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
341503 A. BUILDING __________
B. WING ______________ 		09/08/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AUTHORACARE COLLECTIVE 2500 SUMMIT AVE, GREENSBORO, NC, 27405
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)
L0508      
34981 Based on clinical record review and staff interviews the agency failed to investigate an alleged violation involving mistreatment and or physical abuse for 1 of 3 charts [#1]. The findings included: Patient # 1 had a Start of Care [SOC] date of 5/29/21 and a terminal diagnosis of Huntington ' s Disease [an inherited condition in which nerve cells in the brain break down over time]. A review of the Plan of Care for the certification period 7/28/21 to 9/25/21 revealed order for SN [skilled nursing] 1-2 times per week for 9 weeks and 8 PRN [as needed] for symptom management and educated; aide services 2 times a week for 1 week and 4 times a week for 8 weeks. A review of the aide plan of care revealed the patient required assistance with all ADL ' s [activities of daily living]. A review of the clinical record revealed the following documentation on 9/7/21 by the VP of Quality and Compliance, " ...Notes regarding phone call with daughter ______[name] on Friday, September 3: I spoke with _______[name] of our patient _______[name] today for around an hour and listened to her perspective of what has occurred as it relates to the care of her mother ...She reported that last week during the incident in the home where we had 2 C.N.A.s visiting at the same time, one of the aides ______[employee # 3] grabbed her mother ' s arm and jerked it or dropped it and it now has a bruise and is causing pain to her mother. She reports sharing this incident on a previous call with an _______ [name of agency] leader." On 9/8/21 an interview was conducted with the VP of Quality and Compliance. During the interview the VP advised this surveyor she had no knowledge of the alleged abuse until she was on the phone with the daughter. She reported that after the phone conversation with the daughter she was speaking with the South Team Nursing Director and inquired why she had no knowledge as the daughter's allegation related to her mother being abused by the aide on 8/28/21. The VP advised this surveyor she was told, "because it didn't happen." During the interview with the VP she confirmed the agency did not send a staff member out to do a skin assessment after being notified of the incident by the daughter. This surveyor was also informed the agency did not do any type of investigation related to the incident and continued to allow the staff member to provide care for other patients. On 9/8/21 an interview was conducted with employee # 1. During an interview the employee stated, " the aides called me when they left the patient ' s home and told me what had happened. _______ [employee 3] said she didn ' t even touch the patient. I called triage and told them about what happened. I did not notify any management." There was no evidence employee # 1 notified any member of the management team of the events. A review of a concern/complaint form used by the agency and dated 8/30/21 revealed the form did not include any information related to the incident which happened on 8/28/21.
L0509      
34981 Based on agency policy, clinical record review and staff interviews the agency failed to investigate an alleged violation involving mistreatment and or physical abuse for 1 of 3 charts [#1]. The findings included The policy, Abuse, Neglect and Exploitation 2/19/21, was provided by the Vice President of Quality and Compliance on 9/8/21. The policy stated, "The patient has the right to be free of mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown source, and misappropriation of patient property...It is the responsibility of any staff member who has reason to suspect abuse/neglect of a patient to report it to a Director of Social Work...In addition, allegations of patient abuse, neglect, misappropriation of patient or facility property...by a nurse aide shall be investigated and reported in compliance with Article 15 of the NC Gen. Statutes Chapter 131 E..." Patient # 1 had a Start of Care [SOC] date of 5/29/21 and a terminal diagnosis of Huntington ' s Disease [an inherited condition in which nerve cells in the brain break down over time]. A review of the Plan of Care for the certification period 7/28/21 to 9/25/21 revealed order for SN [skilled nursing] 1-2 times per week for 9 weeks and 8 PRN [as needed] for symptom management and educated; aide services 2 times a week for 1 week and 4 times a week for 8 weeks. A review of the aide plan of care revealed the patient required assistance with all ADL ' s [activities of daily living]. A review of the clinical record revealed the following documentation on 9/7/21 by the VP of Quality and Compliance, " ...Notes regarding phone call with daughter ______[name] on Friday, September 3: I spoke with _______[name] of our patient _______[name] today for around an hour and listened to her perspective of what has occurred as it relates to the care of her mother ...She reported that last week during the incident in the home where we had 2 C.N.A.s visiting at the same time, one of the aides ______[employee # 3] grabbed her mother ' s arm and jerked it or dropped it and it now has a bruise and is causing pain to her mother. She reports sharing this incident on a previous call with an _______ [name of agency] leader." On 9/8/21 an interview was conducted with the VP of Quality and Compliance. During the interview the VP advised this surveyor the agency did not send a staff member out to do a skin assessment after being notified of the incident by the daughter. This surveyor was also informed the agency did not do any type of investigation related to the incident and continued to allow the staff member to provide care for other patients. On 9/8/21 an interview was conducted with employee # 1. During an interview the employee stated, " the aides called me when they left the patient' s home and told me what had happened. _______ [employee 3] said she didn't even touch the patient. I called triage and told them about what happened. " There was no evidence employee # 1 notified any member of the management team of the events. A review of a concern/complaint form used by the agency and dated 8/30/21 revealed the form did not include any information related to the incident which happened on 8/28/21.