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
241533 A. BUILDING __________
B. WING ______________ 		01/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HENNEPIN HEALTHCARE HOSPICE 2000 SUMMER STREET NORTHEAST SUITE 100, MINNEAPOLIS, MN, 55413
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)
L0508      
30922 Based on interview and document review, the hospice failed to ensure the abuse prevention and response policy directed staff and contracted staff to report alleged violations involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of patient property to the hospice administrator immediately. This had the potential to impact all hospice patients. Findings include: The agency's Vulnerable Adult policy, revised 5/14/16, directed staff, "1. Report any suspected Maltreatment of a Vulnerable Adult to the county of residence where the incident occurred within 24 hours from the time there is knowledge of the incident. The reporting procedure herein will assist the healthcare professional in making a report; however any Mandated Reporter may report externally and confidentially at any time without using HHS' reporting procedure as described below. All maltreatment identified by HHS personnel, shall be called into the 24-hour Minnesota Adult Abuse Reporting Center. For inpatient unit,s the mandated reporter shall then contact the social worker assigned to the the patient's unit to assist with assessment of maltreatment allegations and interventions indicated. If after hours, contact ED [emergency department] Social Worker." and "III. If the maltreatment occurred within HHS: A. the Mandated Reporter who identified the Maltreatment shall complete an online safety even report." The procedure did not direct hospice staff and contract staff to notify the hospice administrator immediately of these allegations. On 1/15/20, at 8:26 a.m. the hospice administrator reported staff should notify her immediately of any alleged mistreatment, neglect, abuse, injuries of unknown source and misappropriation of patient property and document this was compelted. On 1/15/20, at 8:44 a.m. a hospice nurse manager (RN)-Z reported the policy did not direct hospice staff and contract staff to notify the hospice administrator immediately, also there was not a system to document this notification.
L0577      
30922 Based on interview and document review, the hospice agency failed to ensure they had an agency wide infection control plan. The Condition of Participation for Infection Control, CFR 418.60 was not met due to the hospice agency not implementing an overall infection control program which included investigation and surveillance of their patients were completed to identify trends of illnesses or infections, and prevent potential outbreaks. This had the potential to affect all current hospice patients, (P19 and P20). Findings include: The agency failed to ensure the agency infection control data was being evaluated as part of the quality assessment and performance improvement (QAPI) program. This has the potential to affect all hospice patients and staff see L580 for additional information. The agency did not consistently track and trend all hospice patients infections but rather only focused on specific infection type and was not based on their hospice population. There were 2 of 20 hospice patients (P19 and P20) records reviewed who had infections but neither of these infections were tracked or trended as part of the agency's infection control surveillance program. See L581 for additional information. Review of HHS [Hennepin Healthcare] Homecare and Hospice Infection Prevention Surveillance Update 2018 Summary and 2019 Planning, undated, revealed no analysis of patient infections other than Central Line Associated Bloodstream Infections (CABS). The Infusion Surveillance for Central Line Associated Blood Stream Infections (CABS) 2019, revealed no catheter related infections for the first three quarters of 2019 and quarter 4 data was pending. P19's physician's certification of terminal illness, dated 4/23/19, revealed P19 was recertified for hospice services, effective 5/1/19. P19's urine culture results, dated 5/10/19, revealed positive lab results for ESBL, Extended Spectrum Beta-Lactamase, pseudomonas aeruginosa, Proteus Mirabilis, enterococcus faecalis and methicillin resistant staphylococcus aureus (MRSA). ESBL and MRSA, are bacterias that are resistant to common antibiotics, causing an increased risk of transmission to family and healthcare providers who provide direct care to the patient. P20's certificate of terminal illness, dated 2/19/20, revealed