplain and volunteer for 6 of 9 (#1, #2, #3 #5 #8, and #9) sampled current hospice beneficiaries. Findings were : 1. Review of the plan of care for Patient #1, #2 #3 #5, #8 and #9 lacked frequency of visits for the social worker, chaplain and the volunteer. During an interview on 12/18/19 at 11:00 a.m., the executive director and the acting director of nursing confirmed that the plan of care for above mentioned records lacked frequencies for the social worker, Chaplain and volunteer. 2. Review of the clinical record for Patient #5 with the recertification period of 10/18/19 to 1/15/20 revealed that the plan of care lacked frequency of visits for the nurse, aide, social worker, chaplain and volunteer. During an interview on 12/18/19 at 11:00 a.m., the executive and the acting director of nursing confirmed that the plan of care lacked frequencies for the nurse, social worker, Chaplain and volunteer.
L0551      
37796 Based on clinical record review, it was determined that the hospice failed to ensure that the plan of care included the interdisciplinary group's documentation of the patient's or representative's understanding, involvement and agreement with the plan of care for 9 of 9 (#1, #2,#3, #4, #5, #6 #7, #8 and #9) sampled patients who were current hospice beneficiaries. Findings were: 1. Review of the plans of care for patients #1, #2, #3, #4, #5, #6, #7, #8 and , #9, revealed that the plan of care for each patient lacked documentation of the patient's or representative's level of understanding, involvement, and agreement with the plan of care 2. In an interview on 12/18/19 at 11:00 a.m., the executive director confirmed the plan of care lacked documentation of the patient or representative's understanding, involvement and agreement with the plan of care.
L0553      
37796 Based on review of clinical records, it was determined the interdisciplinary group failed to ensure that the plan of care review process included documentation of the patient's progress toward the specific goals and outcomes reflected in the plan of care for 7 of 9 (#1, #2, #3, #4, #5, #6, and #9) patients who were current hospice beneficiaries. Findings were: Review of the clinical record for patients #1, #2, #3, #4, #5, #6, and #9 revealed that documentation of the care plan review/revision for each patient lacked documentation regarding the patient's progress or lack of progress toward the specific goals and outcomes reflected in the plan of care. During an interview on 12/18/19 at 11:00 a.m., the executive director and the acting director of clinical service acknowledged the plan of care lacked documentation of the patient progress towards goals.
L0556      
37796 Based on clinical record review and staff interview it was determined the hospice failed to ensure the care and services provided are based on all assessments of the patient and family needs for 1 of 9 (#5) current hospice beneficiaries. Findings: The review of clinical record for patient #5 revealed no documentation of an initial spiritual assessment. During an interview on 12/18/19 at 11:00 a.m., the executive director confirmed that the surveyor was provided all available documentation of patient visits.
L0774      
37796 Based on clinical record review and staff interview, it was determined the hospice failed to ensure a coordinated plan of care that specifically identified the provider responsible for each intervention was included in the plan of care for two of nine (#4 and #6) sampled patients who resided in an assisted living facilities. Findings were: 1. The clinical record for patient #4 reflected that the patient was admitted to the hospice on 3/28/17 and resided in an assisted living facility. The hospice plan of care did not identify the specific provider and discipline responsible and accountable for each intervention/task/function. 2. The clinical record for patient #6 reflected that the patient was admitted to the hospice on 3/19/19 and resided in an assisted living facility. The hospice plan of care did not identify the specific provider and discipline responsible and accountable for each intervention/task/function. During an interview on 12/18/19 at 11:00 a.m., the executive director and the acting director of nursing confirmed that the plan of care did not specifically identify the provider responsible for each intervention/task/function included in the plan of care.