Survey Report for 101562

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	101562	A. BUILDING __________ B. WING ______________	08/16/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
CONTINUUM CARE OF BROWARD LLC	7771 W OAKLAND PARK BLVD STE 150, SUNRISE, FL, 33351
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)
L0545
L0545	33162 Based on record review and interview the Hospice failed to ensure the plan of care was individualized and complete to meet the patient's needs and goals for care, included measurable outcomes, and was updated as conditions changed for 2 of 3 patients (Patients# 1 and 2). The findings included: 1) Review of the record revealed Patient #1 resided in a nursing facility and was admitted to the hospice on 05/12/22 with a terminal diagnosis of senile degeneration of brain. Patient #1's Hospice "Start Of Care" nurse visit note dated 05/12/22 documents she had a Stage 4 pressure ulcer to the sacrum and Stage 3 pressure ulcers to both heels. Stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage, or bone. Upon further review, Patient #1's "Start Of Care" nurse visit note also documents her diagnoses included chronic obstructive pulmonary disease, that she required total care for all activities of daily living and had poor food intake despite much encouragement and assistance to eat. Upon further review, Patient #1's "Start Of Care" nurse visit note documents pain was an active problem for her that affected functional status and the ability to enjoy activities/hobbies, and pain was helped by "medications" and "positioning," without identifying the medications that provided relief or evidence of inquiry to Patient #1's goals for pain management. Review of Patient #1's "Hospice Certification and Plan of Care" (HCPOC) for the certification period of 05/12/22 to 08/09/22 reveals it does not include orders, plans, supplies needed, or goals for wound care or specify who would be responsible to perform wound care but documents under goals, "a nursing plan of care will be established." Furthermore, Patient #1's HCPOC does not include a measurable goal for pain management according to the patient's preference but documents "pain will be managed at a level acceptable to the patient." Patient #1's HCPOC documents under goals "patient will have safety needs met" and "Medications will be managed appropriately as evidenced. Facility nurse will verbalize/demonstrate compliance with medication regimen" (sic) but does not include measurable patient outcomes. Further review of the HCPOC reveals all of Patient #1's medications were oral capsules and pills, with no medications ordered by alternate routes or plans to manage potential anticipated end of life symptoms such as inability to swallow solid medications, pain, shortness of breath, nausea or vomiting, agitation or anxiety, or excess secretions. Further review of the HCPOC reveals a nebulizer was provided but there were no orders or documented plans for nebulizer treatments. Further review of the record documents Patient #1 was discharged from the nursing facility and went home to a private residence with family to provide care on 05/16/22 and had verbal orders dated 05/17/22 for wound care to the sacrum, left heel, and right ankle that was to be completed by the caregiver (family member) twice weekly and PRN (as needed), and by the hospice nurse "as needed." A physician verbal wound care order documented on "Continuum Care Multi-Discipline Notes" for a left ankle wound dated 06/08/22, co-signed by the physician on 08/15/22, documents for the nurse to educate the family member to do this wound care twice a week and "as needed" and the hospice nurse would do wound care "as needed" and assess and obtain weekly measurements. This order also documents on the same page "return demonstration observed by (family member)", education provided and "verbalized understanding." However, there was no documentation that the family member was willing and in agreement to provide wound care and no evidence of updates to the "plan of care" to include the presence and care of wounds, and weekly wound measurements. Furthermore, review of the "Wound Record Report" revealed no measurements of wounds documented after 06/08/22 and the reasons measurements were not taken during the twice weekly nurse visits were documented as "not due," with one exception as "unable" without further explanation on 06/29/22. Further review of the record revealed no evidence of revision to the plan of care, other than new wound care orders, to address Patient #1's changing care needs with the 05/16/22 transition from the nursing facility to home with family. During the survey, the Registered Nurse/Advanced Practice Registered Nurse who had visited Patient #1, Staff A, provided "late documentation" dated 08/15/22 that she provided education to the caregiver regarding wound care, medications, and repositioning the patient and that the caregiver declined a "comfort kit" or any change in medications for symptom management on 05/17/22; that "comfort meds (medications) for advanced pain or shortness of breath" were explained again and declined by the caregiver on 06/24/22; but no evidence that the reasons for the caregiver's reservations were explored so that alternatives could be considered or offered in order to maintain comfort at the end of life. During telephonic interview on 08/16/22 at 1:38 PM, Staff A initially stated the family member did Patient #1's wound care and she (Staff A) had taught her how to do it. Further into this conversation Staff A stated she herself did Patient #1's wound care on her twice weekly visits during which the family member was present, and that she measured the wounds and put that in her notes when she did, but Staff A didn't remember how often she did these measurements and it was "maybe every week." During this interview, Staff A also stated the family member refused a comfort kit and did not want morphine in the home, despite education on its benefits at the end of life, since Patient #1 was still comfortable. Staff A did not report inquiry or discussion of specific reasons for the objection, discussing alternatives to manage end of life symptoms, or consideration of medications that could be given by other routes to have on hand. A nurse visit note for an "as needed" visit 07/02/22 at 4:42 PM documented Patient #1 was unresponsive (and therefore would have been unable to take pills or tablets by mouth) and had dyspnea with severity of 5 out of 10 (10 being the worst), and "gurgling," irregular respirations but there was no comfort kit in the home and the nurse could not find a local pharmacy open at that time, so would have to attempt pharmacies in a larger area. Patient #1's "Coordination Note" on 07/02/22 at 8:47 PM documented a family member (not previously mentioned) called the hospice and described Patient #1's labored breathing, requesting intervention for comfort, and staff called (name of mail-order pharmacy) to help search for a local pharmacy. Patient #1's "Coordination Note" on 07/02/22 at 9:04 PM documented the family member called back to report Patient #1 had died. There was no evidence that orders for symptom management were placed or that a means for after-hours provision of medications to Patient #1 was identified. 2) Review of the record revealed Patient #2 started care with the hospice on 07/21/22 with a terminal diagnosis of cerebral atherosclerosis. Patient #2's Hospice "Start Of Care" nurse visit note dated 07/21/22 documented he had wounds to both legs from external fixator devices for multiple fractures and a wound to his right buttock. Upon further review, Patient #2's "Start Of Care" visit note documents pain was an active problem that affected his appetite, emotions, and mobility, that the pain was continuous aching that interfered with activity or movement "all of the time", and the pain was helped by distraction, medications, and positioning, without identifying the medications that provided relief. Review of Patient #2's "Hospice Certification and Plan of Care" (HCPOC) for the certification period of 07/21/22 to 10/18/22 reveals it does not include orders, plans, supplies needed, or goals for wound care or specify who would be responsible to perform wound care but documents under goals, "a nursing plan of care will be established" and "caregiver will verbalize/demonstrate measures to prevent/manage skin breakdown." Furthermore, Patient #2's HCPOC does not include a measurable goal for pain management but documents "patient will demonstrate improved comfort through massage therapy services." Patient #2's HCPOC documents under goals "Patient/caregiver will administer medications as prescribed as evidenced by no adverse effects from medication error." Further review of Patient #2's HCPOC reveals it does not include any medications for pain, or evidence that the patient declined such medications and alternatives were explored.