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
111708 A. BUILDING __________
B. WING ______________ 		09/23/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMPASSIONATE CARE HOSPICE OF NORTHERN GA, LLC 1061 DOWDY ROAD SUITE 206, ATHENS, GA, 30606
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)
L0584      
38966 Based on clinical record review, staff interviews and reviewed plan of care, agency failed to obtain physician's order to provide sacral wound care treatment for Patient (P#1). Finding Include: A review of P#1 medical record revealed that he was admitted to Hospice on 4/30/20, with a diagnosis of frontal lobe dementia in 2011, with comorbidity of cervical dystonia, both heels pressure ulcer, right heel unstageable and sacral stage 2 pressure ulcer. Registered Nurse (RN) AA obtained treatment order for both heels pressure ulcer. But RN AA failed to obtain physician's order for sacral stage 2 pressure ulcer wound care treatment during the admission for P#1. Licensed Practical Nurse (LPN) BB also performed sacral stage 2 pressure ulcer wound care treatment without physician's order on 5/15/20 LPN BB applied border dressing to cover sacral wound . On 9/21/20 at 2:34 p.m. an interview was conducted with RN AA, stated that P#1 was 80 years old, admitted to hospice on 4/30/20 with a diagnosis of frontal lobe dementia in 2011, with comorbidity of cervical dystonia. P#1 resided at Assisted living Facility (ALF) for three years. P#1 needed maximum assistance for activity of daily living due to decline in health. P#1 was alert and confused and has problems with long-term memory. P#1 left lateral heel wound, and right heel wound unstageable, both heels black eschar noted and sacral middle wound. RN AA stated that he educated staff on proper off-loading of pressure. RN AA stated he obtained new order on 5/5/20 for left heel wound care because the left heel wound appeared necrotic with blanchable redness in the peri-wound area. RN AA stated that he didn't obtain physician's order for sacral wound in P#1's bottom during admission. On 9/21/20 at 2:45 p.m. an interview was conducted with LPN BB, stated that "I provided wound care to P#1 on several occasions. Wounds were located on his coccyx area and bilateral heels. Both heels wounds made significant improvement as documented in home care home base electronic medical record. I am unable to recall his admitting diagnosis. I always pre-medicated patient for comfort prior to wound care." LPN BB stated that she performed sacral stage 2 wound care for approximately three months with no physician's order. On 5/15/20, LPN BB used border dressing to cover sacral stage 2 pressure ulcer wound once. On 5/26/20 and 6/3/20 LPN BB applied skin barrier cream on sacral stage 2 pressure ulcer, again with no physician's order. On 9/22/20 at 9:30 a.m., an interview was conducted with Administrator and Regional Clinical Director, they both expressed their concern that nurses assigned to P#1 failed to obtain physician's order for sacral wound care. The Administrator stated that "the good thing was that they did the wound care." Administrator and Regional clinical director stated that they would conduct in-service. On 9/22/20 at 1:39 p.m., an interview was conducted with RN CC, stated that she visited Pt#1 twice and she performed heels wound treatment, but she could not recollect about P#1 sacral wound.