Survey Report for 231662

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	231662	A. BUILDING __________ B. WING ______________	11/08/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HEART TO HEART HOSPICE OF LANSING	2260 SAGINAW ST, SUITE A, EAST LANSING, MI, 48823
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
L0538	30354 Based on policy review, record review and interview, the hospice failed to ensure the plan of care was specific to the patient/family needs in 2 of 9 records reviewed (MR# 3 and 4), from a total sample of 9 records, resulting in the potential for unmet care needs for all 9 patients admitted to the hospice in the past year. Findings included: **Hospice policy "Interdisciplinary Team, Coordination of Care and Services" (dated 1/15/09) stated, "The Interdisciplinary Team (IDT) ensures the monitoring and coordination of the patient/family's specific needs and problems...The IDT will prepare a written plan of care for each patient/family, which specifies the care and services necessary to meet the patient/family-specific needs identified in the comprehensive assessment..." MR#3: The patient was admitted to hospice program on 1/17/19 with a terminal diagnosis of multiple sclerosis. The patient was residing at an assisted living facility following a recent hospitalization due to dysphagia (difficulty swallowing) in which an NG (nasogastric) tube was placed temporarily for liquid nutrition feedings. The patient/family declined a Peg (permanent tube into stomach for feeding) tube placement for nutrition and the temporary tube was removed. RN#1 (registered nurse) in the start of care assessment on 1/17/19 documented, "Per staff Pt (patient) is only taking sips of water and no food X 4 days, they offer a Boost daily, but she does not drink it." The plan of care specified, "Pureed diet and nectar thicken liquids." Plan of care safety measures stated, "O2 (oxygen) precautions, oxygen safety, and universal precautions." The plan of care safety measures failed to address the patient's difficulty in swallowing/choking. Also, for this patient RN#1 in the start of care assessment documented, "Has an indwelling suprapubic catheter for the past three years..." The plan of care failed to address the suprapubic catheter..." MR#4: This patient was admitted to the hospice program on 1/11/19 with a terminal diagnosis of cerebral atherosclerosis, atrial fibrillation, and chronic obstructive pulmonary disease. The patient resided in an assisted living facility. The start of care initial comprehensive assessment was completed on 1/11/19, RN#1 documented the patient had multiple wounds with a recent history of MRSA (methicillin resistant staphylococcus) in the wound on left foot. The plan of care specified safety measures for clean technique, disposal of medical waste, emergency plan and universal precautions. The plan of care failed to specify MRSA safety precautions. The above findings were reviewed with and acknowledged by PCM#1 (patient care manager) during an interview on 11/8/19 at 1100 hours. PCM#1 stated, "We identified this in our own self audits and have been working to correct the problem."
L0625
L0625	30354 Based on record review and interview, the Registered Nurse failed to ensure the written plan of care for the assigned Hospice Aide provided specific safety precautions and care instructions on the needs of the patient, for 3 (MR #3, 4, and 9) of 9 records with Hospice Aide services ordered, from a total of 9 records reviewed resulting in the potential for unmet care needs and poor patient outcomes for all of the 9 patients served in the past year by the hospice agency. Findings include: *Agency Policy "Implementing Care And Treatment" (revised 8/1/15) stated, "The Agency RN, who is a member of the IDT, will oversee the assignment of a hospice aide to a particular patient, initiating hospice aide services within time frame to meet identified patient's needs and per physician orders..." MR#3: The patient was admitted to hospice program on 1/17/19 with a terminal diagnosis of multiple sclerosis. The patient was residing at an assisted living facility following a recent hospitalization due to dysphagia (difficulty swallowing) in which an NG (nasogastric) tube was placed temporarily for liquid nutrition feedings. The patient/family declined a Peg (permanent tube into stomach for feeding) tube placement for nutrition and the temporary tube was removed. The registered nurse (RN#1) completed the start of care assessment and developed the aide care plan on 1/17/19. The plan of care specified, "Pureed diet and nectar thicken liquids." Plan of care safety measures were, "O2 (oxygen) precautions, oxygen safety, and universal precautions." The aide care plan, completed by the skilled nurse on 1/17/19 failed to specify safety measures for oxygen precautions, oxygen safety and universal precautions. The aide care plan failed to address the patient's difficult in swallowing/choking. MR#4: This patient was admitted to the hospice program on 1/11/19 with a terminal diagnosis of cerebral atherosclerosis, atrial fibrillation, and chronic obstructive pulmonary disease. The patient resided in an assisted living facility. The start of care initial comprehensive assessment was completed by RN#1 and developed the aide care plan on 1/11/19. RN#1 documented the patient had multiple wounds with a recent history of MRSA (methicillin resistant staphylococcus) in the wound on left foot. The plan of care specified safety measures for clean technique, disposal of medical waste, emergency plan and universal precautions. The aide care plan ordered, "Standard, skin integrity, fall, and swallowing precautions." The aide care plan failed to specify MRSA precautions. These findings were reviewed with and confirmed by the Patient Care Manager (PCM#1) during an interview on 11/7/19 at 1345 hours. The RN failed to ensure written patient care instructions for the Hospice Aide provided specific guidance and care instructions on the needs of the patient. 37411 MR #9: The patient's start of care (SOC) was dated 1/17/19 with a terminal diagnosis of Cerebral Atherosclerosis. The start of care initial comprehensive assessment was completed by the Skilled Nurse (SN) and developed the aide care plan on 1/17/19. The plan of care specified safety measures for emergency plan, med precautions, O2 precautions, oxygen safety, universal precautions, and choking precautions. The aide care plan had no safety measures documented. These findings were reviewed with and confirmed by the Patient Care Manager (PCM#1) during an interview on 11/8/19 at 10:45 am. The RN failed to ensure written patient care instructions for the Hospice Aide provided specific guidance and care instructions on the needs of the patient.
