Survey Report for 151621

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	151621	A. BUILDING __________ B. WING ______________	08/25/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
TRANSITIONS INDIANA, LLC	8435 KEYSTONE CROSSING SUITE 108, INDIANAPOLIS, IN, 46240
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)
L0502
L0502	30405 Based on record review and interview, the hospice agency failed to ensure it provided a patient/representative with verbal and written notice of patient/representative rights in the language the patient understood; failed to document the patient's and representative's communication needs; and failed to implement the agency policy which addressed overcoming language barriers, for 1 of 1 patient (patient #4) who was a non-English speaker, of a total sample of 6 patients. The findings included: Review of an agency policy, "C: 1-011.1 Facilitating Communication," last reviewed/revised, October 2019, evidenced the policy stated: "The policy purpose is: To assure that patients, visitors, and personnel with ... a limited command of the English language have access to appropriate interpretive assistance ... Organization's Name does not discriminate against any person .... Personnel will ... use forms of communication appropriate to meet the patient's needs ... Written materials will be made available in the recognized major languages in the area and state where the organization does business ... Organization personnel will consistently and clearly communicate with patients in a language or form they can reasonable understand ... The initial assessment will determine the patient's communication ability ... All related forms, such as Consent for Services, Complaint/Grievance Process, etc., will be available in English and other languages as appropriate. If there is a need to translate these forms to another language an interpreter will be secured ... For all other patients speaking languages other than English, Organization's Name will secure an interpreter to interpret all organization policies and procedures of Organization's Name relevant to the care of the patient. (See Organization List of Interpreters Addendum C 1-011.A for listing) ... The organization will maintain a list of organization personnel who speak languages other than English. (See Organization List of Interpreters Addendum C 1-011.A to assign an interpreter to non-English speaking patients.) ... Document all language assisted care in the patient's clinical record." On 8/25/2020, at 11:39 A.M., the administrator provided the agency policy on communication and translation and confirmed not having any other documents to provide with the policy. When queried if the administrator had read the policy, replied "Yes." When queried if administrator was familiar with Addendum C 1.011.A, the Administrator stated not being aware of the addendum and indicated lacked knowledge of how to locate the addendum policy. The administrator acknowledged the policy was an incomplete template, as noted in 3 areas where "Organization's Name" is used in place of the agency name. The administrator stated the agency did not have a list of employees who speak other languages, as required by agency policy, and confirmed the hospice health aide who has provided translation at the initial assessment, did not also provide written rights translated into Spanish, and admission documents had not been reviewed in detail (e.g. Patient Rights, Consent for Services, Complaint/Grievance Process, and any other forms or written information provided to patient.) The administrator stated the hospice aide provided translation for all visits but was unable to provide any documentation to evidence the hospice aide had done so. Review of clinical record for patient # 4 evidenced documentation at the referral/intake process, dated X-X-XX, evidenced neither the patient nor patient's power of attorney spoke any English. The intake section of the electronic medical record (EMR) evidenced "Spanish" was checked for preferred language. The initial assessment, dated X-X-XX, failed to document a language barrier had been identified and assessed. The initial assessment failed to evidence the specific language spoken by patient #4/ representative, how translation of written documents would be provided, and how verbal communication would occur during the initial assessment and during follow up care visits. Review of the initial assessment for patient #4, dated X-X-XX, failed to evidence documentation indicating the presence of a translator and failed to evidence documentation showing the patient rights were reviewed utilizing a qualified translator from the agency list, who spoke the language the patient [Spanish]and the patient's legal representative understood. Review of visit notes in the clinical record, dated XXXXX to XXXXXXXX, failed to evidence documentation of the identification of a language barrier, the patient/representative's primary language, and the presence of a translator. Review of the care plan failed to evidence the Interdisciplinary Group IDG had established a plan to accommodate patient #4's communication needs. On 8/24/2020, at 2:15 P.M., the administrator, who was also the admitting registered nurse (RN,) was queried concerning patient #4/representative receipt of patient rights in the language which patient #4/ representative could understand and written reference related to rights as a hospice patient, the administrator responded, "We have an aide that is fluent in Spanish." The requirement in CFR 418.52 was read out loud to the administrator, who then stated, "No. We didn't give [sic patient #4/ representative] anything in Spanish."
