Survey Report for 231686

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	231686	A. BUILDING __________ B. WING ______________	05/10/2022
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
JOHN PAUL HOME HOSPICE	30800 TELEGRAPH RD, SUITE 3700, BINGHAM FARMS, MI, 48025
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)
L0505
L0505	38304 Based on document review and interview, the hospice failed to ensure the patient and patient's family were treated with dignity and respect in 1 (MR#1) of 6 clinical records reviewed, resulting in the hospice's inability to ensure the patient's right to exercise their rights and respect for person for all 10 current patients. Findings include: MR#1: This patient (subject of the complaint) was admitted to hospice on 9/22/2021 with diagnoses of end-stage renal disease (ESRD), dementia, and failure to thrive. Review of clinical record noted a skilled nursing visit by Staff D on 9/23/21 at 5:30 PM through 6:30 PM. Staff D documented the following concerning the patient's condition: "Patient recently signed on the hospice service shortly status is active passing away transitioning so notified (Staff D) RN Status is active Alert oriented to person, nonverbal open eyes after reposition Heart sound Noted AP (apical pulse) with Heart Sound S1 S2 SM Respirations 16 to 24 shallow pupil reactive to light stimuli placed non-rebreather mask at 100% infusion well daughter self-catheter early in day only received small amount of concentrated dark amber urine." (sic) The next and last entry in the clinical record was "Discharge - Death" on 9/24/22 by the Director of Clinical Services (Staff B). Staff B documented under "Comments/Summary" the following: "Patient pronounced by Police Department and EMS per family request, ME (medical examiner) provided TOD (time of death) to writer of 06:39 Medical Examiner# 21-11629." Review of a filed Gross Pointe Farms Public Saftey police report on 5/9/22 at 5 PM., noted the following narrative dated 9/24/21 at 07:43 AM. "Dispatched to listed location on report of a Hospice Death for (MR#1). Dispatch advised me there was no Hospice paperwork but there is a ME (medical examiner) number. Upon arrival I spoke with MR#1's daughter, (Family A). (Family A) advised Officers the hospice nurse has yet to arrive at the house to pronounce a time of death. However, John Paul Home Hospice and Hospice nurse, (Staff D), contacted the ME, announced Time of Death, and the ME provided a case number. (Family A) and family were advised by Officers that this was uncommon practice. Director of John Paul Home Hospice, (Staff B), was contacted on behalf of the error. (Staff B) stated they made an error by releasing the Time of Death and contacting the ME without proper medical personnel on scene to examine the body. Note: MR#1was on hospice for Kidney failure. (Family A) saw her father take his last breaths at approximately, 03:00 hours on 9/24/21. (Family A) contacted nurse (Staff D) who claimed to be en route to the home, but still hadn't showed by the time Officers arrived on 06:18. During that time slot, (Staff D) contacted the ME and was given a case number without physically examining the body first. The family of MR#1 was upset on how Hospice had handled the situation and requested John Paul Home Hospice to no longer be of service to them." The Director (Staff B) was queried during the complaint investigation interview 5/10/22 at 11:35 AM., what the agency expectation was for staff to arrive on-site when notified that a patient has passed? Staff B replied, "Within one hour." The complaint intake noted the family had called the Agency to inquire about staff coming and helping the family with the death of MR#1 four times between 3:20 AM and 5 AM. Each time the family was told, "The nurse was on the way and was 20 minutes out." Eventually after no response from the hospice, the family reached to outside resources for help-see police report above. Review of the clinical record found no evidence of call log documentation. When Staff B was asked about the absence of any call logs within the agency, Staff B replied, "I have a notebook at my bedside that I write them down on, as I'm on-call throughout the night." Staff B was further queried if she transferred the notebook call logs to the medical record? Staff B replied, "No." During an interview 5/10/22 at 11:40 AM., Staff B was queried what the agency expectation was for follow-up