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
441557 A. BUILDING __________
B. WING ______________ 		06/08/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ADORATION HOME HEALTH & HOSPICE CARE EAST TENNESSE 2765 EXECUTIVE PARK DRIVE, CLEVELAND, TN, 37312
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)
L0556      
40105 Based on facility policy review, medical record review, and interview, the agency failed to notify the physician to obtain an order for a urinalysis (UA) for 1 patient (Patient #1) of 3 patients reviewed. The findings include: Review of the agency policy titled, "Identification, Prevention, And Treatment Of Secondary Symptoms," revised 5/11/2020, showed "...Symptom control is the foundation of good hospice care...Care will be directed t optimize the patient's comfort and dignity through appropriate treatment of secondary symptoms as well as aggressively managing thee symptoms...The hospice interdisciplinary group will use published standards of care in the treatment of patient symptoms...Interdisciplinary group members will report to the Case Manager symptoms they may observe that are changes or are new from the patient's comprehensive assessments...The Case Manager will receive any and all information and will notify the attending physician...Orders will be obtained as necessary..." Record review revealed Patient #1 was admitted to the agency on 1/14/2022 and discharged on 1/30/2022, she was readmitted on 1/31/2022 and discharged due to moving out of the service area on 3/3/2022 with diagnoses including Senile Degeneration of the Brain, Dementia With Behavioral Disturbance, Anxiety Disorder, Depression, Insomnia, Urinary Tract Infection, Dysuria, and Repeated falls. Review of Patient #1's coordination note dated 3/1/2022, showed "...CG [caregiver] asked for a UA to be done because PT [Patient] is getting agitated, fighting, pushing, being uncooperative which she does when she gets UTI reports CG. Will contact MD [Medical Doctor]..." Record review showed no documentation the physician had been notified of the caregiver's request for a UA to be obtained and no documentation of a physician's order to obtain a UA after the 3/1/2022 coordination note. During a telephone interview on 6/8/2022 at 9:37 AM, Registered Nurse (RN) #1 stated she did not remember if she called the Physician to obtain an order for a UA. She stated she would have documented if she had called the physician even if he did not order a UA. During an interview on 6/8/2022 at 12:55 PM, the Office Manager confirmed the reported symptoms of increased behaviors would have been considered a change that should have been reported to the MD. She confirmed the request for a UA should have been reported to the MD. During a telephone interview on 6/8/2022 at 1:51 PM, the MD stated he would expect the nurse to have called and reported the request for the UA. He stated he would have given the order for a UA to be obtained if the nurse had notified him of the caregiver's request.