L0548
L0548	30405 Based on record review and interview, the hospice Interdisciplinary Group failed to ensure only objective measures individualized to patients' needs were used to measure progress toward goals for 3 of 6 patients (Patients #3, 4, and 5) whose clinical records were reviewed, and failed to set a reasonable outcome timeframe of goals for 2 of 6 patients (Patients #4 and 5.) The findings included: 1. Review of a policy, "Interdisciplinary Group Meeting," last reviewed/revised October 2019, evidenced the policy stated, "An Interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment, and progress toward targeted outcomes ... " 2. Review of the clinical record of Patient #3 evidenced an election of benefit (EOB) date of 2-26-2020, with terminal diagnosis of Senile Degeneration of the Brain. Review of the following Interdisciplinary Group (IDG) and Care Plans evidenced the following: -The 3-4-2020 IDG meeting and plan of care evidenced the problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver. Progress 0%." The goal of "identifies feelings regarding illness and spiritual beliefs," failed to be individualized to patient #3's disease of Senile Degeneration of the Brain; and failed to establish objective and measurable goals. -The 7-29-2020 IDG meeting and updated plan of care evidenced the problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver ... Progress Declining." The measure of "Declining" failed to be objective and measurable. -The 8-12-2020. IDG meeting and updated plan of care evidenced the problem of "Dyspnea" with the goal of "SW [sic social worker] will monitor and assist patient/family to identify and report s/s [sic signs and symptoms] of Depression. Patient/caregiver anxiety with symptom exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient maintains adequate airway and respiratory function within limits of disease process ... Progress Declining;" problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver ... Progress Declining." The measure of "Declining" failed to be objective and measurable. 3. Review of the clinical record of Patient #5 evidenced an election of benefit (EOB) date of 4-6-2020, with terminal diagnosis of Alzheimer's Disease. Review of the 4-15-2020, Interdisciplinary Group (IDG) and Care Plan evidenced the following: The 4-15-2020, IDG meeting and plan of care evidenced the problem of "COVID-19 Education" with the goal of "Patient/family state understanding of signs & symptoms of COVID-19. Patient /family state understanding of ways to prevent infection spread." The "Outcome Timeframe:" was "By time of death/discharge." The goal outcome failed to set a reasonable goal to meet the patients current care needs for education to reduce the risk of disease transmission. Review of the 6-24-2020, IDG meeting and updated plan of care evidenced an identified problem of "In & Out Catherization," with goal of "Patient experiences peaceful death with dignity and symptoms managed within limits of disease. Patient/caregiver verbalizes understanding of Hospice philosophy, team member roles. Patient participates in plan of care and verbalizes wishes." Outcome Timeframe was "By time of death/discharge." The stated goal of "Patient experiences peaceful death," failed to be rationally related to the identified problem of "In & Out Catheterization." Review of the 6-24-2020, IDG meeting and updated plan of care evidenced an identified problem of "COVID-19 Education," with progress of "0 %." Interventions of education had been documented on 4-6, 4-7, 4-12, 4-16, 4-21, 4-25, 4-26, 4-29, 5-5, 5-8, 5-10, 5-14, 5-19, 5-23, 5-24, 5-28, 6-2, 6-6, 6-7, 6-11, 6-16, and 6-21-2020. After 22 care visits with education provided, the IDT failed to measure any progress towards the goal. The IDT should have documented progress toward the goal based on nurse interventions and assessments, or revised the goal. 43294 4. Review of the clinical record for patient #4, evidenced a verbal certification 8-5-2020, for benefit period 8-5-2020-11-02-2020. Review of physician visit note dated 7-31-2020, evidenced diagnoses to include essential hypertension, unstable angina, dementia without behavior disturbance, unspecified dementia, atherosclerotic heart disease, gastro-esophageal reflux (GERD) without esophagitis, insomnia, diabetes mellitus type II, uncontrolled, presence of a pacemaker, failure to thrive (adult), and memory loss. Review