Survey Report for 231638

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	231638	A. BUILDING __________ B. WING ______________	11/10/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
CUSTOM HOSPICE	888 WEST BIG BEAVER ROAD, SUITE 900, TROY, MI, 48084
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
L0500	18299 Based on record review and interview, it was determined the hospice agency failed to ensure the patient's right to receive effective pain management and symptom control was met at the time of admission for 1 of 1 record reviewed (L-512). The cumulative effect of this problem resulted in the hospice agency's inability to ensure the provision of quality health care for the condition of participation 42 CFR 418.52, Patient Rights.
L0512
L0512	20987 Based on record review and interview, it was determined the hospice agency failed to ensure the patient's rights to receive effective pain management and symptom control was met at the time of admission for 1 of 1 record reviewed (MR #1) for unmet pain and uncontrolled terminal illness symptoms in a timely manner. Findings include: MR #1: The patient was admitted to the hospice agency on 09/10/2020 with the terminal diagnoses of, "Atherosclerotic Heart disease of Native Coronary Artery, Essential Hypertension, Cerebral Infarction, Acute Myocardial Infarction, Atrial Fibrillation and Heart Failure." The "Initial Assessment" was signed by Registered Nurse #2 and dated 09/10/2020. The SN (skilled nurse) documented, "the patient lives with husband and daughter. The patient is complete bed-bound requiring assistance with all ADLs and IADLs (activities of daily living). Patient has become more lethargic over past week, has not eaten since Friday 4th (for 6 days)." SN (RN #1) visit note dated 09/11/2020, signed by LPN #1 (licensed practical nurse) documented, "Joint visit with MSW #1 (medical social work) and Aide #1 (hospice aide). Upon arrival patient presented in [a] regular bed, distress noted, increased respirations and heart rate: B/P 157/103 (blood pressure), heart rate 114 irregular and respirations 32. Lung sounds-crackles throughout lung lobes. Non-productive cough, patient unable to cough up mucous. Disoriented and lethargic. Pain intensity: 6/10 score not acceptable to pt/cg, restless, no comfort meds in home. SN (RN #1) ordered [meds] at home visit from medical director. SN assisted Aide #1 with bed bath as tolerated by patient. Family at bedside. SN assisted Aide #1 with bed bath as tolerated by patient. Family at bedside. Patient repositioned to L (left) side until meds received. RN #1 and LPN #1 left patient's home to pick-up meds from CVS pharmacy and Providence hospital. RN #1 and LPN #1 returned for administration of meds and to transport [transfer] patient into ordered hospital bed. MS (morphine sulfate) administered to patient. RN/SN educated husband on dosage and frequency of MS prn, he returned demonstration. Reassessed patient respirations, resp. 26 after 15 min., patient resting." During the time the nurses were out picking up the medications there was no documented evidence the patient's pain and restlessness was being managed. There were no documented evidence medications were provided to manage the patient's pain and restlessness from admission on 9/10/2020 at 9 PM to 9/11/2020 at approximately 12 PM, until after the nurses returned from CVS and Providence Hospital. During an interview on 11/10/2020 at 5 PM, it was queried if the agency provided families with a "Comfort Pack" for pain and symptom management at the time of admission CM #1 replied, "No, this is not our normal practice. The nurse notifies the medical director of the patient's needs when needed, a verbal order is obtained, and the medications are ordered. The nurses do not carry medications in their vehicles. We use a couple different pharmacies to fill the medication orders." And, a "Patient Communication" form signed by RN #5 and dated 9/12/2020 at 1800 (6 PM) documented, "[Daughter] called to request liquid lorazepam for the patient, caller said she is crushing the tablets and giving them the way the nurse showed her this morning but it just is not working out." On the Nursing Initial Assessment dated 9/20/2020 the patient's safety measures included "Aspiration Precautions." The nurse also documented, "patient is not eating/swallowing." The patient's medication list included: Ativan tablet, Haldol Concentrate, Morphine Sulfate concentrate and Hyoscyamine Sulfate tablet. At the time of the 11/10/2020 clinical record review, there was no documented evidence the hospice provided alternative medications to manage the patient's pain and anxiety symptoms, in place of the ativan tablet. During an interview on 11/10/2020 at 5 PM, it was queried if the agency provides concentrated ativan for those patients with swallowing and aspiration precautions, CM #1 replied, "Yes, ativan does come in liquid form, I don't know why the nurse didn't request the concentrated form. We will have to review this practice and see if we can better meet the patient's needs."
