Survey Report for 391660

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	391660	A. BUILDING __________ B. WING ______________	01/19/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
GATEWAY HOSPICE	9380 MCKNIGHT ROAD, SUITE 201, PITTSBURGH, PA, 15237
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)
L0653
L0653	37775 Based on the review of clinical records (CR), facility policy and procedure, facility documentation and staff interview (EMP), the hospice failed to ensure covered services were available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family in accordance with facility policy and procedure for one (1) of three (3) clinical records reviewed (CR1). Findings included: Policy review on 1/19/2022 revealed the following: " ...On-Call/Weekend Services ...Policy No. H:2-040.1 ...Policy ...There will be on-call staff available after hours, Monday through Friday, and 24 hours a day on weekends ...Procedure:..7. On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour whenever possible. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the call.) ..." Review of CR1 on 1/19/22 at approximately 9:45 AM revealed the following: Patient resided in Assisted Living Facility. Start of care 11/2/2021. Certification period 11/2/2021 to 1/30/2022. Facility on-call log revealed a phone call by patient family member requesting hospice visit taken on 11/30/21 at 5:03 AM with on-call skilled nurse (SN) "patched" to call. SN narrative note for on-call PRN (as needed) visit 11/30/21 revealed the following: " ... [phone call] to [family member] ...nurse reassured ...would be on ...way to make visit ...0700 hrs (7:00 am) arrived at facility ..." Further review of facility documentation on 1/19/22 of on-call nursing logs and communication notes for CR1 did not reveal a reason why on-call nursing visit arrival at facility was 7:00 AM on 11/30/21 after phone call was received at 5:03 AM for nurse visit request (from CR1 family member). Time from family member phone call to facility and skilled nurse visit conducted was approximately 2 hours, outside of timely parameters established by facility policy and procedure. An exit conference was conducted on 1/19/2022 at approximately 1:15 PM with EMP1, administrator and EMP2, alternate administrator. Above findings were reviewed.