of initial assessment for patient #4, dated 8/5/2020, indicated, "Patient and family speak no English and require an interpreter." Patient #4 was assessed to have incontinence of bowel and bladder, fall risk, moderate nutritional risk, impaired functional mobility, and cognitive impairment." The assessment documented intact skin, alert, forgetful, oriented to person only, and indicated that the patient was a full code (life saving measures such as chest compression, intubation, medications, tube feedings.) Review of the initial plan of care orders dated 8-5-2020 for benefit period 8/5/2020-11/02/2020 evidenced a list of medications the patient is taking, durable medical equipment, and the initial aide care plan. It also indicated to check oxygen saturation as needed and to give oxygen @ 2-4 liters per nasal cannula as needed for shortness of breath, dyspnea (labor breathing), and oxygen saturations <90%. The only goal listed on the initial plan of care revealed "Patient / Family goals of Care: Comfort measures only." The initial plan of care failed to be individualized and supported by the comprehensive assessment and failed to include measurable goals related to the patient needing an interpreter, incontinence of bowel/ bladder, skin integrity, fall and nutritional risk, impaired functional mobility, cognitive impairment, and code status. Review of the 1st revised plan of care in relation to the first IDG after the patients admission dated 8/12/20, revealed the following information that failed to be individualized, objective, and measurable: Name [sic of Problem]: at risk for skin break down. Goal: Patient experiences peaceful death with dignity and symptom managed within limits of diseases. Patient/caregiver verbalizes understanding of hospice philosophy, team member roles. Patient participates in plan of care and verbalizes wishes. Outcome timeframe: By time of death/discharge. The identified problem of "risk for skin break down" failed to evidence a rationally related, individualized, objective, and measurable goal for integumentary status. Name [sic of Problem]: At risk for falls. Goal: Patient maintains level of mobility and ... within disease limitations. Patient/caregiver demonstrates ... equipment. Patient/caregiver demonstrates ... techniques. Current mobility status (ambulatory, up with assist, bedbound, up with 1 assist, up with 2 assist). Current assistive devices used (wheelchair, walker, cane, Optima chair: Transfer status (gait belt, Hoyer, sit to stand.) Outcome Timeframe: By time of death/discharge Intervention: Identify safety issues. The identified problem of "At risk for falls" failed to evidence an individualized, objective, and measurable goal for risk of falls, and failed to define what was meant by "within disease limitations." Patient #4 had a terminal diagnosis and at least 7 other pertinent diagnoses. Name [sic of Problem]: Nutrition. Goal: Current Diet: regular thin liquids. Outcome Timeframe: By time of death of discharge. The identified problem of "Nutrition" failed to evidence an individualized, objective, and measurable goal for nutrition. "Regular thin liquids" was not a defined, objective, and measurable goal for patient #4. Name [sic of Problem]: at risk for respiratory distress. Goal: Patent/caregiver anxiety with symptoms exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient attains adequate airway and respiratory function within limits of disease process. Outcome timeframe: By time of death/discharge Intervention 1: Assess O2 saturation levels as ordered. The identified problem of "at risk for respiratory distress" failed to evidence an individualized, objective, and measurable goal for respiratory status. "Patient attains adequate airway and respiratory function within limits of disease process," was not an individualized, objective, measurable goal. The goal failed to define what was meant by "within disease limitations." Patient #4 had a terminal diagnosis and at least 7 other pertinent diagnoses. The end of life often presents respiratory inadequacy, therefore the goal outcome timeframe of "by time of death/discharge," was not individualized to address patient #4's current care needs. 5. On 8-25-2020 at 12:15 P.M., the administrator and the compliance officer, employee C, reviewed the above patients' IDG meeting minutes and care plans. The administrator and the compliance officer verified the above findings.
