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
111762 A. BUILDING __________
B. WING ______________ 		09/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AFFINITY HOSPICE 1395 SOUTH MARIETTA PKWY SE, BLDG 400, SUITE 116, MARIETTA, GA, 30067
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)
L0505      
42460 Based on interviews with staff, review of clinical records, in-service education documents and the agencies policy titled "Patient Right's", it was determined that the Hospice Agency failed to ensure that one out of one Hospice patient (#1) was treated with respect. Findings include: On September 16, 2020 at 11:30 an interview with the Administrator was conducted in the Administrator's office. The interview revealed the Administrator had assigned two nurses a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) to do a full body assessment on Patient #1 who resided at an Assisted Living Facility (ALF). While there, the RN asked the Head Med Tech at the ALF to witness the assessment. The Head Med Tech entered the patient's room with a member of ALF's Maintenance Staff. The RN expressed her objections that this was not appropriate for non-clinical personnel to be in the room during a full body assessment of the patient. But the RN was told the Maintenance Staff Member had been approved and directed, by the ALF Leadership, to be in the room. The two hospice nurses proceeded with the assessment with the Maintenance Staff Member present and attempted to cover the patient as much as possible. The administrator stated the two nurses the RN and LPN were counseled and reeducated on all Patient Rights. The two Hospice nurses were also instructed by the Administrator that they should have stopped the assessment and contacted their management. During a telephone interview with the LPN on September 16, 2020 at 12:01 p.m., the LPN stated that she was meeting the RN at the ALF to assist with the assessment. The LPN stated after removing patient #1's shirt a male walked into the room. The LPN stated the RN questioned the Maintenance personnel's presence and was told by the Head Med Tech the Maintenance Staff Member was there to also witness the assessment. During a telephone interview with the RN on September 16, 2020 at 12:15 p.m., the RN stated meeting the LPN in patient #1's room at the ALF was to perform the assessment. The Hospice RN requested an ALF Med Tech to witness the assessment. The Med Tech stated she would get the Head Med Tech to assist. When the Maintenance personnel came into the room, the RN questioned this due to the employee's role being non-clinical. The RN requested another, more appropriate personnel, but was told the ALF's Leadership had approved the arrangement. The RN stated they proceeded with the assessment. The RN also stated coverage and privacy was provided to the patient as much as possible. On September 16, 2020 a record review was performed for patient #1 which revealed two clinical notes documenting assessments performed by a LPN on 8/27/20 from 8:19 a.m. to 8:49 a.m. and a RN on 8/27/20 from 8:00 a.m. to 8:56 a.m. Review of these records did not reveal anything out of the ordinary with patient #1's skin assessment, general assessment, or any mention of the Assisted Living Personnel being present for the assessments. Personnel records for the RN and LPN involved in the above situation were reviewed. Both the RN and the LPN were up to date with training on Abuse and Neglect and Patient Rights. Review of other education records revealed all hospice staff recently received training on Abuse and Neglect. The Administrator stated training is performed annually for all staff and will be completed, to include Patient Rights, by October 1, 2020. Review of the Hospice's Patient Right's Policy revealed a statement that Patients have the "Right to an environment that preserves dignity and contributes to a positive self-image". Another statement in the Hospice's Patient Rights Policy states "The Patient has the right to receive care in a setting that preserves dignity, privacy, and safety to the minimum extent possible". In an exit interview conducted on September 16, 2020 at 1:00 p.m. the Administrator agreed, that in this situation, the hospice failed to uphold the patient's rights.