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
111723 A. BUILDING __________
B. WING ______________ 		01/05/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOMESTEAD HOSPICE & PALLIATIVE CARE 794 MCDONOUGH ROAD, SUITE 107, JACKSON, GA, 30233
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 the review of the agency's, on the call log, on-call policy titled "246. Hospice On-Call Services", staff interviews, and record reviews, it was determined that the hospice failed to provide a nursing visit for a Patient (P)#1 who was exhibiting a significant change in condition. The sample size was four. On 10/21/20 through 10/26/20 P#1 was in a contracted Inpatient Unit (IPU) receiving respite services. A review of the patient's records revealed multiple calls received by Homestead Hospice's on-call service during the respite stay. On 10/24/20 at 7:32 a.m. A call was made from Magnolia IPU to Homestead Hospice reporting that P#1 would not let them change him and he was confused. On 10/24/20 at 11:19 a.m. the contracted IPU contacted Homestead Hospice on-call requesting an order for a laxative, stating that P#1 had not had a bowel movement since arrival on 10/21/20. They further stated that P#1 had an order for Bisacodyl 5 milligrams as needed, but that medication had not come with the patient on transfer to respite They have milk of magnesia in pharmacy stock so they requested this be ordered for constipation. This order was received. On 10/24/20 at 11:36 a.m. the P#1's wife called Homestead Hospice stating she wanted to take him home, patient's wife was told transportation was not scheduled or provided over the weekends. On 10/25/20 at 7:02 a.m. the contracted IPU called Homestead Hospice on-call stating they needed a pill-splitter. P#1 was ordered Hydralazine 50 milligrams twice a day, but he was sent with 100 milligram non-scored tablets. Homestead Hospice did deliver a pill-splitter. On 10/25/20 at 11:13 p.m. the contracted IPU contacted and reported to Homestead Hospice on call that the P#1's blood pressure was 206/107. Homestead hospice on-call instructed the contracted IPU to recheck the blood pressure manually. At 11:25 p.m. the contracted IPU was contacted and reported to Homestead Hospice on-call P#1's blood pressure was 220/108 and he was refusing meds and meals. On 10/26/20 at 6:52 a.m. contracted IPU contacted Homestead Hospice on-call and reported P#1 was not taking meds or food "at first he held them in his mouth but did not swallow when given applesauce, he is verbal and when questioned answers appropriately but has been saying no to meds and meals, he is grimacing and moaning and has increased moans when touched. Will try to give him pain med". On 1/5/20 at 2:00 p.m. The Administrator was asked if there was any additional documentation or visit notes for P#1. The only additional information that could be provided was a visit made after P#1 had left the contracted IPU and returned home on 10/26/20 which was made at 3:04 p.m. A review of the undated policy titled "246. Hospice On-Call Services" the policy states: 1. Provide 24-hour nursing services including after-hours weekends/holiday coverage. 2. Respond to emergency telephone requests for patient care, questions or concerns, and medical emergencies. 3. Phone consultation (triage) conducted by an RN (Registered Nurse) will be used to provide instructions to family/caregivers to help solve problems. After advice is given, the RN will follow up within a reasonable amount of time to reassess the situation. If the is no improvement and/or the situation is unstable, the RN will determine if a visit is warranted. The agency failed to follow their policy titled "246. Hospice On Call Services", in the situation of an unstable patient with a change in condition. This failure resulted in a lack of symptom management and additional anxiety for the family. An exit interview was held on 1/5/21 at 2:45 p.m., the Director of Nursing and the Branch Director did not dispute the findings.