Survey Report for 111780

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	111780	A. BUILDING __________ B. WING ______________	02/20/2020
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)
L0509
L0509	26450 Based on review of clinical records, policy on patients rights, complaint log. and staff interview, it was determined that the hospice violated the rights of 1 of 6 (#4) hospice patients, by failing to investigate a patient's complaint logged into the complaint log. The hospice also failed to investigate and document the incident in accordance with established procedures. Findings were: 1. Review of the complaint log for the year of 2019, revealed a complaint dated 10/31/19 indicating the patient was not satisfied with the services being provided and was seeking to discuss the situation with the agency staff in an attempt to rectify the situation. The complaint involved agency staff not coming when requested and not providing the services as ordered. The complaint log did have the complaint documented however, as of 2/20/20 the complaint log lacked documentation of the agency's attempt to address the patient's concerns. The agency failed to follow it's policy and procedure to address patient complaint and resolutions. Review of agency policy AD.C15 Complaint Resolution, revealed, " the all complaints are documented in a compliant log by the Clinical Director no more than 5 business days from the date the complaint was received. Appropriate personnel will conduct a documented investigation of the all written and verbal complaint received by the hospice. To resolve complaints, three attempts are made to contact the person filing the complaint by telephone. If telephone contact is unsuccessful, a letter is sent. Each contact, attempted contact, or action taken to resolve the issue is documented with the original complaint." During an interview on 2/20/20 at approximately 3:00 p.m., the Administrator did acknowledge that a resolution to the complaint dated 10/31/19 was not documented and could not identify why the complaint had not been addressed.
L0625
L0625	26450 Based on clinical record review and staff interview it was determined that the hospice aide failed to document and report the reason why aide tasks were not performed as ordered for 1 of 5 patients (#4) that required hospice aide visits. Findings were: 1. Review of the clinical record for patient #4 revealed the hospice aide was required to visit the patient 3 times a week to assist with activities of daily living (ADLs) which included a shower bath at each visit. According to the clinical record, the hospice aide visited the patient on 11/11 and 11/12/19 and documented each visit lasted for 15 minutes. The visit notes lacked any documentation of any tasks performed at each visit. The visit notes also lacked documentation to indicate the registered nurse was notified of the inability to perform ordered tasks as required. The aide failed to document reason care plan was not followed. During an interview on 2/20/20 at approximately 2:30 p.m. with the Administrator, it was confirmed that the aides are suppose to call the registered nurse after each visit if unable to perform assignment tasks. It was also confirmed that the aides are required to document in the record if tasks were unable to be completed and why they were not completed.