L0553
L0553	30405 Based on record review and interview, the hospice Interdisciplinary Group failed to update patients' progress towards established goals and outcomes for 2 of 6 patients (Patients #3 and 5) whose clinical records were reviewed. The findings included: 1. Review of a policy, "Interdisciplinary Group Meeting," last reviewed/revised October 2019, evidenced the policy stated, "An Interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment, and progress toward targeted outcomes ... " 2. Review of the clinical record of Patient #3 evidenced an election of benefit (EOB) date of 2-26-2020, with terminal diagnosis of Senile Degeneration of the Brain. Review of the following Interdisciplinary Group (IDG) and Care Plans evidenced the following: The 3-4-2020 IDG meeting and plan of care evidenced the problem of "Dyspnea" with the goal of "SW [sic social worker] will monitor and assist patient/family to identify and report s/s [sic signs and symptoms] of Depression. Patient/caregiver anxiety with symptom exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient maintains adequate airway and respiratory function within limits of disease process ... Progress 0 %;" problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver. Progress 0%." The plan of care and IDG meeting failed to evidence identification of "Emergency Preparedness" as a problem, and failed to establish interventions and goal(s). Patient #3 had been on hospice services for 7 days. The hospice IDG failed to update the plan of care to address "Emergency Preparedness," and therefore failed to document any progress toward that goal. The 7-29-2020 IDG meeting and updated plan of care evidenced the problem of "Dyspnea" with the goal of "SW [sic social worker] will monitor and assist patient/family to identify and report s/s [sic signs and symptoms] of Depression. Patient/caregiver anxiety with symptom exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient maintains adequate airway and respiratory function within limits of disease process ... Progress 0 %;" problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver ... Progress Declining;" problem of "COVID-19 Education" with the goal of "Patient/Family state understanding of signs & symptoms of COVID-19. Patient and family state understanding of ways to prevent infection spread ... Progress 0%;" problem of "Emergency Preparedness" with the goal of "Patient/Family state understanding of personalized Emergency Preparedness action plan ... Progress 0%; problem of "Emergency Preparedness" with the goal of "Patient/Family state understanding of personalized Emergency Preparedness action plan ... Progress 0%." The IDG failed to document any progress towards goals when the e the plan of care was updated. The 8-12-2020 IDG meeting and updated plan of care evidenced the problem of "Dyspnea" with the goal of "SW [sic social worker] will monitor and assist patient/family to identify and report s/s [sic signs and symptoms] of Depression. Patient/caregiver anxiety with symptom exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient maintains adequate airway and respiratory function within limits of disease process ... Progress Declining;" problem of "anxiety" with the goal of "Patient/caregiver identifies feelings regarding illness and spiritual beliefs. Patient/caregiver acknowledges progress in coping with grief. Support to patient and family/caregiver ... Progress Declining;" problem of "COVID-19 Education" with the goal of "Patient/Family state understanding of signs & symptoms of COVID-19. Patient and family state understanding of ways to prevent infection spread ... Progress 0%;" problem of "Emergency Preparedness" with the goal of "Patient/Family state understanding of personalized Emergency Preparedness action plan ... Progress 0%." The IDG failed to update any progress towards goals when the plan of care was updated. Review of the identified "Dyspnea" problem evidenced care visits with interventions performed on 3-11, 3-23, 5-11, 5-21, 5-26, 6-1, 6-4, 6-15, 7-1, 7-15, 7-27, 8-2, 8-3, 8-6, 8-8, 8-9, and 8-11-2020. The IDG group and care plan failed to use an objective measure to update progress toward the goal for "Dyspnea" of "SW [sic social worker] will monitor and assist patient/family to identify and report s/s [sic signs and symptoms] of Depression. Patient/caregiver anxiety with symptom exacerbation is minimized. Patient/caregiver verbalizes factors that may precipitate exacerbation of dyspnea. Patient maintains adequate airway and respiratory function within limits of disease process." The documented progress towards goal of dyspnea on 8-12-2020, was "declining," which failed to be objective and measurable, and failed to evidence the IDG had updated the plan of care. Review of the identified "anxiety" problem evidenced care visits with interventions performed on 3-16, 4-22, 5-15, 5-18, 6-22, 7-5, 7-18, 7-20, 8-2, 8-6, and 8-11-2020. Review of the 7-29-2020 IDG and care plan evidenced progress toward goal of "0%." On 7-29-2020, the progress towards goal for the identified problem of anxiety, after 9 care visits was "0%." After 8 care visits with interventions performed related to the identified problem of anxiety, the progress towards goals should have been greater than "0%," or