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
111750 A. BUILDING __________
B. WING ______________ 		05/18/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SOUTHERN GRACE HOSPICE AND PALLIATIVE CARE 80 CANDLER ROAD, MCDONOUGH, GA, 30253
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)
L0545      
44327 Based on clinical record reviews and staff interviews it was determined that the hospice failed to ensure the plan of care included all necessary services for the management and palliation of the terminal illness based on each of the patient's individualized needs as determined from the comprehensive assessments for four of six patients (P) who were current beneficiaries (P#3, P#4, P#5, P#6). Findings include: 1. Patient #4 was admitted with a hospice diagnosis of coronary artery disease. Review of the plan of care dated 3/16/21 to 6/13/21 it was identified that the admission orders for P#4 were not relevant as P#4 did not have diagnoses for standard, non individualized standing orders. The physician's orders noted on P#4's plan of care included the following standing orders: a. A Foley catheter order without the a catheter size, balloon size, or specify fluid for filling the Foley catheter balloon. b. Initiate bowel protocol without specifying what medications or treatments the protocol would entail for the patient. c. Initiate skin/ wound care protocol for skin breakdown and wound care without specifying what medications or treatments the protocol would entail for the patient. The order for skin treatment also did not specify the site of skin care treatment. d. The Registered Nurse (RN) may change the route of administration for any medication as needed without consulting the physician. Patient #4's clinical record also included a physician's order dated on 4/13/21 to start medication "Temazepam 30 mg QHS (every day at bedtime) r/t (related to) insomnia" The physician's order lacked documentation of the route necessary to administer the medication. 2. A review of P#5's plan of care dated 4/14/21 to 7/12/21 dated 4/14/21 with a hospice diagnosis of unspecified severe protein mal nutrition revealed that the admission orders for the P#5 contained standard, non individualized standing orders for the following; a. Inserting an indwelling catheter for urinary retention or incontinence. The physician's order did not contain a Foley catheter size, balloon size, or specify fluid for the filling Foley catheter balloon. b. The admission order also contained a physician's order to initiate bowel protocol without specifying what medications or treatments the protocol would entail for the patient. c. The admission order contained a physician's order to initiate skin/ wound care protocol for skin breakdown and wound care without specifying what medications or treatments the protocol would entail for the patient. The order for skin treatment also did not specify site the of skin care treatment. d. The admission order also contained a physician's order stating the Registered Nurse (RN) may change the route of administration for any medication as needed without consulting the physician. During an interview on 5/18/21 at 12:30 p.m., at the agency, the Executive Director and Clinical Director acknowledged the plan of care lacked specific interventions needed to individualize each patient's care and management of the terminal diagnosis 37796 3. A review of P#6's plan of care dated 5/11/21 to 8/8/21 revealed P#6 was admitted with hospice diagnosis of metastatic breast cancer. The admission orders for P#6 were not relevant as P#6 did not have diagnoses for standard, non-individualized standing orders. The physician's orders noted on P#6's plan of care included a Foley catheter without the catheter size, balloon size, or specify fluid for inflating the Foley catheter balloon. Patient #6's clinical record also included a physician's order dated 4/13/21 to start medication "Haloperidol 2 mg/ml, 1 mg (0.5 ml) every 4 hours as needed for anxiety or agitation". The physician's order lacked documentation of the route necessary to administer the medication. 4. A review of P#3's plan of care dated 4/9/21 to 7/7/21 revealed P#3 was admitted with hospice diagnosis of metastatic breast cancer. The admission orders for P#3 were not relevant as P#3 did not have diagnoses for standard, non-individualized standing orders. The physician's standing orders noted on P#3's plan included a Foley catheter without the catheter size, balloon size, or specify fluid for inflating Foley catheter balloon. Patient #3's clinical record also included a physician's order dated 4/13/21 to start medication "Methadone 5 mg bid and Roxanol 0.5 cc- 1 cc every two hours as needed for pain and shortness of breath". The physician's order lacked documentation of the route necessary to administer the medication. During an interview on 5/18/21 at 12:30 p.m., at the agency, the Executive Director and Clinical Director acknowledged the plan of care lacked specific interventions needed to individualize each patient's care and management of the terminal diagnosis.