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
231581 A. BUILDING __________
B. WING ______________ 		02/11/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ELARA CARING 900 COOPER STREET, JACKSON, MI, 49202
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)
L0500      
37411 Based on record review and interview, it was determined on 2/11/20 that an Immediate Jeopardy existed because the hospice failed to protect and promote the right of patients to receive adequate and appropriate pain and symptom management in 1 of 1 records reviewed (MR#1) (G512). These deficient practices could affect the provision of patient's rights for all 513 patients admitted over the last year. Findings include: 1. The patient did not receive effective symptom management related to her diagnosed terminal illness in a timely manner. (See L 512)
L0512      
37411 Based on record review and interview, it was determined the hospice failed to ensure the patient received effective symptom management related to her diagnosed terminal illness in 1 (MR #1) of 1 record with reported agitation and restlessness, from a total of 4 sampled records reviewed, resulting in the potential lack of peace and comfort during the end of life transition, and unmet care needs. Findings include: The Agency's "Pain and Symptom Management" policy number: PC.P10, reviewed 5/8/19 documented, "The hospice nurse assesses the patient's pain and other symptoms as part of the initial assessment. Based on findings from the initial assessment, the hospice nurse ensures that the patient's immediate care and support needs are met. The pain assessment includes: History of pain and its treatment (pharmacologic & non-pharmacological), Characteristics of the pain: Intensity, descriptors, patter, location and radiation of pain, frequency, impact of pain on availability of life (sic), precipitations of pain, strategies and factors that reduce pain. Patient / family's goals for pain management and their satisfaction with the current level of pain control ... Guidelines and/or protocols are developed for the assessment and management of common physical symptoms that are addressed by the interdisciplinary team in the patient's plan of care, including, but not limited to: ...Restlessness and agitation." MR #1: The patient's hospice start of care (SOC) was 12/13/19 at 4:25 pm at an adult foster care (AFC) with a terminal diagnosis of Coronary Artery Disease (CAD). The patient had a fall on 12/12/19 and was admitted to the hospital with fractures to her left femur and left radius. The Hospice Plan of Care (POC) completed by Staff-A at the SOC documented, "Morphine Concentrate Oral 0.25mL every 3 hours as needed for pain and Ativan 0.5 mg every 6 hours as needed for anxiety or agitation" An interview with the complainant on 2/11/20 at 3:10 pm, attested that there was no Morphine or Ativan for the patient to use at the SOC. Three on-call notes were documented for the morning of 12/14/19: 2:04 am, 5:52 am and 6:22 am. The first on-call at 2:04 am documented by Staff-B stated, "RCVD (received) a call from AFC that patient is very restless." At 2:13 am Staff-C documented, "Returned call to AFC who reported that patient is very restless. Reports that patient only sleeps for short amount of time and then is back up trying to remove hospital gown and trying to climb out of bed. AFC staff reports that patient has a broken arm and broken hip. Reports that patient does not have any medications ordered for restlessness. Patient has not received anything for pain, AFC staff reports that patient can have Tylenol 500 mg 1-2 tabs as needed. Advised AFC staff to administer Tylenol as restlessness may be due to pain, AFC staff verbalized understanding. Call placed to SOC nurse who reported that she will order a follow up visit in the morning. Reinforced to call hospice for any further needs." (sic) At 5:52 am Staff-D documented, "Received call from husband stating that patient is agitated and restless. States they need something to calm her down..." At 6:22 am Staff-C, the same staff member returning the call at 2:13 am, documented, "Received call from patient's spouse who reported that agitation and restlessness has continued through the night and they need something to help calm patient. Report given to Staff-A who will address medication issue and follow up with spouse at this time." Staff-A documented a return call to the AFC at 6:49 am stating, "This nurse contacted AFC and informed staff of Haldol being ordered through the local Walgreens, and of hospice staff plans of picking up prior to SOC follow up visit today ..." Prior to receiving any visits or medications, another call was placed to the hospice on 12/14/19 at 1:44 pm. Staff-F documented, "Rec'd (received) call from facility stating that they still have not rec'd medication. Writer advised caller that nurse is working on getting medication now." Staff-G documented a call to the AFC at 1:57 pm, "Spoke with AFC staff, she and family are very upset that medications were not delivered in a timely fashion (SN (skilled nurse) present now). AFC states client is all over the place and did not have anything to give her. Will forward to clinical team." A complaint report was reviewed on 2/11/20 that documented a hospice agency investigation into the above instances dated 12/20/19 by Regional Dir.