P20 was admitted to hospice with an effective date of 2/12/20. P20's terminal diagnosis was adenocarcinoma of rectum metastatic to lung (rectal cancer). P20's urinalysis, dated 5/3/19 revealed the following abnormal lab results: turbid appearance, large blood value in urine, positive for nitrates in urine and moderate values of leukocyte esterase. P20's urine culture, dated 5/6/19, revealed lab results of ESBL greater than 100,000 organisms/ml, which indicated positive for infection. On 1/15/20, at 10:00 a.m. the infection preventionists registered nurses from Hennepin Healthcare system (RN)-X and (RN)-Y and hospice administrator explained the infection control program. RN-Y reported the hospice did not track hospice patient illness and infections other than CABS. Also, there was very few patients on hospice that received infusion services. They identified P19 and P20's UTI infections were not tracked or trended, even though they had ESBL and MRSA identified. They continued to state if their hospice patients were admitted for inpatient hospital services they would be tracked for infections as part of the hospital based program, but not included in hospice tracking or trending. They identified there was a infection control surveillance policy for the health system as a whole, but nothing specific to hospice patients. The hospice administrator reported staff discussed infections as part of interdisciplinary group meetings every two weeks but patient infections were not tracked, trended or analyzed as part of the hospice program. The Infection Prevention Surveillance and Public Reporting policy, last revised 9/26/17, directed staff "Infection Prevention will perform surveillance on patients with devices and/or procedures at high risk for infection, as well as antibiotic resistant organisms using current CDC [Centers for Disease Control and Prevention] surveillance definitions." and "The following are public reporting measures: abdominal hysterectomy surgical site infection (SSI), catheter associated urinary tract infection (CAUTI), central line associated blood stream infection (CABS), colon procedures SSI, Clostridium difficile C difficile, [and] Methicillin Resistant Staphylococcus aureus (MRSA) bacteremia" The policy further directed staff, "Additional HHS [Hennepin Healthcare System] focused surveillance includes: A. All MRSA-hospital and community onset (in addition to the bacteremia as listed above) B. All Vancomycin Resistant Enterococcus (VRE)-hospital and community onset C. All Multiple Drug Resistant Organism (primarily gram negative organisms) (MDRO)-hospital and community onset D. Hospital onset C difficile E. Ventilator Associated Event infection surveillance F. Select SSI surveillance, in addition to those listed as above as publicly reported, as determined by IP [infection prevention] and the Surgery Program. G. Other select surveillance measures related to the prevention of infections as determined by IP and departmental leadership." The policy did not include any hospice specific surveillance procedures but used these guidelines for their overall health care system for all their entities which included, inpatient hospitalization and other outpatient services.
L0580      
40556 Based on interview and document review the agency failed to ensure the agency infection control data was being evaluated as part of the quality assessment and performance improvement (QAPI) program. This has the potential to affect all hospice patients and staff. Findings include: Review of the QAPI Committee Agenda/Minutes from January 2019 to December 11, 2019, lacked any documentation of any current infection control practices were being followed, reviewed or discussed at the agency QAPI meetings. Review of the Hospice 2019 QAPI Plan power point presentation indicated there was no discussion by the committee of an infection control audit or how the QAPI program monitored the effectiveness of this program. Review of the "2019 - 2020 Performance Improvement Plan" dated 3/27/19, indicated leadership is accountable for achieving results based on areas including regulatory requirements in their plan. There was no indication that infection control was reviewed as part of the QAPI program. During an interview on 1/15/2020, at 8:30 a.m., with the Quality Analyst stated infection control has not been officially included in the monthly QAPI meetings but this area has been discussed within the departments. There was no indication the hospice agency had an ongoing assessment, auditing, and ongoing monitoring of their infection control program through QAPI.
