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 ______________	11/06/2019
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)
L0523
L0523	38989 Based on medical record review, it was determined that the comprehensive assessment that includes psychosocial and spiritual evaluations of the patient was not completed within five calendar days after admission as required for two of five patient medical records reviewed. Findings were: 1. Review of the medical record for patient # 1 (P#1) revealed the SOC was 7/12/2019. A spiritual assessment was not completed until 7/25/2019, twelve days after admission. 2. Review of the medical record for P # 2 revealed the patient did not have the psychosocial assessment within five days of admission. The SOC was 8/1/2019 The psychosocial assessment was completed on 8/10/2019, eight days after admission.