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 ______________ 		01/15/2021
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)
L0648      
42460 A Complaint survey investigating GA00211319 was conducted at Aberdeen Place Hospice on 1/15/21. The complaint was substantiated with deficiencies. On 1/15/21 a determination was made that a situation in which the agency's noncompliance with a Conditions of Participation had the likelihood to cause serious injury, harm, impairment, or death to patients. The agency's Administrator and Associate Administrator were informed of the immediate jeopardy on 1/15/21 at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 1/11/21. The immediate jeopardy was abated on 1/15/21. The immediate jeopardy is outlined as follows: The immediate jeopardy was related to the agency's noncompliance with the program requirements at 42 C.F.R. Part 418. Requirements for Hospices. C.F.R. 418.100 Organization and Administrative Services (L648); C.F.R.418.C.F.R.418.100(c)(2) Services (L653)Nursing Services available 24 hours a day seven days a week. The cumulative effects of these systemic problems resulted in the hospice agency's inability to ensure the provision and availability of all services that effectively met the needs of patients and their caregivers.
L0653      
42460 Based on staff and family interviews, record reviews and review of the agency's, on-call logs, on-call schedule, on-call policy titled "Policy #8806 After hours Service" it was determined the hospice failed to ensure that its resources were managed and administered to meet the needs one patient (P#1) of two patients reviewed. The hospice facility contracts with an answering service that takes calls after hours then contacts the nurse on call. A review of the on-call schedule showed Registered Nurse (RN) AA was on-call 1/9/21 beginning at 5:00 p.m. until 1/11/21 at 8:30 a.m. The schedule also showed the Administrator and the Associate Administrator as the backup positions for the on-call nurse. On 1/11/21 at 3:27 a.m Patient (P)#2's family called the answering service. The service attempted to contact the on-call nurse RN AA and did not receive an answer. At 3:43 a.m. the answering service contacted the Administrator. The Administrator requested the service attempt to contact RN AA again after 15 minutes. Documentation from the answering service shows the service relayed the message from P#2 to RN AA at 3:55 a.m. On 1/11/21 at 3:54 a.m. the answering service received a call from the contracted nurse who was providing continuous care to P#1. The contracted nurse was calling to report the death of P#1. The service attempted to reach RN AA with no answer. Documentation from the answering service shows attempts to contact RN AA at 4:11 a.m., 4:28 a.m., 4:30 a.m., 4:47 a.m., and 4:56 a.m., all with no answer. On 1/11/21 at 4:59 a.m. the answering service attempted to contact the Administrator regarding P#1 with no answer, then at 5:05 a.m., the service attempted to contact the Associate Administrator with no answer. At 5:14 a.m. the service again attempted to contact RN AA, then the Administrator at 5:15 a.m., RN AA at 5:27 a.m., 5:28 a.m., 5:41 a.m., the Administrator at 5:42 a.m., then RN BB at 5:44 a.m., RN AA at 5:52 a.m., all with no answer. The service was able to reach RN AA at 5:58 a.m. RN AA visited and pronounced P#1 at 7:15 a.m., over 3 hours and 15 minutes since the first call was made at 4:59 a.m. The Administrator failed to ensure that all calls were responded to after having the knowledge that RN AA phone was not working when the answering service contacted the Administrator regarding P#2 at 3:43 a.m. An interview with the Administrator was conducted on 1/15/21 at 11:00 a.m. The Administrator stated she received a call from the answering service 1/11/21 before 4:00 a.m. informing her they could not reach RN AA. The Administrator told the service to try and contact RN AA again in 15 minutes. The Administrator stated that within a few minutes RN AA texted the Administrator and stated her phone had died. The Administrator told RN AA to contact the answering service. Documentation from the answering service shows the service relayed the message from P#2 to RN AA at 3:55 a.m. When the Administrator was asked why the answering service was unable to reach her at 5:15 a.m. and 5:42 a.m. she stated her phone had been turned off. A phone interview was conducted with RN AA on 1/15/21 at 11:26 a.m. RN AA stated her phone's battery had died, and she was not receiving any calls. RN AA reviewed the two situations with P#2, then P#1, and that she did eventually receive the messages and that they were handled. She could not give any explanation why steps were not taken to avert the situation. On 1/15/21 A telephone interview was conducted with a family member of P#2 at 3:31 p.m. The family member of P#2 stated she did receive a call back on 1/11/21 at around 4:00 a.m. The family member of P#2 stated she was satisfied with the timeliness of the return call, and her questions were addressed to her satisfaction. A review of the policy titled" After Hours Services-Policy #8803" with a revision date of 10/2019 states "The Hospice ensures twenty-four-hour care seven (7) days a week to meet the needs of patients and caregivers. The policy further states under Procedure-"1)The Administrator/designee is responsible for assuring coverage after regular hours. The facility failed to ensure that nursing services were available to patients 24 hours a day seven days a week. This failure could have resulted in a delay in rendering symptom management to patients.