L0581      
30922 Based on interview and document review the agency did not have an agency wide infection control program that included investigation and surveillance of patients to identify trends of illness, and implement interventions to prevent potential outbreaks. The agency did not consistently track and trend all hospice patients infections but rather only focused on specific infection type and was not based on their hospice population. There were 2 of 20 hospice patients (P19 and P20) records reviewed who had infections but neither of these infections were tracked or trended as part of the agency's infection control surveillance program. This has the potential to affect all hospice patients. Findings include: P19's plan of care information, revealed an admission to hospice on 1/31/19 with a primary diagnosis of renal failure, acute. P19's plan of care 1-update E, dated 4/9/19 to 4/22/19, revealed the following diagnoses: E. coli urinary tract infection and sepsis due to Escherichia coli. [Sepsis is a life-threatening illness caused by your body ' s response to an infection. E. coli (Escherichia coli), is a type of bacteria that normally lives in your intestines. Some kinds of E. coli can cause diarrhea, while others cause urinary tract infections, respiratory illness and pneumonia, and other illnesses.] A registered nurse care coordinator note, dated 4/8/19, read "New infection(s) reported since last update: yes, [R19] had an infected nephrostomy site [A nephrostomy tube is a catheter that ' s inserted through the skin and into the kidney to drain urine from the body.] He was on Clindamycin [antibiotic medication] for 7 days. Infection has cleared up." No order for Clindamycin was found in the medical record. P19's urinalysis, dated 4/16/19, revealed the following results outside of normal limits: turbid (cloudy, opaque or thick) appearance, large blood in urine and above normal limits of protein, white and red blood cells and leukocyte esterase (enzyme found in white blood cells) in urine. P19's urine culture results, dated 4/19/19, revealed Escherichia Coli (ESBL) at amounts greater than 100,000 organisms/ml (milliliter), which indicated positive for infection. P19's progress note, dated 4/18/19, revealed, "Patient on IV antibiotics for infection at nephrostomy site." P19's plan of care 2, dated 4/23/19 to 5/22/19, revealed the following diagnoses: E.coli urinary tract infection and sepsis due to Escherichia coli. A registered nurse care coordinator note, dated 4/22/19, revealed "New infection(s) reported since last update: yes. Ron was hospitalized last week d/t [due to] infection and was discharged back to [care home] without antibiotics." P19's physician's certification of terminal illness, dated 4/23/19, revealed R19 was recertified for hospice services, effective 5/1/19. The progress note further revealed, "[elderly] male with a terminal diagnosis of recurrent pyelonephritis with sepsis and nephrostomy tube. This is a change in his terminal diagnosis." P19's urine culture results, dated 5/10/19, revealed positive lab results for ESBL, Extended Spectrum Beta-Lactamase, pseudomonas aeruginosa, Proteus Mirabilis, enterococcus faecalis and methicillin resistant staphylococcus aureus (MRSA). ESBL and MRSA, are bacterias that are resistant to common antibiotics, causing an increased risk of transmission to family and healthcare providers who provide direct care to the patient. These infections can be spread by touching the patient or items in the room, and healthcare workers should wear gown and gloves while caring for the patient. There was no indication in the record that patient, family or care givers were educated/communicated of what precautions should be implemented to decrease their risk of transmission of ESBL or MRSA. P20's certificate of terminal illness, dated 2/19/20, revealed P20 was admitted to hospice with an effective date of 2/12/20. P20's terminal diagnosis was adenocarcinoma of rectum metastatic to lung (rectal cancer). P20's urinalysis, dated 5/3/19 revealed the following abnormal lab results: turbid appearance, large blood value in urine, positive for nitrates in urine and moderate values of leukocyte esterase. P20's urine culture, dated 5/6/19, revealed lab results of ESBL greater than 100,000 organisms/ml, which indicated positive for infection. P20's plan of care 2 information, dated 5/7/19 to 7/13/19, revealed a registered nurse care coordinator update, dated 5/7/19, "[R20] was treated for UTI with abx [antibiotics] per pt [patient] and POA [power of attorney] preference. Orders for antibiotics were not found in R20's record. P20's physician's certificate of terminal illness, dated 5/11/19, revealed P20 was recertified for hospices services, effective 5/13/19 with a diagnosis of adenocarcinoma of rectum metastatic to lung. The note revealed, "[P20] has developed a UTI [urinary tract infection], and has had increased confusion." The HHS [Hennepin Healthcare] Homecare and Hospice Infection Prevention Surveillance Update 2018 Summary and 2019 Planning, undated, revealed no analysis of patient infections other than Central Line Associated Bloodstream Infections (CABS). The Infusion Surveillance for Central Line Associated Blood Stream Infections (CABS) 2019, revealed no catheter related infections for the first three quarters of 2019 and quarter 4 data was pending. On 1/15/20, at 10:00 a.m. the infection preventionists registered nurses from Hennepin Healthcare system (RN)-X and (RN)-Y and hospice administrator explained the infection control