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
111752 A. BUILDING __________
B. WING ______________ 		08/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ABERDEEN PLACE HOSPICE 900 OLD ROSWELL LAKES PARKWAY, SUTE 130, ROSWELL, GA, 30076
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)
L0798      
37796 Based on interviews with facility staff and hospice staff and family the review of the hospice's policy # 803, titled "After Hours Services,the agencies answering services report, dated 8/4/20, Skilled nurse (SN) visit note dated 8/4/20, it was determined that the hospice failed to ensure that the on-site nursing services were made available within one hour of notification where patients experiences a symptom-management crisis situations in accordance to all applicable Federal, State, and local laws and regulations related to the health and safety of patients for 1 of 5 Patients (P #1) sampled patients . Findings include; Review of the on-call report dated 8/4/2020 revealed the Hospice agency received a call at 5:20 a.m., from an Assisted Living Facility (ALF) where patient #1 resides. According to the on-call report, the patient had a fall and sustained "gash on head", 911 was called to take the patient to the hospital and the paramedics are present and ready to transfer the patient to the hospital. Upon review of the clinical coordination note from the Director of Nursing (DON), revealed that at 5:30 a.m., the DON discussed the patient status with the paramedics and according to the paramedics, patient is stable and is in no distress. Paramedics also stated that they cleaned the wound and applied a dressing. The clinical note revealed that the DON advised the facility staff and the paramedics not to take the patient to the hospital. According to the SN visit note dated 8/4/20, the SN arrived at the patient's residence at 10.30 a.m. The SN visit note revealed that the SN assessed the triangular shaped wound tear wound located above the left eye. The wound was covered with dry sterile dressing . SN spoke with the staff at the facility and called 911 and transported the patient to the hospital. The SN also notified the patient's daughter that patient is being transferred to the hospital. The daughter agreed with the plan. Upon interview with the DON on 8/12/20 approximately 3:30 p.m., the DON verbalized that according to the paramedic's assessment patient was stable and not in distress and advise the case manager to visit the patient on the same day. Based on the review of the hospice's policy # 803, titled "After Hours Services "requires that the hospice maintains twenty-four (24) hour availability for patients, caregivers and referral sources. The policy also requires that the onsite nursing services are made available within one hour of notification, where the patient experiences a symptom management crisis. Agency failed to follow the policy for after hour services. During an interview with the administrator and the director of nursing 8/13/20 at 1.00 p.m.,it was confirmed that the agency did not follow the policy #803 titled " After Hours Services , which requires the nurse to make an onsite nursing services with in one hour of notification where the patient experiences a symptom management crisis.