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
151615 A. BUILDING __________
B. WING ______________ 		08/07/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PHYSIOCARE HOSPICE LLC 1440 INNOVATION PLACE, WEST LAFAYETTE, IN, 47906
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)
L0538      
42617 Based on record review and interview, the hospice agency failed to ensure the plan of care (POC) contained specific and individualized treatments and interventions for 3 of 3 active records reviewed (#1, 2, 3), in a total sample of 4 records. Findings include: 1. An undated agency policy titled "The Plan of Care," policy number 9-017, stated " ... Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program ... This plan will focus on identified problems, goals, and interventions ... Procedure ... 4. The plan of care will identify the patient's needs and services to meet those needs ... 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes ... 12. The written plan of care will contain, but will not be limited to, the following: ... L. Individualized interventions to assist with end-of-life care ... P. Pain and symptom management interventions Q. Drugs and treatments (including allergies) ...." 2. An agency document titled "Updating the POC," dated 8/10/2020, stated "1 ... Please make sure all interventions and goals are individualized to that specific patient and that they are all measurable ...." 3. The clinical record of Patient #1 was reviewed on 10/20/20, and indicated a hospice election date of 10/9/2020. The clinical record contained a plan of care for the benefit period of 10/9/20 - 1/6/21, and indicated the patient's diagnoses included but were not limited to "chronic systolic (congestive) heart failure ... Hypertensive [high blood pressure] heart and chronic kidney disease." The "Nutrition / Hydration" interventions included "SN [Skilled Nurse] to monitor medication administration, side effects, and response every visit. SN to notify MD of possible side effects or adverse reactions. The medication list on the POC failed to evidence the patient was currently taking any medications or other treatments for nutrition-related conditions. The "Pain" interventions included "SN to assess pain status every level [sic] ...." The POC's Pain interventions failed to specify which pain scale the nurse was to use when assessing the patient's pain and failed to specify the frequency the nurse was to assess the patient's pain. The "Respiratory" interventions included "Administer oxygen at LPM [liters per minute] via NC [nasal canula] for patient's comfort. May titrate for patient comfort ... May check O2 saturation per MD order and prn. Initiate oxygen therapy for respiratory distress or O2 saturation less than 85% if family/patient agreeable. Notify MD of need to initiate oxygen therapy ...." The POC's Respiratory interventions failed to specify how "patient comfort" was to be assessed and measured (such as pain, anxiety, presence of air hunger, etc). 4. The clinical record of Patient #2 was reviewed on 10/20/20, and indicated a hospice election date of 9/21/18. The clinical record contained a plan of care for the benefit election period of 9/10/18 - 11/8/20, and indicated the patient's diagnoses included but were not limited to "Cerebral ischemia [loss of blood flow to the brain, usually due to a stroke] ... Dysphagia [difficulty swallowing] ... dementia ... Essential (primary) hypertension [high blood pressure without a known cause] ... Chronic obstructive pulmonary disease [COPD] ... Gastro-esophageal reflux disease ...." The "Respiratory" interventions included "SN may check O2 saturation as needed for s/s [signs and symptoms] of respiratory distress per MD orders. SN may administer oxygen at 2L [2 Liters per minute] per NC as a nursing measure for patient comfort per MD standing orders for comfort care ...." The POC's Respiratory interventions failed to specify how "patient comfort" was to be assessed and measured (such as pain, anxiety, presence of air hunger, etc). 5. The clinical record of Patient #3 was reviewed on 10/20/20, and indicated a hospice election date of 6/16/20. The record contained a benefit election period of 9/14/20 - 12/12/20, and indicated the patient's diagnoses included, but were not limited to, stated "Atherosclerotic heart disease ... Essential (primary) hypertension ...." The "Nutrition/Hydration" interventions included "Patient/Caregiver to administer medications per MD order." The medication list on the POC failed to evidence the patient was taking medication(s) with a nutrition and/or hydration indication. The "Nutrition/Hydration" interventions failed to evidence which medications the patient was to be taking related to this problem. The "Urinary Elimination" interventions included "Patient/Caregiver to administer medications per MD order." The medication list on the POC failed to evidence the patient was taking medication(s) with a urinary elimination indication. The "Urinary Elimination" interventions failed to evidence which medications the patient was to be taking related to this problem. 6. An interview was conducted with the administrator on 10/20/20 at 12:35 PM. During the interview, the administrator indicated the plan of care should contain specific and individualized interventions. The administrator stated, "that's what they [agency Registered Nurses] went in and redid ... we tried to get rid of all generic interventions."
