Survey Report for 441504

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	441504	A. BUILDING __________ B. WING ______________	10/22/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE OF CHATTANOOGA INC	4411 OAKWOOD DRIVE, CHATTANOOGA, TN, 37416
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)
L0511
L0511	31210 Based on agency policy review, review of facility investigation, and interview, the agency failed to immediately report an allegation of abuse for 1 patient (#1) of 5 residents reviewed. The findings include: Review of the agency's policy "Reporting Possible Abuse/Neglect," undated revealed "...Report: Any report received by...a verbal and/or written statement of abuse and/or neglect...will submit a verbal report of the suspected abuse/neglect to the proper authorities, in accordance with state law...within 24 hours of the incident..." Medical record review revealed Patient #1 was admitted to the agency on 3/31/2017 with diagnoses including Arteriosclerotic Cardiovascular Disease, Hypertensive Heart Disease, Congestive Heart Failure, and Diabetes Mellitus. Review of the medical record revealed Patient #1 resided with family members. Review of the agency's Complaint Control Log revealed on 9/14/2020 Patient #1's family member had reported allegations that a Hospice Aide (HA) from the agency had stolen money and forged checks from the patient over the past month. Further review revealed the HA #1 was suspended the following day on 9/15/2020. Review of the agency's investigation dated 9/15/2020 revealed a night shift nurse had received a call from the family of Patient #1 stating that HA#1 had stolen more than $2,000 and forged checks from the patient over the past month. The family further informed they had proof and wanted to ensure HA #1 did not return to Patient #1's property. Interview with the Chief Compliance Officer (CCO) on 10/21/2020 at 11:16 AM, revealed the Chief Operating Officer (COO) and Chief Nursing Officer (CNO) had contacted her by phone on 9/14/2020 after hours regarding an incident involving Patient#1 and a HA #1. Further interview revealed the CCO and the Director of Human Resources had conducted an investigation and terminated the employment of the HA #1. Interview with the CCO confirmed the agency had reported the abuse allegations to Adult Protective Services but had failed to report the allegations to the State Agency.