program. RN-Y reported the hospice did not track hospice patient illness and infections other than CABS. Few patients on hospice were provided with infusion services. Other infections, such as urinary tract infections, would not be tracked or trended. P19's and P20's infections were not tracked or trended. Hospice patients admitted for inpatient hospital services would be tracked for infections as part of the hospital based program, but not included in hospice tracking or trending. The infection control surveillance policy was for the health system as a whole, and not specific to hospice. The administrator reported staff discussed infections as part of interdisciplinary group meetings every two weeks. The patient infections were not tracked, trended or analyzed. On 1/21/20, at 1:58 p.m. the representative from the infusion center reported CABS information for referrals from the Hennepin Health hospital were included in the report provided to Hennepin Healthcare. The Infection Prevention Surveillance and Public Reporting policy, last revised 9/26/17, directed staff "Infection Prevention will perform surveillance on patients with devices and/or procedures at high risk for infection, as well as antibiotic resistant organisms using current CDC [Centers for Disease Control and Prevention] surveillance definitions." and "The following are public reporting measures: abdominal hysterectomy surgical site infection (SSI), catheter associated urinary tract infection (CAUTI), central line associated blood stream infection (CABS), colon procedures SSI, Clostridium difficile C difficile, [and] Methicillin Resistant Staphylococcus aureus (MRSA) bacteremia" The policy further directed staff, "Additional HHS [Hennepin Healthcare System] focused surveillance includes: A. All MRSA-hospital and community onset (in addition to the bacteremia as listed above) B. All Vancomycin Resistant Enterococcus (VRE)-hospital and community onset C. All Multiple Drug Resistant Organism (primarily gram negative organisms) (MDRO)-hospital and community onset D. Hospital onset C difficile E. Ventilator Associated Event infection surveillance F. Select SSI surveillance, in addition to those listed as above as publicly reported, as determined by IP [infection prevention] and the Surgery Program. G. Other select surveillance measures related to the prevention of infections as determined by IP and departmental leadership." The policy did not include any hospice specific surveillance procedures. Although P19's and P20's had infections these were not tracked or trended placed an increased risk for transmission of ESBL and MRSA to the patient, their family and healthcare workers whom could them transmit to other patients or family members if precautions were not implemented.
L0771      
22581 Based on interview and document review, the hospice failed to identify in their skilled nursing facilities contracts, the hospice's obligation to report allegations of abuse, neglect, injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the skilled nursing facility administrator within 24 hours of becoming aware of the allegation. This had the potential to affect all patients residing in 4 of 4 skilled nursing facilities (SNF-A , SNF-B, SNF-C,and SNF-D) the agency has contracts. Findings include: The service agreements signed between the hospice agency and SNF-A, SNF-B, SNF-C and SNF-D were reviewed. Neither SNF-A or SNF-B, SNF-C or SNF-D contract included the hospice's obligation to report all alleged violations involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of patient property by anyone unrelated to the hospice to the skilled nursing facility administrator within 24 hours of the hospice becoming aware of the alleged violation. On 1/16/19 at approximatly 10:30 a.m., the accreditation program manager reviewed the contracts and verified the component was missing from 4 of the 5 contracts. The accreditation program manager indicated when there were a merger of services, not all contracts were rewritten to include the correct information.
L0782      
22581 Based on interview and document review the agency failed to provide the nursing home staff with ongoing training of the hospice philosophy, policy and procedures for 4 of 4 skilled nursing homes (SNF- A, SNF-B, SNF-C and SNF-D). This had the potential to affect all hospice patients who resided in these skilled nursing facility. Findings include: The services agreement between SNF-A, SNF-B, SNF-C, SNF-D read under the caption Hospice Care Training: "HHS shall provide orientation and ongoing hospice care training to Facility's personnel as necessary to facilitate the provision of safe and effective care to hospice patients. Such orientation must include HHS (Hennepin Healthcare Hospice) policies and procedures, regarding methods of comfort, pain control and symptom management as well as principles about death and dying. Individual responses to death, patient rights, appropriate forms and record keeping requirements. Interview with the hospice clinical director, 1/16/19 at 10:45 a.m. indicated there was a pamphlet that was shared with facilities. It was titled Education for the community and professionals, a free service to help your organization succeed. The agency had no documentation as to who it had been shared with, when it had been given to facilities and what was the facilities response. The clinical director confirmed the agency lacked documentation or record keeping that education of Hospice policies and procedures had been offered to the facilities reviewed.