-A which acknowledges the deficient practices. The findings stated, "Staff-A was assigned admission for patent MR#1. Started admission at 4:25 pm. Patient had left hip fracture and left arm fracture and had been discharged from the hospital. Clinician profiled medications in patient's chart including Morphine and Ativan, however did not request scripts for these meds to be sent and left the admission visit with no meds at the facility (AFC) other than Tylenol for pain. Staff-A indicated in her admission note that patient was comfortable, and pain managed but did not order anything for anticipatory pain management (patient with acute fractures should have meds ordered for anticipatory pain). At 2:13 am, facility called triage and indicated patient was very restless and they needed something to calm her. Triage contacted Staff-A who stated she would order a follow up visit for the morning (standard practice would have been to complete a visit at that time as patient was having needs). 5:52 am, the spouse called reporting patient was still agitated and restless and they needed something to help calm the patient. Triage contacted Staff-A again, who stated she would address the medication issue and follow up with the spouse. Staff-A again did not make a visit, which was needed due to patient needs and unmanaged symptoms. 6:49 am note was entered by Staff-A stating that she contacted AFC and informed that Haldol had been sent to Walgreen's and that hospice staff would pick up the med on day shift prior to the SOC follow up visit. Again, she did not make a visit and patient had delay in receiving medications needed for symptom management. An email was not sent to triage or to the nurses coming on shift by Staff-A to notify them of need to pick up the meds or need for follow up visit. The only way the med need was known is that the facility called back again and asked where the nurse was who was supposed to be coming with the meds." It took nearly 12 hours for the pain medication to be delivered, from the first on-call documentation at 2:13 am until 1:50 pm, when Staff-E arrived at the facility with the medication. Over the remaining 24 hours of the patient's life, her pain management was acceptable based on the clinician documentation, and staff and complainant interviews. The patient passed away 12/14/19, at 2:00 pm. The above findings were acknowledged during an interview with Clinical Manager-A on 2/11/20 at 11:15 am.
L0520      
30354 Based on record review and interview, it was determined an Immediate Jeopardy existed on 2/11/20 because the agency failed to document a patient-specific comprehensive assessment in 1 of 1 record reviewed (MR#2) in a timely manner, resulting in the potential for patients not receiving services necessary prior to dying (See L521). This deficient practice of not evaluating patients timely for hospice services could affect the initial comprehensive assessment and services needed for all 513 patients admitted over the last year. Findings include: 1. The hospice did not document a patient-specific comprehensive assessment for 27 days after the initial referral (See L521).
L0521      
30354 Based on record review and interview, it was determined that the agency failed to document a patient-specific comprehensive assessment in 1 of 1 record reviewed (MR#2) in a timely manner, resulting in the potential for patients not receiving services necessary prior to dying. **Agency Policy "Assessment-Comprehensive Assessment Of The Patient" (reviewed 4/8/19) stated, "The hospice interdisciplinary team conducts and documents a patient-specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care...The hospice nurse makes an initial assessment visit to the patient/caregiver within forty eight (48) hours after the hospice receives a physician's admission order...in order to determine the patient's immediate care and support needs.." **Agency Policy "Admission To Hospice-Criteria" (reviewed 4/8/19) stated, "Prior to admission hospice staff will collect the following: Admitting diagnosis/prognosis...Current medical findings...Dietary restrictions...Orders for treatments and symptom management...Information about medical management of patient conditions unrelated to the terminal illness...Designation of an alternative physician to contact in case the attending physician is unavailable...If it is determined that the patient does not meet the criteria for admission, reasons for non-acceptance are documented and communicated to the referrer and patient/caregiver as appropriate...A plan for follow up contact with non-accepted patients is developed and recorded..." MR#2: This patient was admitted to the hospice on 1/13/20. The 1/13/20 plan of care specified a terminal diagnoses of mild protein-calorie malnutrition, constipation, and major depressive disorder. During record review on 2/10/20, it was determined Elara Caring home health agency referred MR#2 to the Elara Caring Hospice on 12/17/19. The home health discharge stated, "Had assist with all needs. He is spending majority of time in bed. Admits to depression at times. His skin is intact...CGS (caregivers) assist with all needs such as meal, assist, bathing, tolieting, dressing, med administration, application of barrier cream to buttocks..." Referring Nurse Practitioner-G (MR#2's physician/nurse practitioner), signed orders for a hospice evaluation which was received by the agency (documented in electronic record) on 12/23/19 (fax stamped Dec 23, 2019 10:28 AM). The agency failed to document in the clinical record that the ordering practitioner was notified of a late initial comprehensive assessment. On 1/13/20, an initial comprehensive assessment was completed by RN-F and hospice services were initiated for MR#2, 27 days after the initial referral from home health. Hospice Physician-D signed the plan of care for MR#2 on 1/14/20. During an interview on 2/11/20 at 1605 hours, Director-A explained that the expectation for start of care is, "24 hours after patient referral an evaluation should be completed by a hospice registered nurse."