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
101516 A. BUILDING __________
B. WING ______________ 		09/23/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOPE HOSPICE AND COMMUNITY SERVICES INC 9470 HEALTHPARK CIRCLE, FORT MYERS, FL, 33908
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)
L0519      
22651 Based on medical record review and staff and family interviews, the hospice center failed to ensure information about the scope of services the hospice will provide and specific limitations of those services for 1 (Patient #1) of 10 sampled patients reviewed for Patient Rights. The findings included: Review of Patient #1 Medical Record the Hospice Admission Sheet dated 7/23/20 documented the patient's family express their and patient's End of Life wishes. The Admission Sheet notes the family decision mother is not to go to the hospital. The medical record failed to provide documentation of family advance notification of patient's transfer to hospital. The patient was admitted to Hospice House from a Long-Term Facility with a high COVID -19 rate and mortality rate, with a pending COVID test result. The patient was placed on contact isolation in the Hospice House. A (+) COVID test results was returned on 7/31/20. The patient was maintained, in Hospice House on contact isolation. On 9/22/20 at 1:20 p.m., in a interview the patient's daughter said, "I do not have issues with the staff, it is the Administration. Mother was transferred from the Nursing Home to Hospice House. Hospice tested mother on 7/26/20 and 7/30/20 and was (+) for COVID-19. They did not transfer her to the hospital until 4 days later. They did give me a call notifying me they do not have a COVID unit and she must be transferred to the hospital. I told them she is End of Life; can't you take care of her there? They were to wait before the transfer, I had to call my brother. They transferred her before I could get back to them. We did not approve the transfer. Mother died in the hospital. Administer gave me a call and apologized for what happened." On 9/23/20 8:58 a.m., a second call was made to the complainant who confirmed the families request not to send mother to the hospital. She said "We have had other family members there and they give good service, that is why we chose Hope Hospice. We were not informed of the hospice COVID restriction. If we knew that she might be (+) we would not have her moved, they should not have accepted. They could have provided the End of Life Care there." On 9/22/20 2:30 p.m., in an interview the Hospice Medical Director said, "The patient was declining, we thought death was imminent. The patient appeared to rally and required nebulization treatment. That would require respiratory isolation and we don't have the accommodations or reverse ventilation room, the decision to transfer to the hospital was made. We must think of the other patients. I am not privy to the conversations that were had with the family. If I was aware of this admission, I would not have accepted her knowing the environment she was coming from." The facility failed to honor the family's End of Life decisions.