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
111780 A. BUILDING __________
B. WING ______________ 		09/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BRIDGEWAY HOSPICE 2000 RIVERSIDE PARKWAY, SUITE 107, LAWRENCEVILLE, GA, 30043
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)
L0555      
40978 Based on clinical record reviews and staff interview, it was determined that the hospice failed to ensure the frequency of visits for the skilled nurse and hospice aide were provided in accordance with the patients' plan of care for 7 of 10 (#1, #3, #4, #7, #8, #9, and #10) sampled current hospice beneficiaries. Findings were: 1. The interdisciplinary plan of care for P#1 required the skilled nurse (SN) to visit the patient one time per week effective 7/11/20. The clinical record lacked documentation of a SN visit for the week of 7/27/20 to 8/3/20. The clinical record contained a verbal order dated 7/11/20 one time a week for six weeks. In review of the complaint log family member contacted the hospice on 7/31/20 patient had no SN for two weeks. At the time of the record review the record lacked documentation to indicate the SN visit for the week of 7/27/20 to 8/3/20. The agency failed to follow the frequency for the SN visits as per the plan of care. 2. The interdisciplinary plan of care for P#3 required the SN to visit the patient one time a week for ten weeks. The clinical record lacked documentation of SN visit the week of 8/3/20 to 8/10/20. According to the complaint log P#3 family member called on 8/6/20 to complain that patient had pain on the side of her head. The family member verbalized P#3 had no SN visit this week. P#3 had pain 8/6/20 and skilled nurse visit to P#3 was made 8/11/20. The follow up by the clinical director on the complaint was SN visit was to occur on 8/6/20 to address P#3 pain. The clinical record on 8/6/20 lacked documentation of a SN visit. The agency failed to follow regulations of a hospice patient experiencing pain. 3. The interdisciplinary plan of care for P#4 required the SN to visit the patient one time per week every fourteen days. According to the complaint log P#4 family member contacted the hospice on 7/31/20 stating that P#4 had no skilled nurse visit in three weeks. In reviewing the complaint log the resolution by the hospice was to have a SN visit to P#4 by 8/6/20. The clinical record lacked documentation of SN visit on 8/6/20. The frequency on the Plan of Care for P#4 was a SN to visit P#4 every fourteen days. The agency failed to follow the frequency for the SN visit as per the plan of care. 4. The interdisciplinary plan of care for P#7 revealed inconsistencies in the visit frequencies the skilled for home health aide (HHA) and skilled nurse (SN) per week for weeks effective 07/26/20 to 10/23/20. The record lacked documentation of skilled nursing visits for weeks starting 08/16/20, 08/23/20, and 08/30/20. With an interview of the Administrator, there were inconsistencies found with frequency of home visits. The Administrator stated initially there were "6 skilled nursing visits per first week" ordered with original POC orders, however there was a change to "2 skilled nursing visits for the remaining visits." There was no order found to verify this change of frequency. At the time of the record review with the electronic health records and client visit summary reports, the record lacked missed visit notes to indicate the reason for the missed visits or physician notification of the missed visits. The agency failed to follow the ordered frequency for SN visits as per the plan of care. 5. The interdisciplinary plan of care for P#8 revealed inconsistencies in the visit frequencies the skilled for home health aide (HHA) and skilled nurse (SN) per week for weeks effective 07/22/20 to 10/19/20. The record lacked documentation of SN and HHA visits the week of 8/30/20. Upon interview of the Administrator, there was inconsistency found with frequency of home visits. At the time of the record review with the electronic health records and client visit summary reports, the record lacked missed visit notes to indicate the reason for the missed visits or physician notification of the missed visits. The agency failed to follow the ordered frequency for SN visits as per the plan of care. 26450 6. The interdisciplinary plan of care for P#9 required the skilled nurse (SN) to visit the patient one time per week for 12 weeks effective 8/26/20. The record lacked documentation of a SN visit the week of 8/30/20. Additionally, the clinical record contained a verbal order dated 8/27/20 which required the SN to visit the patient two times a week for one week, one time a week for 3 weeks, two times a week for 1 week, 1 time a week for 4 weeks, then two times a week for one week. This new visit frequency was effective the week of 9/13/20. The clinical record lacked documentation to indicate the SN visited the patient the week of 9/13/20. At the time of the record review, the record lacked missed visit notes to indicate the reason for the missed visits or physician notification of the missed visits. The agency failed to follow the ordered frequency for SN visits as per the plan of care. 7. The interdisciplinary plan of care for P#10 required the skilled nurse (SN) to visit the patient one time per week for one week then two times a week for eight weeks. The clinical record did not reflect a physician's order to change the SN visit schedule during this time frame. According to the clinical record documentation, the SN only visited the patient 1 time weekly from 8/9 to 9/19/20 instead of two times as ordered. The record lacked any additional SN visits for these weeks. At the time of the record review, the record lacked missed visit notes to indicate the reason for the missed visits or physician notification of the missed visits. The agency failed to follow the ordered frequency for the SN visits as per the plan of care. .
L0651      
40978 Based on interviews with staff, review of clinical records and inservice training , it was determined that the Hospice Administrator failed to ensure that the patients skilled nurse visit frequencies followed the Plan of Care. Findings include: On 9/ 21/20 at 1:45 p.m., an interview was conducted with Administrator. The Administrator stated that the Corporate Clinical Director became the Administrator/Director of Nursing on 8/6/20 upon the termination of the previous Administrator and Director of Nursing; therefore, no lapse in leadership. Administrator verbalized the hospice was lacking skilled nurse (SN) and new SN's have been recently hired. Administrator verbalized around 8/15/20 the hospice realized the problem of the skilled nurse visits not following the Plan of Care. On 8/21/20 an inservice training was facilitated on scheduling. The Administrator provided Surveyor with a copy of the scheduling training manual. The Administrator verbalized "she was newly appointed on 8/31/20 to the Administrator position". The Administrator verbalized meeting with the schedulers on 9/10/20 to review reports of frequency of SN visits. On 9/17/20 Administrator met with schedulers to mandate that frequency of visit reports be printed out twice daily in the morning and afternoons to ensure skilled nurse visits or followed as written on the Plan of Care. On 9/25/20 Administrator verbally warned the schedulers and documented the incident. Administrator verbalized termination would be the next result. The Administrator verbalized a Performance Improvement Project (PIP) was added and being tracked through Quality Assurance and Performance Improvement (QAPI). Administrator verbalized the hospice has a corporate compliance team who does the internal audits. The SN frequency reports will be audited by the compliance team. On 9/ 29/ 20 at 10:45 a.m. an interview was conducted with the scheduler. The scheduler had training on 8/31/20 to review how to do scheduling. The scheduler verbalized running reports twice a day at 7:30 a.m. and 4:30 p.m. The scheduler verbalized if the reports data has a missed visit the Administrator contacts the SN and the patient.