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
111680 A. BUILDING __________
B. WING ______________ 		11/17/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
LONGLEAF HOSPICE, LLC 2310 PARKLAKE DRIVE SUITE 325, ATLANTA, GA, 30345
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)
L0653      
42460 Based on a review of the answering services report, on-call log, clinical records, complaint logs,staff interview and policy titled, "No. H:2-040.1 titled "After Hours/Weekend Services" dated October 2015 , it was determined that the hospice failed to ensure that the on-call system allowed for on a 24-hour basis to calls received from patients and caregivers for five of five patients (P#) #1, #2, #3, #4 and #5) who experienced changes in their physical condition or at the time of death. Findings include: A review of the on-call log and patient record reviews revealed the following: 1. Review of the agency's documentation for the investigation revealed the family of P#1 called the answering service on 9/26/20 at 7:30 a.m. reporting the patient had died. The answering services records reported the call was relayed to the on-call nurse at 7:30 a.m. Another call was received by the answering service from the family of P #1 at 8:04 a.m. and relayed to the on-call nurse at 8:08 a.m. A third call was received by the answering service from the family of P#1 at 8:32 a.m. and patched through to the on-call nurse. A fourth call was received by the answering service from the family of P#1 at 9:03 a.m., and relayed to the on-call nurse at 9:10 a.m. P #1 was pronounced at 9:50 a.m. The agency's documentation of the incident further stated the "the time from the initial call to the pronouncement 7:38 a.m. to 9:50 a.m. was too long". The patient record did not contain any documentation from RN AA that she received these calls or contacted the family each time the answering service relayed a call to her. The only documentation provided was the visit note. 2. On 9/15/20 the Family of P #2 called the answering service at 3:30 a.m. to report the patient had died, the call was relayed to the nurse at 3:34 a.m. The family of P #2 called again at 4:44 a.m. and the call was relayed to the nurse at 4:49 a.m. RN BB arrived at P #2's home at 5:56 a.m. and pronounced the patient at 6:01 a.m. The patient record did not contain any documentation from RN BB regarding the calls or whether the family was contacted each time the answering service relayed the call. The only documentation provided was the visit note. 3. On 10/5/20 the family of P #3 called the answering service at 6:57 p.m. and the call was relayed to the nurse at 7:05 p.m. At 9:02 p.m. RN CC arrived at P #3 home to pronounce the patient. The patient record did not contain any documentation from RN CC regarding the calls or whether the family was contacted by the nurse after the answering service relayed the call. The only documentation provided was the visit note. 4. On 9/25/20 the family of P #4 called the answering service at 5:54 p.m. the call was relayed to the nurse at 6:11 p.m. The patient's record did not contain any documentation related to this call. 5. On 9/24/20 the family of P #5 called the answering service at 5:27 p.m. and the call was relayed to the nurse at 5:32 p.m. There is no documentation in the patient record for this call. A routine visit was made on patient #5 the following day 9/25/20 at 1:05 p.m. On 11/17/20 at 11:45 a.m. the Director of Clinical Services was not able to provide additional documentation from the patient records. A review of the hospice's policy No. H:2-040.1 titled "After Hours/Weekend Services" and dated October 2015 revealed the following information. "The on-call nurse will provide follow up appropriate to the call: Call the patient/family/caregiver; visit the patient if necessary. The policy also stated "The on-call nurse will document each patient family interaction in a clinical note" The policy went on the state, "The on-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page)." Finally, a statement on the policy under "Guidelines" reads "The following is meant to guide the after-hours nurse. It is not an exhaustive list but includes many problems that may require a visit from the hospice nurse." The first bullet point is "Death, suspected death." Based on record reviews, review of complaint logs, on-call policy and logs, and interviews with staff, the hospice violated their after-hours policy, Additionally, the hospice failed to ensure patients and families had timely access to 24-hour nursing services. This failure had the potential to cause the bereaved families additional stress. In an exit interview on 11/17/20 at 12:15 p.m., the Administrator and the Director of Clinical Services did not dispute the findings.