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
391741 A. BUILDING __________
B. WING ______________ 		10/25/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
BAYADA HOSPICE 1400 N PROVIDENCE ROAD SUITE 200, MEDIA, PA, 19063
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)
L0591      
37972 Based on review of hospice policy, clinical records (CR) and staff interview, the agency failed to ensure the needs of the patients were met for one (1) of one (1) CRs reviewed with documented wounds (CR #2). Findings Include: Review of hospice policy "0-3230 Wound Care Assessment and Treatment" on October 19, 2021, at approximately 11:00 A.M. stated, "11.3 Size: Wound should be measured in centimeters (cm) once per week and/or as per physician's order.... " Review of CR on October 19, 2021, at approximately 10:00 A.M. revealed: CR #2, start of care October 2, 2021, certification period reviewed, October 2, 2021, through December 30, 2021, contained orders for skilled nursing (SN) one (1) visit per week for one week, then two (2) visits per week for thirteen (13) weeks. Review of SN visits revealed that an initial SN visit was conducted on October 2, 2021. The SN documented three wounds on the wound assessment sheet. Wound #1 on left hand, which was bandaged and wound care had been completed by the caregiver, was not assessed. Wound #2 on the left patellar area was documented as a stage 2, was not measured due to patient refusal. Wound care was performed. Wound #3, on the right buttock was documented as a stage 3, was not measured due to patient refusal. The SN documented, "Pt (patient) with severe contractures. Sacral wound decubitus ulcer and several other ulcers, treatment complete, due to pt screaming, unable to fully assess..." October 5, 2021, SN visit conducted, wound care documented as follows: Wound #1, caregiver provided wound care, wound not assessed. Wound #2, refused measurement. Wound care provided, cleansed with NSS (normal saline solution), applied MediHoney, covered with gauze. Wound #3, refused measurement, wound care provided, cleansed with NSS, MediHoney applied and covered with gauze. October 7, 2021, SN visit conducted. Wound care provided as ordered for wound #1, 2, and 3. Patient refused measurements. October 11, 2021, SN visit conducted. Wound #1 and 2, care provided by caregiver, not assessed. Wound #3, wound care provided per physician orders. Measurement 5 cm (centimeters) by 5 cm by 0.5 cm. October 14, 2021, SN visit conducted. Wound #1 and 2, care provided by caregiver, not assessed. Wound #3, wound care provided per physician orders, no measurements taken. The SN documented that skin protectant was ordered. October 18, 2021, SN visit conducted. Wound #1 measured 2cm by 2cm by 0.3 cm. Wound #2 measured as 10cm by 6 cm by 0.3 cm. Wound #2 measured 5 cm by 5 cm by 0.5 cm. Wound care provided per physician orders. The SN documented "Patient is unable to reposition. Sacral wound increased in depth and area. Wound care provided..." October 19, 2021, the clinical manager documented the SN reported wound score deviation and conferenced with medical director on change in severity. New orders were obtained for calcium alginate and transparent film dressing. Interview with the clinical manager on October 19, 2021, at approximately 11:00 A.M. confirmed the above findings. A follow-up telephone call with the clinical manager on October 22, 2021, confirmed the above findings.