the IDG should have revised the care plan and/or goal. Review of the identified "Emergency Preparedness" problem evidenced on 7-29-20, progress of "0%," and on 8-12-2020, progress of "0%." Review of visit notes evidenced care visits with interventions performed on 4-7, 5-6, 5-11, 5-18, 5-21, 6-1, 6-11, 6-15, 6-20, 6-25, 7-1, 7-15, 7-18, 7-23, 7-27, 8-2, 8-6, 8-10, and 8-11-2020. After 19 care visits with interventions performed related to Emergency Preparedness, the goal outcome should have been greater than 0%, or the IDG should have revised the care plan and/or goal. Review of the problem of "COVID-19 Education" evidenced visit notes with interventions performed on 4-7, 4-22, 5-6, 5-8, 5-11, 5-15, 5-18, 5-21, 5-26, 5-29, 5-30, 6-1, 6-4, 6-8, 6-11, 6-15, 6-22, 6-25, 7-1, 7-4, 7-5, 7-9, 7-15, 7-18, 7-20, 7-23, and 7-27-2020. The IDG group and care plan failed to update progress toward the goal of "COVID-19 Education in relation to goal of "Patient/Family state understanding of signs & symptoms of COVID-19. Patient and family state understanding of ways to prevent infection spread." After 27 care visits with education provided related to signs and symptoms of COVID-19 and ways to prevent infection spread, the goal outcome should have been greater than 0%, or the IDG should have revised the care plan and/or goal. The IDG care planning for patient #3 failed to evidence the IDG and care plan had addressed Emergency Preparedness for patient #3 within 7 days of election of benefit and care provision, and failed to evidence the IDG either updated progress towards goals after numerous care visits, to greater than 0%, or revised the care plan and/or goal. 3. Review of the clinical record of Patient #5 evidenced an election of benefit (EOB) date of 4-6-2020, with terminal diagnosis of Alzheimer's Disease. Review of the 6-24-2020, IDG meeting and updated plan of care evidenced an identified problem of "COVID-19 Education," with progress of "0 %." Interventions of education had been documented on 4-6, 4-7, 4-12, 4-16, 4-21, 4-25, 4-26, 4-29, 5-5, 5-8, 5-10, 5-14, 5-19, 5-23, 5-24, 5-28, 6-2, 6-6, 6-7, 6-11, 6-16, and 6-21-2020. After 22 care visits with education provided, the IDT failed to document/update any progress towards the goal. The IDT should have documented progress toward the goal based on nurse interventions and assessments, or revised the care plan/goal. 4. On 8-25-2020 at 12:15 P.M., the administrator and the compliance officer, employee C, reviewed the above patients' IDG meeting minutes and care plans. The administrator and the compliance officer indicated the above patients' goals had not been updated with progress towards goals when plans of care were revised.
L0651
L0651	30405 Based on record review and interview, the Governing Body failed to ensure the hospice adopted a discharge summary policy which met the regulatory requirement for 1 of 7 policies and for 1 of 2 discharged patients whose clinical record was reviewed (patient #6) of a total sample of 6 patients and failed to ensure processes were put into place to ensure the personnel files of 2 administrators contained the correct job description for 2 of 2 administrators (Employees A and D), of a total of 5 staff whose personnel files were reviewed. The findings included: 1. Review of a policy, "Discharge summary," last reviewed/ revised 10-2019, evidenced the policy stated "All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Procedure 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: A. The date of discharge, the date the physician and patient informed of discharge B. The reason for discharge, including the name and the organization to which the patient is being transferred C. The status of problems identified at admission and during the provision of care D. The resolution of identified problems E. Continuing symptom management needs F. The overall status of the patient G. A summary of the care or services provided H. The patient's current plan of care I. The patient's latest physician orders The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service ... " Review of 42 CFR 418.104(e)(3), evidenced "a hospice discharge summary as required by (e)(1) and (e)(2) of this section must include (i) A summary of the patient's stay including treatments, symptoms and pain management; (ii) The patient's current plan of care; (iii) The patient's latest physician orders; and (iv) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility." 2. Review of the clinical record for patient #6, evidenced an election of benefits date of 4-22-2020, and date of revocation of 8-17-2020, with terminal diagnosis of senile degeneration of the brain, and other pertinent diagnoses of anxiety, depression, hypertension, and edema. Patient #6 had received physical therapy services in June and July 2020, to stabilize/improve gait. Review of a discharge summary for patient #6, dated 8-17-2020, evidenced "Revocation Statement, Revocation Date: 8/17/2020. Comments: Email and clinical note template for revocations Mandatory call to Executive Director Patient Name: [name of patient #4] Facility or patient location: [name of an Assisted Living Facility/Skilled Nursing Facility] Date of Revocation: 8/17/2020. Details on why family revoked hospice: The patient's left