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)
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37796 42460 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 two of six (#1 and #4) patients who currently receive hospice services. Findings: 1. Review of the clinical record for patient #1 revealed that the patient was admitted on 1/25/20. Documentation revealed the social worker contacted patient on 1/29/20 and left a voicemail. The record revealed documentation at the 2/5/20 interdisciplinary team meeting that services had been declined. The record had no further documentation of additional attempts to contact patient. The record had no documentation that patient or representative had declined social work services. 2. Review of the clinical record for patient #4 revealed that the patient was admitted on 2/9/20. Documentation reflected that the social worker contacted the caregiver by phone on 2/12/20. The social worker documented the caregiver declined a visit at this time. The records revealed no further contact to arrange a visit. The clinical record lacked specific documentation that the caregiver was declining social work services. During an interview on 3/3/20 at 11:30 a.m. the executive director verified that social worker services had been declined by both patients, but agreed there was no clear documentation of patient refusal.
L0543      
37796 42460 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 three of six sampled patients ( #3, #5 and #6) who were receiving hospice services. Findings were: 1. Review of the clinical record for patient #3 revealed that patient was admitted to the inpatient unit under general inpatient level of care on 2/29/20 with a terminal diagnosis of COPD. Admission orders were for continuous administration oxygen at 3 liters per minute via a nasal cannula. The patient also had an order for Bilevel positive airway pressure (BiPAP). The order had no specified frequency as in: continuous, as needed, or only at night. The medical record reveals no skilled nurse assessment findings of the patient wearing the BiPAP, only the oxygen, on record reviewed from 2/29/20-3/1/20. The record also did not have any orders to discontinue the BiPAP. The patient also had a peripheral intravenous access device in the right inner arm. The orders were to flush the device with 5 milliliters of normal saline daily and following administration of intravenous medications. The normal saline flush was not listed on the patient's medication list. The medical record nor the medication administration record documented daily flushes or flushes with intravenous medication administration. However, the medication administration record did reveal the patient receiving the morphine sulfate intravenously throughout their stay. During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the plan of care lacked identified clinical nursing assessments/needs and the plan of care was not followed. 2. Review of clinical record for patient #5 revealed the patient was admitted to the inpatient unit under general inpatient level of care on 2/27/20 with a terminal diagnosis of malignant neoplasm of the pancreas. The patient had a Foley catheter. The hospice aide care plan required the aide to perform catheter care twice per shift. The care plan did not specify the type of catheter care. There is no documentation that catheter care was performed on either shift on any records reviewed from 2/27/20-3/1/20. During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the plan of care lacked identified clinical nursing assessments/needs and the plan of care was not followed. 3. Review of clinical record for patient #6 revealed the patient was admitted to the inpatient unit under general inpatient level of care on 2/25/20 with a terminal diagnosis of Parkinson's Disease. The patient also had a Foley catheter and the hospice aide care plan specified catheter care twice a shift. The care plan did not specify the type of catheter care. There is no documentation that catheter care was performed on either shift on any records reviewed from 2/25/20-3/2/20. Further review revealed on 2/26/20 the register nurse documented the patient had "complicated technical delivery of medication requiring registered nurse to do calibration, tubing changes, or site care." Patient does have three medications requiring IV administration which are: Ativan 1 milligram intravenous (IV) every 4 hours as needed for agitation, Morphine Sulfate 10 milligrams IV three times a day at 8 am, 2 pm, and 8 pm, and Robinul 0.2 milligram IV every 4 hours as needed for secretions. Further review of the medical record and medication administration record did not reveal any other specific orders or assessment finding for an intravenous access device, yet the orders were for at least one scheduled IV medication. During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the plan of care lacked identified clinical nursing assessments/needs and the hospice aide care plan was not specific and not followed 4. Review of the clinical record for patient #4 revealed that patient was admitted on 2/9/20 with a terminal diagnosis of non traumatic intracerebral hemorrhage. The patient also has a Foley catheter. On the initial plan of care the orders read: maintain Foley catheter, size: 14 French; balloon size: 10cc of saline. Change: prn (as needed). The skilled nurse assessment on 2/17/20 does not reference a catheter. The assessment findings read: incontinent, adult undergarments, number per day 3. The 2/27/20 skilled nurse assessment reads urinary catheter 16 French, balloon volume 5, balloon size During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the plan of care lacked consistent clinical nursing assessments/needs and the orders at not specific in keeping with standards of care. 5. Review of patient records revealed initial plan of care not consistently signed by the registered nurse for 6 of 6 patients (#1, #2, #3, #4, #5, and #6) who are receiving hospice services. During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the plan of care lacked registered nurse signatures. The director stated this was due to their electronic medical record program(EMR), but the agency is committed to correcting this problem. The director stated they would print plan of cares for signature and are planning on changing EMR programs later this year.
L0544      
37796 42460 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 1 of 6 (#4) sampled patients receiving hospice services. Finding were: 1. Review of clinical records for patient #4 lacked documentation of patient specific education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care. Teaching was documented in broad generalities: Medication side effects and monitoring and reporting, as opposed to which medications and side effects were taught. During an interview on 3/3/20 at 11:30 a.m., the executive director confirmed that the patient teaching was generalized and not patient specific.