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
111717 A. BUILDING __________
B. WING ______________ 		01/13/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AFFINITY HOSPICE 138 MOUNTAIN BROOK DRIVE, SUITE 102, CANTON, GA, 30115
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)
L0560      
37796 Based on review of the hospice's quality assurance manual and staff interview, it was determined the hospice failed to ensure a comprehensive quality assessment and improvement program (QAPI) was in place that required ongoing evaluation and review of all hospice services ( including services provided under contract or arrangements), implementation of solutions, assessment of solutions, documentation of performance improvement project(s), and the hospice's compliance with all regulatory requirements. The findings include: Review of the Vaccine Management System (VMS) log revealed a conflicting documentation of name of vaccine and the birthday's given to R #2 and R#3. The log revealed R#2 and R#3 received both Moderna and Johnson and Johnson. The Johnson and Johnson manufactures instructions stipulates, 18 years and older to receive the vaccine . Review of the QAPI notes dated 5/10/21, 7/27/21 and 10/27/21, lacked evidence of an vaccine administration and vaccine surveillance program. The QAPI program did not include vaccine accelerations or evidence of reviewing reporting and documentation of the discrepancies identified on the VMS log. The hospice failed to develop, implement, and maintain a comprehensive vaccine administration program that ensured the protection of patients, staff, and families, by preventing and controlling infectious and communicable diseases During an interview on 1/13/22, at 3:30 p.m., the Administrator and the vaccine coordinator confirmed the Quality assurance manual did not have documentation regarding the discrepancies related to the Covid-19 vaccine administration that were found on the VMS log.
L0580      
37796 Based on staff interview, observations, and review of the infection control log it was determined the hospice failed to develop, implement, and maintain a comprehensive vaccine administration program that ensured the protection of patients, staff, and families, by preventing and controlling infectious diseases for two of two recipients (R) (R#2 and R#3) who received COVID -19 vaccine. The hospice failed to incorporate vaccine administration and vaccine surveillance into their quality assessment and performance improvement (QAPI) program. The findings include: Review of the Vaccine Management System (VMS) log revealed conflicting documentation of name of vaccine and birthday's given to R#2 and R#3. The log revealed R#2 and R#3 received both Moderna and Johnson and Johnson. The Johnson and Johnson manufactures instructions stipulates, 18 years and older to receive the vaccine. The infection control documentation lacked evidence of reviewing , reporting and documentation of the discrepancies identified on the VMS log. The vaccine data collection was not included in the QAPI program. During an interview on 1/13/22 at 3:30 p.m., the Administrator and the vaccine coordinator confirmed the infection log, and the QAPI manual did not have documentation regarding the discrepancies related to the Covid-19 vaccine administration found on the VMS log.