L0548      
42617 Based on record review and interview, the hospice agency failed to ensure the plan of care contained specific, individualized, and measurable outcomes for patient and/or caregiver goals for 3 of 3 active records reviewed (#1, 2, 3), in a total sample of 4 records. Findings include: 1. An undated agency policy titled "The Plan of Care," policy number 9-017, stated " ... Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program ... This plan will focus on identified problems, goals, and interventions ... Procedure ... 7. Each patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goals ... 12. The written plan of care will contain, but will not be limited to, the following: ... N. Statement of treatment goals ... T. Measurable outcomes anticipated from implementing and coordinating the plan of care ...." 2. An agency document titled "Updating the POC," dated 8/10/2020, stated " ... Please make sure all interventions and goals are individualized to that specific patient and that they are all measurable ...." 3. The clinical record of Patient #1 was reviewed on 10/20/20 and indicated a hospice election date of 10/9/2020. The clinical record contained a plan of care for the benefit period of 10/9/20 - 1/6/21, and indicated the patient's diagnoses included but were not limited to "chronic systolic (congestive) heart failure ... Hypertensive [high blood pressure] heart and chronic kidney disease." The POC contained a bowel elimination goal which indicated the "Patient/Caregiver will demonstrate ability to manage bowel routine by: 10/31/2020," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient (different for every patient). The cardiovascular goals indicated "Patient/caregiver will receive ongoing teaching and support as cardiac and pulmonary functions change during care through 01/06/2021," but failed to evidence specific teaching and support which was to be provided by hospice staff. The cardiovascular goals also indicated "Patient/caregiver will verbalize understanding of medications and treatments through 01/06/2021," but failed to evidence which medications and/or treatments the patient was to verbalize understanding of. The nutrition/hydration goals indicated "Promote patient's nutrition/hydration during care," but failed to evidence specifically what the normal or optimal nutrition and hydration was for the patient. The physical mobility goal indicated "Patient's hygiene will be maintained during care through 01/06/2021," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. The respiratory goal indicated "Patient respiratory status will be maintained at a comfort level of 3 per patient/caregiver reports through 01/06/2020," but failed to evidence which comfort scale was being utilized to measure this goal. 4. The clinical record of Patient #2 was reviewed on 10/20/20 and indicated a hospice election date of 9/21/18. The clinical record contained a plan of care for the benefit election period of 9/10/18 - 11/8/20, and indicated the patient's diagnoses included but were not limited to "Cerebral ischemia [loss of blood flow to the brain, usually due to a stroke] ... Dysphagia [difficulty swallowing] ... dementia ... Essential (primary) hypertension [high blood pressure without a known cause] ... Chronic obstructive pulmonary disease [COPD] ... Gastro-esophageal reflux disease ...." The POC contained a bowel elimination goal which indicated the "Caregiver will demonstrate to [sic] effectively manage bowel routine thru 11/08/2020," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The cardiovascular goals indicated "Caregiver will receive teaching and support as cardiac and pulmonary functions change during care through 11/08/2020," but failed to evidence specific teaching and support that was to be provided by hospice staff. The coping goals indicated "Facility nurse understands and properly administers medications/treatments for distressful symptoms as needed and recommended thru cert period, 11/6/20," but failed to evidence which medications and/or treatments the facility nurse was to verbalize understanding of and administer, and failed to evidence what "distressful symptoms" were. The physical mobility goal indicated "Personal hygiene will be maintained during care through 11/8/2020," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. 5. The clinical record of Patient #3 was reviewed on 10/20/20 and indicated a hospice election date of 6/16/20. The record contained a benefit election period of 9/14/20 - 12/12/20, and indicated the patient's diagnoses included, but were not limited to, stated "Atherosclerotic heart disease ... Essential (primary) hypertension ...." The POC contained a bowel elimination goal which indicated the "Patient/Caregiver will demonstrate ability to manage bowel routine thru 12/12/2020," but failed to evidence specifically what a "normal" or "optimal" bowel routine was for the patient. The cardiovascular goals indicated "Patient/caregiver will receive teaching and support as cardiac and pulmonary functions change during care through 12/12/2020," but failed to evidence specific teaching and support which was to be provided by hospice staff. The cardiovascular goals also indicated "Patient/caregiver will verbalize understanding of medications and treatments through 01/06/2021," but failed to evidence which medications and/or treatments the patient was to verbalize understanding of. The MSW coping goals indicated "Patient/caregiver understands and properly administers medications/treatments for distressful symptoms as needed and recommended thru cert period. 11/10/20," but failed to evidence which medications and/or treatments the patient and/or caregiver was to verbalize understanding of and administer and failed to evidence what "distressful symptoms" were. The nutrition/hydration goals indicated "Promote patient's nutrition/hydration during care through 12/12/2020," but failed to evidence specifically what the normal or optimal nutrition and hydration was for the patient. The physical mobility goal indicated "Patient's hygiene will be maintained during care through 12/12/2020," but failed to indicate specifically what was normal or optimal mobility and hygiene for the patient. 6. An interview was conducted with the administrator on 10/20/20 at 12:35 PM. During the interview, the administrator indicated all goals on the plan of care should be specific and measurable.