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
111793 A. BUILDING __________
B. WING ______________ 		01/21/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GUARDIAN ANGELS HOSPICE 3469 LAWRENCEVILLE HWY #205, TUCKER, GA, 30084
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)
L0700      
38966 Based on review of clinical records, staff and family interviews, review of the agencies written policy titled "Management and Disposal of Controlled Drugs for Patient and Families it was revealed that the hospice failed to ensure compliance regarding the destruction of controlled drugs in the patients home and at the agency. The Administrator failed to investigated immediately and report as required to the appropriate State authority when controlled drugs were not destroyed and/or accounted for following the patient's death for 2 of 7 (P#6 and P#7) sampled patients. Findings Include: 1. The clinical record for Patient #6 revealed that the patient received hospice services in the personal care home setting from 1/13/19 to 1/17/20. The clinical record lacked documentation that a hospice nurse actually destroyed the controlled drugs after the patient's death. Reviewed P#6 record revealed that patient was placed on Morphine 0.25 Milliliters (ML) every 30 minutes as needed for moderate to severe pain or difficulty in breathing. P#6 expired on 1/17/20. The Pharmacy delivered 36 syringes of Morphine 0.26 milliliters to personal care home on 1/9/20. On 1/17/20 after hospice nurse pronounced P#6's death, the remaining Morphine 0.25 milliliters 31 syringes were handed over to hospice nurse. The narcotic record revealed that hospice nurse and personal care home staff destroyed Morphine 0.25 milliliters 31 syringes and signed the document on 1/17/20. On 1/21/21 at 10:30 a.m., an interview was conducted with the Administrator who was the hospice nurse that pronounced P#6, stated that she and personal home care staff destroyed Morphine 0.25 milliliters 31 syringes on 1/17/20. On 1/21/21 at 12:30 p.m., surveyors observed Morphine 0.25 milliliters seven syringes labeled with P#6's name dated 1/9/20, expiring in 6/2021, locked in the cabinet in the Administrator's office. During the interview the Administrator, she stated that she forgot to destroy them and said that she could not explain how she forgot to destroy the Morphine 0.25 milliliters seven syringes. 2. Patient #7 resided in his private home, was admitted to the hospice on 2/25/20, and expired on 7/19/20. Prescribed for P#7 were Roxanol 0.75 milliliters (ML) liquids every two hours for pain, and Morphine 15 milligrams (MG) tablets, give one tablet oral three times daily for pain. On 1/21/21 at 11:02 a.m., an interview was conducted with P#7's family, stated that on the day her father expired, she gave all his medications to the hospice nurse to destroy, and that was all she could remember. On 1/21/21 at 12:30 p.m., surveyors observed Roxanol 15 ml liquids inside plastic container labeled and dated 6/18/20 for P#7, and Morphine 15 mg eight tablets inside plastic container dated 3/24/20 for P#7. During the interview with Administrator, she stated that P#7's daughter gave her Roxanol and Morphine to destroy, and she brought them to the office, locked them in the cabinet and forgot to destroy them. The agency failed to follow their written policy titled "Management and Disposal of Controlled Drugs for Patients and Families" which documents specific directions for families and patients to destroy controlled drugs to ensure prescription drugs are not diverted. It was determined during interviews with agency staff and families that the controlled drugs were not disposed in accordance to the policy when the patients expired at home.