Survey Report for 111740

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	111740	A. BUILDING __________ B. WING ______________	10/17/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
RELIANCE HOSPICE CARE	625 CARVER ROAD, GRIFFIN, GA, 30224
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)
L0533
L0533	42460 Based on clinical record review and staff interview, it was determined that the hospice failed to ensure the registered nurse completed a comprehensive assessment to assess the patient's status at a minimum of every 15 days. For 2 of 5 (#1 and #3) sampled patients who currently receive hospice services. Findings were: 1.Review of the clinical record for patient #1 revealed that the patient was seen by the nurse on 9/23/19 and as of 10/17/19 had not been seen by a nurse. 2.Review of the clinical record for patient #4 revealed that the patient was seen by the nurse on 6/24/19, then was not seen again as of 10/17/19. The clinical records lacked documentation regarding the staff's delay in completing the assessments.
L0555
L0555	42460 Based on clinical record review, it was determined that the interdisciplinary group failed to ensure that the frequency of visits for the hospice nurse, chaplain and social worker were provided in accordance with the patient's plan of care for 2 of 5 (#1,#3, ) sampled patients who were current hospice beneficiaries. Findings were: 1.The interdisciplinary care plan reviews for patient #1, dated 7/1/19-9/29/19 required social worker to visit one time a month, documentation reflected no social worker visit for the month of September 2019. The interdisciplinary care plan dated 7/1/19-9/29/2019 required nursing visits every 14 days. The clinical record reflected no nursing visits had been made since 9/23/19. 2. The interdisciplinary care plan reviews for patient # 3 dated 6/21/19-7/18/19 required the nurse to visit the patient every 14 days. The clinical record lacked documentation of any nursing visits between 6/25-7/18/19 when the patient was hospitalized. The clinical records lacked documentation regarding the staff's delay in completing the assessments.