great toe is necrotic and left foot is not receiving enough blood for healing. The podiatrist recommended a vascular consult and the family would like to proceed in treatment/possible surgery that may be needed in order for the left foot to heal. Hospice diagnosis: Senile degeneration of the brain. Code Status: DNR [Do Not Resuscitate] Discussion with POA [power of attorney]/Pt (document who you spoke with POA Carol, daughter, Sharon, social worker, 2 transition nursing staff, the ED [Executive Director] and DON [Director of Nursing] of [name of facility] all present in meeting. Who was present from Transitions, and what was offered: employee I, RN, employee L, RN case manager, and employee O, social worker. Continue on hospice/change to palliative care/and care at this time. PCP [primary care physician], FSN [Facility Skilled Nurse], notified (document who you spike with specifically): Person P, nurse practitioner, and person Q, FSN, was notified Revocation paperwork signed: By who / Date: [name of POA] on 8/17/2020. Distribution of Revocation Paperwork signed: (Facility, faxed to office, copy to POA) POA, facility obtained copies of paperwork. Paperwork scanned to Transitions Binder removed and returned to office, paperwork given to medical records if in a facility: Any other pertinent details. No AME [Medical Equipment] Notified and pick up requested: Yes PBM [pharmacy benefit manager] notified: [name of entity] ... Electronically signed by employee L, RN " The discharge summary failed to evidence any documentation of therapy treatments. The discharge summary failed to evidence a summary of patient #6's stay to include all treatments and symptoms. On 8-25-2020 at 12:15 P.M., the administrator, when queried why there was no minimum requirement for the content of a discharge summary, stated not having an explanation, as had only been in the position for about 3 weeks. The administrator compared the agency policy with the regulation and confirmed the policy did not require the minimum content of a discharge summary as listed in the federal regulation. The administrator stated a copy of the patient's latest care plan accompanied the discharge summary, along with a copy of the revocation of hospice benefit election, neither of which contained a summary of patient #6's hospice stay to include treatments and symptoms. The administrator verified the above discharge summary for patient #6 did not evidence a complete summary of patient #6's stay during hospice care. 3. Review of a job description approved by the governing body 7-21-2016, evidenced, "ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES 1. Operational planning and budgeting. 2. Ensuring organizational compliance with legal, regulatory and accreditation requirements. 3. Assures that all business conduct is above the minimum standards required by law and will not condone any activities that achieve results through violation of the law, unethical business or patient care practices. 4. Monitoring business operations to insure financial stability. 5. Evaluating hospice services and personnel using measurable outcomes and objectives. 6. Conflict and complaint management and resolution. 7. Establishing and maintaining effective channels of communication including integration or technology, as applicable. 8. Ensuring hospice personnel stay current with clinical information and practices. 9. Ensuring adequate and appropriate staffing 10. Staff development including orientation, inservice, continuing education, competency testing and quality assessment performance improvement. 11. Ensuring that interdisciplinary care is provided. 12. Ensuring supportive services are available to personnel. 13. Ensuring coordination with other departments, services and senior management, as appropriate. 14. Ensuring staff and organization stay current on local and national hospice issues and trends. 15. Ensuring that appropriate service policies and procedures are developed and implemented to accomplish identified outcomes. 16. Directing staff in performance of their duties including admission, discharge, transfer, revocation, and provision of service to patients. 17. Ensuring appropriate staff supervision during all service hours. 18. Monitoring service utilization to ensure delivery of comprehensive care. 19. Ensuring services provided by other agencies are authorized by hospice. 20. Monitoring operational progress toward accomplishing operational and strategic goals. 21. Ensuring appropriate data collection and regular complete reports are received by the Governing Body. 22. Ensuring adequate space, equipment and supplies are available. 23. Ensuring actionable objectives are derived from evaluation of hospice services and personnel. 24. Ensuring that structure and systems promote interdisciplinary care. 25. Ensuring collaboration with agencies and vendors for effective management of services. 