Survey Report for 261506

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	261506	A. BUILDING __________ B. WING ______________	01/12/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SAINT LUKE'S HOSPICE	3516 SUMMIT STREET, KANSAS CITY, MO, 64111
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)
L0555
L0555	33392 Based on policy review, record review, and interview, the agency failed to ensure that the care and services were provided in accordance with the plan of care (POC) when the interdisciplinary group (IDG) failed to ensure the visit frequency was followed, in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to adversely affect the care provided to all the agency's patients. Findings included: Review of the agency's policy titled, "HOSP Interdisciplinary Team Group (IDG) - Hospice," updated 08/01/2013, showed, in part, the following: - All hospice services are delivered under the direction, supervision, and evaluation of the IDG; - The IDG establishes the POC, maintains records of services that are provided and evaluates all services delivered; and - The IDG meets every two weeks to review and update the POC for each patient receiving hospice care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 03/17/2020 with a terminal diagnosis of multiple myeloma. The patient lived at home with his/her spouse. Review of the IDG dated 04/29/2020 showed skilled nurse visits were to be once a week through 6/13/2020. Review of the clinical record showed: - Documented nurse visit notes were provided for 5/6/2020, 5/18/2020, and 5/28/2020; - The record failed to show documentation of nursing visits for the week of 5/10/2020 to 05/16/2020; and - The IDG failed to ensure nurse visits were provided as ordered one time a week on the week of 05/10/2020 (no nurse visit). During interview on 01/12/2021 at 12:36 PM, the administrator said: - She would have expected a skilled nurse visit to have been made the week of 05/10/2020; -The Registered Nurse Case Manager (RNCM) was terminated due to missed documentation and late documentation; and - The agency has no documentation the visit was done.