Survey Report for 231560

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	231560	A. BUILDING __________ B. WING ______________	02/11/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ASPIRUS AT HOME	1101 N ELEVATION ST, HANCOCK, MI, 49930
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)
L0658
L0658	18299 Based on documents reviewed and interview the agency failed to ensure lines of authority, and professional and administrative control was clearly delineated in the hospice's organizational structure.........and must be traced to the location issued the certification number. Findings include; During review of the agency organizational chart it was observed that the Agency's hospice was combined with the Home Health agency operated from the same office (237212) on the same document. An interview conducted with parent site manager #1 (Mgr #1) on 2/9/21 at 1400 hrs, it was clarified that the total FTE hours identified on the organizational chart were hours combined between the hospice parent site, the proposed multiple site and the Home Health Agency (237212) FTE hours. The hospice program was not clearly delinieated from the HHA program.