26. Ensuring standards of ethical business and clinical practice are maintained. POSITION QUALIFICATIONS A Bachelor's degree in Business Administration, Masters Degree in health care or related field preferred. Two (2) to five (5) years experience in health care management. Demonstrates an ability to supervise and direct professional and administrative personnel. Has an ability to deal tactfully with the community. Has knowledge of corporate business management. Understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group. Intimate knowledge of Medicare Hospice Certification." Review of the personnel file of administrator, employee A, evidenced a job description signed by the administrator on 7-24-2020, and evidenced date of hire of 7-24-2020. Review of the job description for administrator, which reported to the Chief Operating Officer, evidenced job summary of "2. Assist with coordination, evaluation, and planning of home care services 3. Monitor the provision of services by the in-home services workers to assure that clients receive quality of services which meet the needs of the client as requested 4. Develop, implement, and evaluate strategic plans, goals and objectives. 5. Ensure client satisfaction review is conducted in accordance with policy 6. Ensure that associates are competent and meet requirements 7. Evaluating, in writing, each each in-home Personal Care Attendant's performance at least annually. 8. Communicate changes in any client's condition, changes in scope or frequency of service delivery and recommending changes in the amount of service per month including written documentation of that communication. 9. Assure that all contractors and associates that provide direct care have a signed agreement detailing the employment arrangement, including all rights and responsibilities. Such agreement would apply to all individuals hired through contract or other employment arrangement. 10. May appoint and direct others to fulfill or assist with the operation of the agency." Under Qualifications "1. Minimum [sic] of 10 years paid work experience in a health care or geriatric organization in a management level position or experience as a Case Manager, Social Worker, or Nurse and four (4) years experience. 2. Experience and passion for working with the geriatric population 3. Ability to lead a team 4. Understanding of Indiana Code to operate a Personal Services Agency 1. Verbal and written communication skills 2. Knowledge of normal aging process 3. Knowledge of health care industry, community needs and community resources 4. Leadership, supervision, and management 5. General knowledge of all facets business operations 6. Valid driver's license ... Under responsibilities the job description evidenced, ... Ensure that a service plan has been implemented on each client per Indiana Code 16-27-4-10." The job description the administrator was provided and signed on 7-24-2020, described the administrator of a home health agency which offered personal services. On 8-21-2020 at 11:13 A.M., the administrator stated when queried of not having a minimum of 10 years of paid work experience in health care or geriatric organization because has had nursing license 8 years; stated not having any knowledge of the Indiana Code related to operation of a Personal Services Agency. Employee A met the other requirements listed in the signed Administrator's job description. The administrator verified there were no hospice specific qualifications or responsibilities in the signed job description, such as interdisciplinary group and plans of care. 4. Review of the personnel file of the former administrator, employee D, evidenced a signed job description dated 4-1-2019, for the position of administrator, which position reported to the governing body. The job description evidenced Under "Position Qualifications," the job description evidenced "A Bachelor's degree in Business Administration, Masters degree in health care or related field preferred. Three (3) to five (5) years experience in health care management. Demonstrates an ability to to supervise and direct professional and administrative personnel. Has an ability to deal tactfully with the community. Has knowledge of corporate business management. Understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group. Intimate knowledge of Medicare Hospice Certification. Review of the personnel file evidenced former administrator, employee D, had an Bachelor of Science in Nursing as highest college degree, had more than 5 years experience in health care management to include supervision of clinical and administrative staff. During interview with former administrator on 8-21-2020 at 9:14 A.M. was conversant with all queries made related to hospice Medicare certification compliance requirements . Review of the list of separated employees evidenced the administrator separated employment on 7-24-2020. The job description in formerly employed administrator's personnel file was not the job description approved by the governing body on 7-21-2016. 5. On 8-21-2020, at 1:32 P.M., employee C, chief operating officer, stated neither the former administrator's nor the current administrator's job descriptions were the correct job descriptions approved by the governing body on 7-21-16, which had not been amended since 2016, for the administrator position. Employee C offered a corrected job description for the current administrator, dated 8-21-2020, prior to survey exit. When queried why the agency had not noticed the discrepancies in the personnel files, employee C stated not being aware of the issue until brought to the hospice's attention during the survey.