condolences/emotional support concerning family members of the deceased. Staff B replied, " We send out a sympathy card at 3, 6, 9, and 13 months, and of course whenever there's a need." When asked who's responsible for this follow-up, Staff B replied, "That would be the Chaplin, and if they are refused due to religious reasons, then the Social Worker would do it." Further review of the clinical record found no evidence of a bereavement risk assessment, or bereavement services following the patient's death. Subsequently, the Medical Social Worker (Staff E) was interviewed on 5/10/22 at 12:54 PM., concerning the events surrounding MR#1. Staff E was queried about bereavement services and why the clinical record was void of any documented efforts made to offer emotional support to the family. Staff E replied, "I was new at the time and didn't know better. I take responsibility for that. Now I know the process, and I contact them (family) if the Chaplin is refused." On 5/10/22 at 1:15 PM., interviews concerning the above findings were conducted with the Administrator (Staff A), Director of Clinical Services (Staff B) and the Office Manager (Staff C). The findings were reviewed and acknowledged by Staff A, B, and C. Staff A stated, "We're going to learn from this and get better. At least we did the right thing and terminated (Staff D) within a week of this happening." The Agency failed to ensure appropriate and timely measures were taken to help assist family members with the death of a hospice patient and failed to offer continuing emotional support and bereavement services to family members of the deceased.
L0517
L0517	34701 Based on record review and interview, the agency failed to ensure the patient and family were free from mistreatment and neglect for 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice neglecting the needs of the patient and family. Findings include: **Agency policy: Death of Patient in the Home, page 154, dated 2014 stated, "At the time of death, family should be asked to call the Homecare/Hospice office or after-hours number and nurse [sic] will go to patient's home to pronounce the patient." On 9/24/21, the complainant stated in the complaint that, "The patient passed away at 3:00 a.m. A call was made to the hospice at 3:20 a.m. to report the death and request the nurse to come out. We were told they would contact the nurse and that he would be on the way shortly. When they had not arrived by 4:15 a.m., we called back. We were told that the nurse was on the way and would be at our house in 20 minutes. Around 4:45 a.m., staff from the funeral home came to the house to take the patient into their care. We were surprised because the hospice nurse still had not come to examine the patient. When the hospice nurse had not arrived by 5:00 a.m., we called back. Again, we were told the nurse was on the way and was 20 minutes out. The hospice nurse still had not arrived by 6:15 a.m. At that point, the funeral home called the police. The police arrived at the patient's home. After talking with the family, the funeral home, the medical examiner and the hospice staff, the police stated, "The hospice got a death certificate case number from the medical examiner without ever coming to the home after death, without examining the patient or pronouncing the patient's death. The police contacted Emergency Medical Services (EMS), who arrived at the house and declared the time of death. During record review on 5/10/22, it was discovered that no skilled nursing visit was documented for 9/24/22. An agency nurse never arrived at the home to pronounce the time of death. The nurse neglected the needs and wishes of the family by not visiting the patient's house to pronounce a time of death. This neglect caused undo stress and anxiety on the family as stated by the complainant, "The death of a loved one is hard enough to endure without the added stress of an incompetent, uncaring and neglectful hospice involvement. We would have been better off without having this hospice involved in our father's care. They caused increased anxiety, frustration, grief to our family." During an interview on 5/10/22 at 10:40 a.m., the Director of Clinical Services (Staff B) was asked about the agency's time frame expectation for the nurse to arrive at the home to pronounce the time of death. Staff B stated, "Our expectation is to arrive within one hour from notification of the patient's death."
