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
111731 A. BUILDING __________
B. WING ______________ 		08/12/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ATLANTA FAMILY HOSPICE AND PALLIATIVE CARE II, LLC 5950 LIVE OAK PARKWAY, SUITE 240, NORCROSS, GA, 30093
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)
L0682      
37796 Based on the staff and family interviews, clinical record review and review of the agencies discharge list dated 2/27/2020 , it was determined that the hospice failed to ensure that their written form titled "Revocation or Transfer", the discharge summary and the clinical record for 1 of 3 sampled Patients (P #3) who were previous hospice beneficiaries. Findings include: The plan of care dated 1/22/20 for patient #3 reflected that the patient was admitted to hospice services on 1/22/20. Review of the on-call report dated 2/27/20 at approximately 9:15 a.m., reflected that P#3's family called and reported that the patient needs to be seen today and the family is canceling hospice services. Review of the on-call log dated, 2/27/20 at 5:47 p.m., reflected that the patient was admitted to the hospital. Review of the discharge check list dated 2/27/20, noted P#3 was discharged because patient was admitted to a non-contracted facility. Review of the clinical record lacked the "Revocation or Transfer" form that would include the patient's signature and date. There was no documentation of the events that resulted in the transfer to the hospital , the revocation, discharge summary of the patient's stay including treatment, symptoms and pain management, patient's current plan of care, current physician orders, nor any other documentation that would assist in post-discharge continuity of care. In addition there was no documentation that the attending physician and/or medical director were notified. During an interview on 8/12/2020 at 10:45 a.m., the Administrator and the Director of nursing confirmed that the clinical record for P #3 lacked evidence that the"Revocation or Transfer form was forwarded to the family and to the new hospice agency upon request on 2/28/20. They also confirmed that the clinical record lacked a discharge summary and documentation that the attending physician and/or medical director were notified.
L0684      
37796 Based on the staff and family interviews, review of the clinical records and the agencies discharge list dated 2/27/2020, it was determined that the hospice failed to ensure that the records included complete documentation of the events that resulted in the revocation of hospice services and a discharge summary, which includes documentation to assist in continuity of care post-discharge from the hospice for 1 of 3 ( P #3) sampled Patients who were previous hospice beneficiaries. Findings include: Review of the plan of care dated 1/22/20 for P #3 reflected that the patient was admitted to the hospice services on 1/22/20. Review of the on-call report dated 2/27/20 approximately 9:15 a.m., for P #3 reflected that the patient's family called and reported that the patient needs to be seen today and the family is canceling hospice services. The on-call log dated, 2/27/20 at 5:47 p.m., reflected that the patient was admitted to the hospital. Review of the discharge check list dated 2/27/20, reflected that P#3 was discharged because patient was admitted to a non-contracted facility. The clinical record lacked documentation of the events that resulted in the transfer to the hospital and the revocation. The clinical record also lacked a discharge summary that included a summary of P#3's stay including treatment; symptoms and pain management; the patient's current plan of care, the latest physician orders, documentation that the attending physician and/or medical director were notified and any other documentation that would assist in post-discharge continuity of care. During interview on 8/12/2020 at 10:45 a.m., the Administrator and the Director of nursing confirmed that the clinical record for P #3 lacked evidence of discharge summary and documentation that the attending physician and/or medical director were notified.
L0687      
37796 Based on staff and family interviews, review of clinical records and a pharmacy invoice dated 12/18/20, it was determined that the hospice failed to provide Emergency Kit (E-kit) medications upon admission to hospice services for patient's with terminal diagnosis for 1 out of 4 sample Patients. (P#2) Findings include: Review of the start of care admission visit note for P#2 with the certification period of 12/16/19 to 3/14/2019, revealed that the patient was admitted to the hospice services on 12/16/19. The initial plan of care dated 12/16/2019 lacked orders for emergency - kit (E-kit). Furthermore, the review of skilled nurse (SN) visit note dated 12/17/2019 revealed that the nurse educated the patient on the E-kit, and the nurse documented that the E-kit has not been delivered to the patient's home. According to the physician order form dated 12/18/20, the E-kit was ordered for P#2 two days after the admission to the hospice services. The order was written on 12/18/20, for the E-kit, which includes Morphine Sulfate for pain and shortness of breath, Lorazepam, for agitation, Promethazine for nausea, Tylenol suppository for fever and pain, Atropine sulfate for secretions, and Dulcolax suppository for constipation. The order is written for same day delivery to the patient's house. According to the pharmacy invoice dated 12/18/20, the order was scheduled to be delivered on 12/18/19, but the E-kit was never delivered. During an interview with the pharmacy manager, on 8/11/20 approximately 1.00 p.m., the pharmacist verbalized that a nurse from hospice called and faxed in the order on 12/18/19 around 8.00 p.m. The pharmacist also stated that the same nurse called back and advised the pharmacy to cancel the delivery. Clinical record lacked evidence that the E-kit was delivered to the patient's home. Clinical record also lacked evidence that the physician and the family was notified of patient not receiving the E-kit as ordered by the physician. During an interview the Administrator and the Director of nursing on 8/12/20 at 10:30 a.m., it stated that the medications (E-Kit), related to the P#2's hospice diagnosis were not ordered at the time of the admission and was not delivered as ordered by the physician on 12/18/2020.