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
151521 A. BUILDING __________
B. WING ______________ 		01/21/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE 2720 DUPONT COMMERCE COURT, SUITE 210, FORT WAYNE, IN, 46825
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)
L0512      
44599 Based on record review and interview, the agency failed to ensure patient received effective symptom management for related conditions in 2 of 7 patients (#1 and 6). Findings include: 1. Review of an agency policy dated 6/2016 titled "Patient's Rights and Responsibilities" indicated " ... the patient has the right to the following ... receive effective pain management and symptom control from the hospice for conditions related to the terminal illness ...." 2. Review of an agency document dated 7/2021 titled "Hospice Levels of Care" indicated " ... hospice has four levels of care including routine home care, continuous home care, respite care, and general inpatient care ... general inpatient care ... available during an acute medical ... episode and provides symptom management ... of severe short-term problems related to the terminal condition that cannot be managed in the regular home setting ... continuous care is provided to patients in crisis ... to manage acute medical symptoms ...." 3. Record review for Patient #1 was completed on 1/21/2022, Election date 10/16/2021, for benefit period 10/16/2021-12/14/2021, with a primary diagnosis of unspecified sequelae of cerebral infarction (residual effects of a stroke) and other diagnoses (but not limited to), essential, primary, hypertension (high blood pressure that's not due to a medical condition), and vascular dementia without behavioral disturbances (problems with memory and other thought processes caused by brain damage from impaired blood flow to the brain). Review of a document titled "Client Coordination Note Report" dated 10/26/2021, indicated " ... pt [patient] in bed curled into a fetal position ... patient making moans and groaning sounds ... patient refused any type of care provided ... dtr [daughter] ... attempted to give patient liquid Ativan [for agitation] and liquid morphine [for pain] ... patient would not open mouth ... RNCM [registered nurse case manager] assisted and was not able to get syringe into mouth either ... has not been able to take any routine medications, comfort medications or recently prescribed antibiotics ... patient taken to hospital ER ...." Patient revoked hospice benefit on 10/26/2021. The document failed to evidence the agency provided symptom management by offering to provide another form of administering pain management, general inpatient care or continuous home care level of care to manage patient's symptoms. Review of a document titled "Hospice Certification and Plan of Care" indicated patient was readmitted to hospice on 10/31/2021 with a primary diagnosis of parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination). Review of a document titled "Client Coordination Notes Report" dated 12/1/2021 indicated " ... received direct call from ... daughter ... pt is c/o [complaining of] chest pain, HR [heart rate] 103 and can't take a deep breath ... social worker met daughter ... in emergency department ... daughter signed revocation paperwork ...." The document failed to evidence the agency provided symptom management by offering to provide another form of administering pain management, general inpatient care or continuous home care level of care to manage patient's symptoms. Review of a document titled "Visit Note Report" for Hospice Election date 12/5/2021, indicated " ... went to hospital on 11/30/2021 due to complaints of chest pain, increased confusion and sore on mid chest ...." During an interview on 1/20/2022 at 3:30 PM, when asked what support the agency provides when symptom management isn't controlled, the director of professional services indicated symptom management cards are left in the home and a nurse practitioner can be utilized. When asked who offers the options of other levels of care when having uncontrolled symptoms, the director of professional services indicated the RN case manager. 4. Record review for Patient #6 was completed on 1/19/2022, Election date 1/25/2021, for benefit period 1/25/2021-4/24/2021, with a primary diagnosis of primary pulmonary hypertension (high blood pressure in the lungs) and other diagnoses but not limited to, cor pulmonale (condition that causes the right side of the heart to fail). Review of a document titled "Hospice Certification and Plan of Care" for benefit period 1/25/2021-4/24/2021, indicated " ... medications ... lorazepam intensol ... as needed every 4 hours ... reason ... anxiety or air hunger [feeling of breathlessness] ...." Review of a document titled "Visit Note Report" dated 3/1/2021, indicated " ... breathing very labored ... no Lorazepam available in the home ... unable to chatch [sic] ... breath ... 911 contacted ...." The agency failed to ensure the patient had an adequate supply of medications to manage symptoms. The document failed to evidence the agency provided symptom management by offering to provide another form of administering symptom management such as morphine to assist with shortness of breath, general inpatient care or continuous home care level of care to manage patient's symptoms. During an interview on 1/20/2022 at 3:30 PM, when asked what happened to the Lorazepam that was supposed to be in patients' home, the administrator of Mishawaka indicated the Lorazepam was never delivered. When asked what the RN case managers responsibility was to ensure prescribed medications are in the patients' home, the administrator indicated the RN case manager is responsible to make sure the medication is ordered and in the home.
L0715      
44599 Based on record review and interview, the agency failed to ensure hospice training was provided to employees providing hospice care in 1 of 2 facilities with written agreements for short term inpatient hospice care (A). Findings include: Review of an agency contract log indicated the agency had a general inpatient agreement with facility A. Agreement indicated annual training with the description of the training and the names of agency staff providing the training was to be completed. During an interview on 1/21/2022 at 9:10 AM, when asked for documentation of the training provided to facility A, the administrator indicated the agency hospital liaison provides the training titled "GIP (general inpatient) Steps and Process" on an individual basis when the agency has a patient in the facility. Director of Professional Services indicated a hospice patient received inpatient hospice care in facility A on 4/9/2021. When asked for the proof of staff training, the administrator indicated the training was provided but not documented.