Survey Report for 111754

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	111754	A. BUILDING __________ B. WING ______________	10/07/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
MAGNOLIA HOSPICE	1374 MANCHESTER DRIVE NE, CONYERS, GA, 30012
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)
L0729
L0729	37796 Based on the family/staff interviews and review of the complaint logs, it was revealed that the agency failed to provide accommodations for family members to stay with the patient during the night for one of one patient. (P#1) who was a recipient of a respite services at this facility. Findings include: Review of the admission note dated November 26, 2020 for P#1, revealed that patient was admitted for Respite care on November 26, 2019 to December 1, 2019. During an interview with the P#1's daughter on September 29, 2020 at 11:30 a.m., the daughter stated that the agency refused to allow the daughter to spend the night with the patient. During an interview on September 29, 2020 at 1:30 p.m., with the Regional Clinical Director, she confirmed that the agency did not allow P#1's daughter to stay with patient during the night as requested. During a phone interview on October 7, 2020 at 2:00 p.m. with the Administrator and the Regional Clinical Director they confirmed that the agency did not allow the patient's family to stay overnight with the patient. They stated that the staff nurse who no longer with the facility did not allow them to spend the night.