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
491619 A. BUILDING __________
B. WING ______________ 		10/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ATHC - HOSPICE LLC 287 MCLAWS CIRCLE - SUITE 1, WILLIAMSBURG, VA, 23185
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      
36944 Based on clinical record review, staff interviews, agency on-call log review and emails, it was determined the agency failed to ensure an RN (Registered Nurse) was made available on a 24 hour basis, 7 days per week in three (3) of five (5) clinical records reviewed in the survey sample. Clinical records: #2, #3 and #4. The findings: Five (5) clinical records who utilized on call services were reviewed offsite as a virtual review in read-only mode from 10/13/2020 through 10/15/2020. 1. The clinical record for patient #2 was reviewed for the certification period of 7/8/2020 to 10/5/2020. A review of the patient's record revealed there were requested on-call visits for 9/15/2020 at two separate time intervals. The first call for 9/15/2020 with a visit made at 1:20 p.m. and the second requested on-call was at 9:04 p.m. There is no documentation of a nurseing visit for this second on-call time of 9:04 p.m. An interview was conducted with the on call nurse (staff member #3) who was caring for patient #2 on 9/15/2020. Staff member #3 stated, yes I remember the patient's daughter called me directly and I came out that day around noon because the patient fell. Then I received an on-call around 9 p.m. from the previous visit and so I called and educated on signs and symptoms of a concussion and she did not warrant an emergency department visit. I know I need to document better. Staff member #3 also sent an email on 10/14/2020 at 4:27 p.m. of the events for patient #2 regarding 9/15/2020 and reads as follows: "Return call to (patient's daughter) she stated to me that her mother who was present felt she had a concussion. Signs and symptoms of concussion, headache, nausea, vomiting, dizziness or blurry vision reviewed with daughter and patient. None of these symptoms were present patient only experiencing discomfort from cut to upper lip. Discussion regarding evaluation for concussion in emergency department with patient and daughter. Daughter who is patient's caregiver agreed to monitor patient for symptoms as described. No further treatment given daughter declined RN PRN (as needed) visit." The clinical record contained no evidence of an on-call phone call or a in home visit for patient #4 by a nurse for 9/15/2020 around 9 p.m. 2. The clinical record for patient #3 was reviewed for the certification period of 7/16/2020 to 10/13/2020. A review of the patient's record revealed on-call visits for 7/18/2020 and 8/11/2020, however the on-call log documented a call from patient #3's spouse on 8/10/2020 at 9:30 p.m. with an outgoing call to an agency's staff member who was no longer employed with this agency at 9:41 p.m. Subsequently, the on-call vendor called this previous agency's staff member again at 10:14 p.m., 10:51 p.m., 11:26 p.m., 12:06 a.m. and 12:07 a.m. The on-call vendor then called another staff member at 12:07 a.m. who contacted a staff member that made an on-call phone visit at 12:26 a.m. It is documented by the on-call vendor that patient #3's spouse had called five times by 11:38 p.m. on 8/10/2020. On 10/13/2020 at 12:00 p.m. the Director of Operations (DOO) provided this MFI (Medical Facilities Inspector) with an email exchange with the agency's on-call vendor. The email from the DOO dated 7/18/2020 submitted the on-call staff schedule for 7/21/2020 through 9/1/2020 to the on-call vendor, and the on-call vendor confirmed the updated on-call staff schedule. An email dated 7/27/2020 from the DOO sent an updated schedule to the on-call vendor to remove an agency staff member who was no longer working for them and the on-call vendor confirmed the updated on-call staff schedule. Another email dated 8/11/2020 from the on-call vendor apologized for the error of not removing an agency staff member who was not working with the agency anymore from the on-call rotation and verified that they are now using the updated schedule as previously sent on 7/27/2020. The clinical record contained documentation that it took approximately 3 hours from the time the patient's spouse utilized the on-call services to obtain the correct nurse for on-call services. 3. The clinical record for patient #4 was reviewed for the certification period of 6/30/2020 to 9/27/2020. A review of the patient's record revealed a requested on-call visit for 7/3/2020, however there is no documentation of a nurseing visit for 7/3/2020. An interview was conducted with the DOO on 10/14/2020 at 2:27 p.m. regarding the on-call nurse visit note for 7/3/2020. The DOO stated, I can't find any notes for that patient for the 7/3/2020 on call. An interview was conducted with the on call nurse (staff member #3) caring for patient #4 on 10/14/2020 at 2:43 p.m. Staff member #3 stated, I remember the on call for that day and the patient's spouse had a question about the oxygen concentrator but I did not document it. The clinical record contained no evidence of an on-call phone conversation or an in home visit for patient #4 by a nurse. The agency's policy, On-Call/Weekend Services Policy No. 1-012.1 was reviewed and partially reads as follows: "Clinical personnel are expected to perform visits on an as-needed basis, including weekends. There will be on-call staff available after hours, Monday through Friday, and 24 hours a day on weekends. The schedule will be forwarded to the answering service and on-call staff. The on-call nurse will provide follow-up appropriate to the call: A. Call the patient/family/caregiver B. Visit the patient, if necessary C. Obtain physician orders, as needed D. Arrange for other hospice services, as needed." The DOO confirmed the above noted findings prior to and during the exit conference on 10/15/2020 at 10:30 a.m.
L0672      
36944 Based on a review of clinical records and staff interviews it was determined the staff failed to maintain sufficient clinical notes in order to verify on call responses for two (2) of five (5) patients in the survey sample. Clinical records: #2 and #3 The findings: Five (5) clinical records who utilized on call services were reviewed offsite as a virtual review in read-only mode from 10/13/2020 through 10/15/2020. 1. The clinical record for patient #2 was reviewed for the certification period of 7/8/2020 to 10/5/2020. A review of the patient's record revealed requested on-call visits for 9/15/2020 at two separate time intervals. The first call for 9/15/2020 was with a visit made at 1:20 p.m. and the second requested on-call was at 9:04 p.m. There is no documentation of a nurse phone call or an in home visit for this second on-call time for 9:04 p.m. An interview was conducted with the on call nurse (staff member #3) that was caring for patient #2 on 9/15/2020. Staff member #3 stated, yes I remember the patient's daughter called me directly and I came out that day around noon because the patient fell. Then I received an on-call around 9 p.m. from the previous visit and so I called and educated on signs and symptoms of a concussion and did not warrant an emergency department visit. I know I need to document better. The clinical record contained no evidence of an on-call phone conversation or an in home visit for patient #4 by a nurse for 9/15/2020 around 9 p.m. 2. The clinical record for patient #4 was reviewed for the certification period of 6/30/2020 to 9/27/2020. A review of patient's record revealed a requested on-call visit for 7/3/2020, however there was no documentation of a nurseing visit for 7/3/2020. An interview was conducted with the DOO on 10/14/2020 at 2:27 p.m. regarding the on-call nurse visit note for 7/3/2020. The DOO stated, I can't find any notes for that patient for the 7/3/2020 on call. An interview was conducted with the on call nurse (staff member #3) that was caring for patient #4 on 10/14/2020 at 2:43 p.m. Staff member #3 stated, I remember the on call phone call for that day and the patient's spouse had a question about the oxygen concentrator but I did not document it. The clinical record contained no evidence of an on-call phone or in home visit for patient #4 by a nurse. The agency's policy, On-Call/Weekend Services Policy No. 1-012.1 was reviewed and partially reads as follows: "6. The on-call nurse will document each patient/family interaction in a clinical note." The DOO confirmed the above noted findings prior to and during the exit conference on 10/15/2020 at 10:30 a.m.