L0671
L0671	37411 Based on record review and interview, it was determined that the hospice failed to ensure clinical record documentation was complete, descriptive and accurate in 2 of 9 records reviewed (MR #7, and 9) out of a total sample of 9 records reviewed, which resulted in the potential for patient needs not being met or incorrect care being provided. Findings include: Agency policy "Medical Record Content", revision date 10/01/11, stated "Purpose: To ensure each medical record, whether paper, electronic or combination, contains information which identifies the patient, describes problems and needs of the patient, justifies patient care, and accurately describes care provided, results, and continuity among disciplines." MR #7: The patient's start of care (SOC) was 5/8/19 with a terminal diagnosis of Cerebral Atherosclerosis. The plan of care (POC) dated 5/8/19, specified a Skilled Nursing (SN) visit frequency of 2w1 (2 times a week for 1 week), 1w12. The POC also contained a Home Health aide (HHa) frequency of 1w1, 2w12. During record review on 11/7/19, it was noted that the first visit by the HHa was completed on 5/17/19. The SN completed HHa supervision notes on 5/9/19, 5/13/19, and 5/16/19 containing "Yes" answers for "Does the aide follow the plan of care, does the aide have the ability to perform tasks, do the services meet the needs of the patient?" The SN failed to properly document supervision of an HHa prior to care being provided. MR #9: The patient's SOC was 1/17/19 with a terminal diagnosis of Cerebral Atherosclerosis. The POC dated 1/17/19, specified a SN visit frequency of 2w12. The POC also contained an HHa frequency of 2w11. During record review on 11/5/19, it was noted that the first visit by the HHa was completed on 1/21/19. The SN completed HHa supervision notes on 1/18/19 containing "Yes" answers for "Does the aide follow the plan of care, does the aide have the ability to perform tasks, do the services meet the needs of the patient?" The SN failed to properly document supervision of an HHa prior to care being provided. The Patient Care Manager (PCM#1) was questioned on 11/8/19 at 10:55 am and confirmed the findings stating, "My expectation is that the nurse would look at the calendar to make sure the aide had completed visits prior to documenting supervision notes."
L0684
L0684	37411 Based on policy review and record review, it was determined the hospice failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management, the current plan of care, the latest physician orders, and any other documentation in 3 of 4 records reviewed in which the patient was discharged (MR # 3, 4, and 9). Findings include: Agency Policy: "Patient Discharge Notice," revised 07/01/13 stated, "...11. The Discharge summary includes at least the following: A summary of the patient's stay including treatments, symptoms and pain management..." MR #9: The patient's start of care (SOC) was dated 1/17/19 with a terminal diagnosis of Cerebral Atherosclerosis. During record review of the Skilled Nurse (SN) discharge summary dated 5/2/19, it was documented, "Patient was admitted on hospice received scheduled and PRN (as needed) visits from RN (Registered Nurse) home health aide chaplain and social work patient died peacefully in her sleep with family at bedside family grieving appropriately." (sic) The hospice agency failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management. The Patient Care Manager (PCM#1) was questioned on 11/8/19 at 10:45 am and confirmed the findings stating, "My expectation is that the discharge summary would be more detailed and provide an overall summary of care provided." 30354 MR#3: The patient was admitted to hospice program on 1/17/19 with a terminal diagnosis of multiple sclerosis. During record review on 11/7/19 of skilled nurse discharge summary dated 1/21/19, it was documented, "Pt (patient) had been declining and family was present during patient passing, she passed peacefully and comfortably." The hospice agency failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management. MR#4: This patient was admitted to the hospice program on 1/11/19 with a terminal diagnosis of cerebral atherosclerosis, atrial fibrillation, and chronic obstructive pulmonary disease. During record review on 11/8/19 of skilled nurse (SN) discharge summary dated 3/23/19, it was documented, "Pt (patient) admitted with cerebral Athero (sic)." The hospice agency failed to ensure the discharge summary compiled the patient's course of care, including treatments, symptoms, and pain management. The Patient Care Manager (PCM#1) was questioned on 11/8/19 at 10:45 am and confirmed the findings stating, "My expectation is that the discharge summary would be more detailed and provide an overall summary of care provided."