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
361681 A. BUILDING __________
B. WING ______________ 		04/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BROOKDALE HOSPICE COLUMBUS 2550 CORPORATE EXCHANGE DRIVE, SUITE 101, COLUMBUS, OH, 43231
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)
L0537      
32059 Based on medical record review, staff interview, and policy review, the agency failed to designate an interdisciplinary group or groups which, in consultation with the patient's attending physician, must prepare a written plan of care for four of five medical records reviewed (Patient #1, #3, #4, #5). The agency census was 57. Findings include: Review of agency policy titled, Interdisciplinary Group (IDG) Membership and Responsibilities, revised 11/21, revealed the hospice interdisciplinary group (IDG) collaborates with the patient's attending physician to develop and maintain a patient-directed, individualized plan of care. If the agency has more than one interdisciplinary group, it must designate, in advance, the group responsible for program oversight and the establishment of policies that govern the day-to-day provision of hospice care and services. 1). Review of the Interdisciplinary Comprehensive Assessment and Plan of Care Report for Patient #1 dated 03/03/22, 03/17/22, 03/23/22, 04/07/22, and 04/21/22 lacked evidence of a physician signature. 2). Review of the Interdisciplinary Comprehensive Assessment and Plan of Care Report for Patient #3 dated 03/03/22 lacked evidence of a physician signature. 3). Review of the Interdisciplinary Comprehensive Assessment and Plan of Care Report for Patient #4 dated 03/03/22, 03/17/22, 03/23/22, and 04/07/22 lacked evidence of a physician signature. 4). Review of the Interdisciplinary Comprehensive Assessment and Plan of Care Report for Patient #5 dated 02/03/22, 02/17/22, 03/03/22, 03/17/22, 03/23/22, and 04/07/22 lacked evidence of a physician signature. Staff E confirmed the above findings on 04/26/22 at 9:09 AM in an interview during the electronic medical records review. This deficiency substantiates Substantial Allegation OH00131239.
L0667      
32059 Based on medical record, staff interview, and policy review, the agency failed to ensure the medical director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course for three of five medical records reviewed (Patient #1, #4, #5). The agency census was 57. Findings include: Review of the policy titled, Certification of Terminal Illness, revised 04/01/22, revealed the purpose is to ensure physician certification of terminal illness and authorization of hospice services in accordance with applicable state and federal regulations and payor requirements. In order to meet eligibility criteria for the Medicare or Medicaid hospice benefit, a patient must be certified as terminally ill, meaning that the patient has a medical prognosis that their life expectancy is six (6) months or less if the illness runs its normal course. The initial certification of terminal illness must be completed by the Medical Director of the hospice (or other physician member of the hospice Interdisciplinary Group) and the patient attending physician, if the patient has chosen to have an attending physician. If a patient has chosen a nurse practitioner or physician assistant as an attending physician, the hospice Medical Director or physician member of the hospice IDG certifies the patient as terminally ill. 1). Review of the medical record for Patient #1 noted a verbal order for the certification of terminal illness dated 02/17/22 which lacked a physician signature to date. 2). Review of the medical record for Patient #4 noted a verbal order for the certification of terminal illness dated 02/14/22 which lacked a physician signature to date. 3). Review of the medical record for Patient #5 noted a verbal order for the certification of terminal illness dated 01/21/22 which was not signed by a physician until 04/18/22. An interview was conducted with Staff A on 04/26/22 at 1:58 PM who reported the agency transitioned the electronic medical records system on 02/01/22 and there were glitches in the system for the physician to electronically sign. The agency was currently working on getting caught up on the backlog of documents requiring a physician signature. This deficiency substantiates Substantial Allegation OH00131239.