L0684
L0684	30405 Based on record review and interview, the Governing Body failed to ensure the hospice adopted a discharge summary policy which met the regulatory requirement for 1 of 7 policies reviewed. The findings included: Review of a policy, "Discharge summary," last reviewed/revised 10-2019, evidenced the policy stated "All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. Procedure 1. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: A. The date of discharge, the date the physician and patient informed of discharge B. The reason for discharge, including the name and the organization to which the patient is being transferred C. The status of problems identified at admission and during the provision of care D. The resolution of identified problems E. Continuing symptom management needs F. The overall status of the patient G. A summary of the care or services provided H. The patient's current plan of care I. The patient's latest physician orders The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service ... " Review of the clinical record for patient #6, evidenced an election of benefits date of 4-22-2020, and date of revocation of 8-17-2020, with terminal diagnosis of senile degeneration of the brain, and other pertinent diagnoses of anxiety, depression, hypertension, and edema. Patient #6 had received physical therapy services in June and July 2020, to improve gait. Patient #6 had received physical therapy services in June and July 2020, to improve gait, nursing services, hospice aide services, chaplain/pastoral services, and medical social worker services. Review of a discharge summary for patient #6, dated 8-17-2020, evidenced "Revocation Statement, Revocation Date: 8/17/2020. Comments: Email and clinical note template for revocations Mandatory call to Executive Director Patient Name: [name of patient #4] Facility or patient location: [name of an Assisted Living Facility/Skilled Nursing Facility] Date of Revocation: 8/17/2020. Details on why family revoked hospice: The patient's left great toe is necrotic and left foot is not receiving enough blood for healing. The podiatrist recommended a vascular consult and the family would like to proceed in treatment/possible surgery that may be needed in order for the left foot to heal. Hospice diagnosis: Senile degeneration of the brain. Code Status: DNR [Do Not Resuscitate] Discussion with POA [power of attorney]/Pt (document who you spoke with POA Carol, daughter, Sharon, social worker, 2 transition nursing staff, the ED [Executive Director] and DON [Director of Nursing] of [name of facility] all present in meeting. Who was present from Transitions, and what was offered: employee I, RN, employee L, RN case manager, and employee O, social worker. Continue on hospice/change to palliative care/and care at this time. PCP [primary care physician], FSN [Facility Skilled Nurse], notified (document who you spike with specifically): Person P, nurse practitioner, and person Q, FSN, was notified Revocation paperwork signed: By who / Date: [name of POA] on 8/17/2020. Distribution of Revocation Paperwork signed: (Facility, faxed to office, copy to POA) POA, facility obtained copies of paperwork. Paperwork scanned to Transitions Binder removed and returned to office, paperwork given to medical records if in a facility: Any other pertinent details. No AME [Medical Equipment] Notified and pick up requested: Yes PBM [pharmacy benefit manager] notified: [name of entity] ... Electronically signed by employee L, RN " The discharge summary failed to evidence patient #6 had received physical therapy services [completed], pastoral/chaplain services, and social worker services. The discharge summary failed to evidence a summary of patient #6's stay to include treatments and symptoms. On 8-25-2020 at 12:15 P.M., the administrator, when queried why there was no minimum requirement for the content of a discharge summary, stated not having an explanation, as had only been in the position for about 3 weeks. The administrator compared the agency policy with the regulation and confirmed the policy did not require the minimum content of a discharge summary as listed in the federal conditions of participation. The administrator stated a copy of the patient's latest care plan accompanied the discharge summary, along with a copy of the revocation of hospice benefit election, neither of which provided a summary of patient #6's stay to include discipline treatments and symptoms. The administrator verified the above discharge summary for patient #6 did not evidence a complete summary of patient #6's stay during hospice care.