L0546
L0546	20987 Based on record review and interview, it was determined the hospice agency failed to develop a patient specific plan of care with specific interventions for pain and symptom management for 1 of 1 record reviewed (MR #1), for a potential of unmet care needs. Findings include: MR #1: The patient was admitted to the hospice agency on 09/10/2020 with the terminal diagnoses of, "Atherosclerotic Heart disease of Native Coronary Artery, Essential Hypertension, Cerebral Infarction, Acute Myocardial Infarction, Atrial Fibrillation and Heart Failure." The "Initial Assessment" was signed by Registered Nurse #2 and dated 09/10/2020. The SN (skilled nurse) documented, "the patient lives with husband and daughter. The patient is complete bed-bound requiring assistance with all ADLs and IADLs (activities of daily living). Patient has become more lethargic over past week, has not eaten since Friday 4th (for 6 days), Soft diet with thickened liquids." SN (RN #1) visit note dated 09/11/2020, signed by LPN #1 (licensed practical nurse) documented, "Joint visit with MSW #1 (medical social work) and Aide #1 (hospice aide). Upon arrival patient presented in [a] regular bed, distress noted, increased respirations and heart rate: B/P 157/103 (blood pressure), heart rate 114 irregular and respirations 32. Lung sounds-crackles throughout lung lobes. Non-productive cough, patient unable to cough up mucous. Disoriented and lethargic. Pain intensity: 6/10 score not acceptable to pt/cg, restless, no comfort meds in home. SN (RN #1) ordered [meds] at home visit from medical director. SN assisted Aide #1 with bed bath as tolerated by patient. Family at bedside. Patient repositioned to L (left) side until meds received. RN #1 and LPN #1 left patient's home to pick-up meds from CVS pharmacy and Providence hospital. RN #1 and LPN #1 returned for administration of meds and to transport [transfer] patient into ordered hospital bed. MS (morphine sulfate) administered to patient." There was no documented evidence medications were administered to manage the patient's pain and symptoms at the time of admission on 9/10/2020 until after the nurses return from picking up the medications from CVS and Providence Hospital on 9/11/2020. SN visit dated 09/12/2020, signed by RN #2 (registered nurse) documented, "Patient has minimal audible secretions, spits out SL (sublingual) Levsin (used for secretions) when administered. Patient will not allow nasal cannula to be administered, once [when] Cg/nurse (caregiver) tries to put it back on she starts swatting hands away." There was no documented evidence the SN administered medication to manage the above terminal illness symptoms. And, a "Patient Communication" form signed by RN #5 and dated 9/12/2020 at 1800 (6 PM) documented, "[Daughter] called to request liquid lorazepam for the patient, caller said she is crushing the tablets and giving them the way the nurse showed her this morning but it just is not working out." The patient's safety measures include "Aspiration Precautions," the patient is not eating/swallowing. The patient's medication list included: Ativan tablet, Haldol Concentrate, Morphine Sulfate concentrate and Hyoscyamine Sulfate tablet. There was no documented evidence the hospice provided alternative medications to use to manage the patient's pain and anxiety symptoms, in place of the ativan tablet, that the caregiver could not use. SN visit note dated 9/13/20, signed by RN #4 documented, "Husband, daughter, and grandson at bedside. Patient expired during visit. During an Interview on 11/10/2020 at 4:30 PM it was queried if the patient's Lorazepam (Ativan-used for anxiety/agitation) could have been administered in a liquid form instead of a tablet? The Clinical Manager #1 (CM #1) replied, "Yes, it could've been ordered in a liquid since the patient wasn't swallowing tablets, I don't know why the nurse didn't order the liquid form." It was also queried if the agency provides the families with a "Comfort Pack" at the time of admission to manage the patient's pain and terminal symptoms? CM #1 replied, "No, this is not our normal practice. The nurse notifies the medical director of the patient's needs, a verbal order is obtained, and the medications are ordered. We use a couple different pharmacies to fill the orders. We will have to review this practice and see if we can better meet the patient's needs."
L0557
L0557	20987 Based on record review and interview, it was determined the hospice failed to maintain coordination and sharing of information between disciplines, for 1 of 1 record reviewed (MR #1) for a lack of communication and maintaining a current medical record. Findings include: MR #1: The patient was admitted to the hospice agency on 09/10/2020 with the terminal diagnoses of, "Atherosclerotic Heart disease of Native Coronary Artery, Essential Hypertension, Cerebral Infarction, Acute Myocardial Infarction, Atrial Fibrillation and Heart Failure." The "Initial Assessment" was signed by Registered Nurse #2 and dated 09/10/2020. The SN (skilled nurse) documented, "the patient lives with husband and daughter. The patient is complete bed-bound requiring assistance with all ADLs and IADLs (activities of daily living). Patient has become more lethargic over past week, has not eaten since Friday 4th (for 6 days), Soft diet with thickened liquids." SN visit dated 09/12/2020, signed by RN #2 (registered nurse) documented, "Pain zero, current pain management effective, frequency daily but not constantly. Patient minimally responsive, unable to eat any food d/t (due to) aspiration risk. Patient received in bed, eyes closed, breathing with her mouth open. Won't let writer assess her B/P, [patient] becomes restless when touched, calm when left alone. Patient has minimal audible secretions, spits out SL (sublingual) Levsin (used for secretions) when administered. Patient will not allow nasal cannula to be administered., once [when] Cg/nurse (caregiver) tries to put it back on she starts swatting hands away." The SN documented, "Pain Intervention: MS PRN (morphine sulfate-as needed). There was no documented evidence of the dose and frequency the MS was administered. And, a "Patient Communication" form signed by RN #5 and dated 9/12/2020 at 1800 (6 PM) documented, "[Daughter] called to request liquid lorazepam for the patient, caller said she is crushing the tablets and giving them the way the nurse showed her this morning but it just is not working out." The patient's safety measures include "Aspiration Precautions," the patient is not eating/swallowing. The patient's medication list included: Ativan tablet, Haldol Concentrate, Morphine Sulfate concentrate and Hyoscyamine Sulfate tablet. There was no documented evidence the hospice provided an alternative medication to use to manage the patient's pain and symptoms, other than the ativan tablet. And there was no documented evidence RN #5 notified the physician of the problem the family was having administering the Ativan in a tablet form. SN visit note dated 9/13/20, signed by RN #4 documented, "Husband, daughter, and grandson at bedside. Patient expired during visit." The Aide #1 (Hospice Aide #1) documented a "Missed Visit Note" dated 9/14/2020. The patient's date of death was 9/13/2020. The Clinical Manager #1 stated, "This is a coordination issue. We have already identified we have a problem with coordination between the disciplines, we are working on it."