L0585
L0585	34701 Based on record review and interview, the agency failed to ensure the registered nurse (RN), and the medical social worker (MSW), actively participated in the coordination of all aspects of the patient's hospice care in 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice not meeting the counseling, education, and emotional support needs of the patient and family. Findings include: Agency policy: Death of Patient in the Home, page 154, dated 2014 stated, "At the time of death, family should be asked to call the Homecare/Hospice office or after-hours number and nurse [sic] will go to patient's home to pronounce the patient." Agency policy: MSW Coordination of Services, dated 5/2012, page 286: Responsibilities; section 2-n stated, "Assessing bereavement needs. Assessing need for counseling related to risk assessment for pathological grief." During review of the complaint on 5/10/22 it was documented that the complainant stated, "Hospice agreed to meet us at home on the day of discharge (9/21/22). They did not and told us it was too late." During record review on 5/10/22, it was discovered that no agency visits were documented for 9/21/22. On 9/22/22, the complainant stated in the complaint that, "An agency nurse would be out to the house at 10:00 a.m. They did not come until 11:00 a.m., after we called to request." During record review on 5/10/22, it was discovered that the initial agency visit (Skilled nursing), was documented on 9/22/22 at 10:30 a.m. On 9/23/22, the complainant stated in the complaint that, "We called the hospice at 9:00 a.m., to report that the patient had taken a turn for the worse (Unresponsive, trouble breathing, wet respirations) and that we wanted a nurse to come out and assess him as soon as possible (ASAP). We also told the agency that the patient had low to unreadable oxygen saturations. The patient had a nasal cannula with oxygen, but the patient was a mouth breather and needed a different set-up. The nurse did not come to the house until 5:30 p.m., and the new oxygen set-up did not arrive until 6:30 p.m." During record review on 5/10/22, it was discovered that a skilled nursing visit was documented on 9/23/22 at 5:30 p.m., 8.5 hours after requested. On 9/24/21, the complainant stated in the complaint that, "The patient passed away at 3:00 a.m. A call was made to the hospice at 3:20 a.m. to report the death and request the nurse to come out. We were told they would contact the nurse and that he would be on the way shortly. When they had not arrived by 4:15 a.m., we called back. We were told that the nurse was on the way and would be at our house in 20 minutes. Around 4:45 a.m., staff from the funeral home came to the house to take the patient into their care. We were surprised because the hospice nurse still had not come to examine the patient. When the hospice nurse had not arrived by 5:00 a.m., we called back. Again, we were told the nurse was on the way and was 20 minutes out. The hospice nurse still had not arrived by 6:15 a.m. During record review on 5/10/22, it was discovered that no skilled nursing visit was documented for 9/24/22. During an interview on 5/10/22 at 10:40 a.m., the Director of Clinical Services (Staff B) was asked about the agency's time frame expectation for the nurse to arrive at the home to pronounce the time of death. Staff B stated, "Our expectation is to arrive within one hour from notification of the patient's death." During record review on 5/10/22, it was discovered that a medical social worker (MSW) missed visit (Initial assessment visit) had been documented on 9/22/21. The missed visit reason was, "Patient transitioned prior to MSW being able to complete assessment. There was no documented evidence that any further visits were provided or attempted by the MSW.
L0595
L0595	34701 Based on record review and interview, the agency failed to ensure the medical social worker (MSW) provided counseling/bereavement servicies for 1 of 1 records reviewed (The subject of the complaint, MR#1), resulting in the hospice not meeting the counseling, or emotional support needs of the patient and family. Findings include: **Agency policy: MSW Coordination of Services, dated 5/2012, page 286: Responsibilities; section 2-n stated, "Assessing bereavement needs. Assessing need for counseling related to risk assessment for pathological grief." During record review on 5/10/22, it was discovered that a medical social worker (MSW) missed visit (Initial assessment visit) had been documented on 9/22/21. The missed visit reason was, "Patient transitioned prior to MSW being able to complete assessment." During a phone interview with the MSW on 5/10/22 at 12:50 p.m., when asked about the bereavement process stated, "The spiritual counselor handles the bereavement process." When asked who handles bereavement when spiritual counseling is declined the MSW stated, "The MSW handles the bereavement process when spiritual counseling is declined. I was new to the hospice position at that time, and I did not know about the MSW bereavement responsibilities when chaplain/spiritual services were declined. I was not familiar with follow-up appointments for bereavement at that time either."