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
261547 A. BUILDING __________
B. WING ______________ 		01/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE COMPASSUS-TRI LAKES MISSOURI 3044 SHEPHERD OF THE HILLS EXPRESSWAY, SUITE 200, BRANSON, MO, 65616
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      
17006 Based on policy review, record review, grievance file review and interview the agency failed to promote and protect the following patient rights: - If a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patient's behalf (L506); - The agency will immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures (L509); and - The patient/legal representative has the right to be involved in developing his or her hospice plan of care (L513). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.
L0506      
17006 Based on policy review, record review, and interview, the agency failed to ensure that the rights of the patient were exercised by the person appointed pursuant to state law to act on the patient's behalf in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect the exercise of the rights of all patients served by the agency. Findings included: Review of agency policy titled, "Policy C5 - Patients' Rights," dated 07/05/19 showed: - Surrogate decision-maker, a person authorized by state statute to make medical decisions on behalf of a person who is mentally or physically incapacitated; and - If a patient has been adjudged incompetent, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patient's behalf. Review of the patient rights information included in the patient admission packet titled, "Patients' Bill of Rights," dated August, 2019 showed that the patient has the right to: - Participate in the planning of his/her care, and to be informed of such right in advance of implementation of changes to the plan of care; and - The patient's guardian may exercise the patient's rights when the patient is unable to do so. RECORD/PATIENT #1: Review of a court order dated 08/03/2020 showed: - The patient was, by reason of total physical, mental, and cognitive incapacity, unable to manage the essential requirements for food, clothing, shelter, safety or other care, or financial resources and lacked the capacity to vote, marry, or drive an automobile; - The appointed guardian may act in the patient's behalf with full powers as provided by law; and - The guardian shall allow the visiting child (VC) to visit the patient at the guardian's home subject to the following conditions: *The VC may visit Monday, Wednesday, and Friday only at such time when a hospice worker shall also be present. Review of the hospice start of care visit dated 08/24/2020 showed: - The patient was admitted to hospice service with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a chronic, inflammatory lung disease that causes obstructed airflow from the lungs); - The patient resided in the guardian's home; and - The patient exhibited abnormal attention, did not follow conversation, or answer questions appropriately. Review of the signed informed consent and notice of patient rights form dated 08/24/2020 showed: - A statement that the patient understood that he/she had a choice of hospice providers, and would be involved in the planning of his/her care (including the right to review the plan of care, set goals, make suggestions, and refuse a particular treatment or service); - A statement that the patient received a copy of the hospice bill of rights; and - The signature of the guardian as the patient's legal representative. During an interview on 01/05/2021 at 4:25 PM, the guardian stated that he/she: - Was very concerned about exposing his/her fragile family member, and him/herself to the Coronavirus; - Put a sign on the front of the house to tell people about the Centers for Disease Control (CDC) guidelines and a table so people could be screened before they came into the house (this was for every person that came to the house, even if they were to visit me); and - Asked every person to wear a mask and sit behind the tape marker on the floor (to assure social distancing). Review of MSW (masters of social work) visit note narrative dated 09/09/2020 showed; an argument started between the VC and the guardian during the supervised visit. The guardian did not want the VC to cross over the taped line on the floor. The social worker informed the guardian that the VC could get as close to the patient as desired because the patient was the VC's family member too. During an interview on 01/05/2021 at 4:25 PM, the guardian stated that: - On October 2, 2020, the chaplain made a joint visit with the VC; - The chaplain entered the house rather forcefully, shoved a piece of paper into the guardians face, and told the guardian to read it; - At the same time, the VC moved past the guardian, and into the room with the patient; - The VC then proceeded to hug and kiss the patient; - The VC then held up the piece of paper in front of patient's face, and read it to him/her line by line; - The chaplain and VC were told to leave our house more than once; they didn't leave; - He/she called the office and told the office staff that that they were fired from being hospice providers for the patient, and still the chaplain and VC didn't leave; - He/she called the police and the chaplain and VC remained in the home; - The chaplain and VC finally left the house as the police arrived; and - He/she felt that their rights were violated, the chaplain and VC should have left the home when they were told. Review of the statement of events written by the chaplain on October 5, 2020 showed that: - The chaplain and the VC arrived at the guardian's home on October 2, 2020 at 12:50 PM, and entered the home at 1:00 PM; - The guardian requested that he/she and the VC leave the home on three separate occasions, and even called the police to report that there were people in his/her home that would not leave; and - The chaplain and the VC exited the guardian's home at 1:30 PM. During an interview on 01/05/21 at 3:30 PM, when asked to summarize the events of 10/02/20, the chaplain stated that: - There was a court order that mandated supervised visitation for the VC with the patient at the guardian's home; - The visits were three days a week and the hospice staff members took turns performing the supervised visitation; - Most of the supervised visits went well; - The VC wanted to actually touch the patient; - They (the agency) developed a supervised visitation protocol to clarify what was allowed during the supervised visits; - He/she took three copies of the protocol to the patient's home on 10/02/2020; - He/she gave the VC a copy of the supervised visitation protocol outside of the patient's home prior to entering for the supervised visit; - He/she then gave a copy of the supervised visitation protocol to the guardian upon entering the home and told the guardian to read it; - The VC proceeded to visit the patient, sitting beside the him/her, and touching the patient's hands and face; and - During the supervised visit: * The guardian was loud and angry; * He/she called the agency office and "fired' them; and * He/she called the police. - The chaplain stated that he received a call from the director of clinical services and was directed to leave the home at that point. The chaplain stated that the police arrived as the he/she and the VC were leaving the home.
L0509      
17006 Based on policy review, grievance file review, and interview, the agency failed to document the investigation of all alleged violations in accordance with established procedures in two (Complaint #1 and #2) of two complaint records reviewed. This deficient practice has the potential to affect the investigation of complaints and/or grievances of all patients served by the agency. Findings included: Review of the agency policy titled, "Complaints and Grievances," dated 03/01/2020 showed: - The area executive of clinical services or designee (AECS/D) would be responsible for: * The investigation of the complaint within five working days to determine appropriate corrective actions; * Should the investigation reveal actions that violate agency policy, and/or local, state, or federal laws/regulations, the AECS/D will consult with regional vice president, regional executive of clinical operations, vice president of human resources and/or the compliance officer for further decision-making; * Within 30 days, the AECS/D will contact the complainant either via telephone or with a letter detailing the steps toward resolution. If composing a letter use standard business letter format and seek guidance on appropriate wording from the compliance department. Retain a copy of any correspondence sent to the complainant and attach to the complaint form; * Within 14 working days after the initial resolution communication, the AECS/D will provide a follow-up contact with the complainant to determine satisfaction with the resolution; if the complainant is not satisfied, review the process for seeking further resolution via the corporate office and/or the state's licensure or health division; * Documentation of investigative actions, corrective actions, and follow-up contacts on the bottom portion of the complaint report. Complaint #1: Review of complaint #1 with report date of 10/02/2020 showed the complaint form failed to contain documentation of: - The efforts of the AECS/D to comply with the policy regarding: * The investigation of the complaint, * The corrective actions taken to resolve the complaint, * The efforts to complete communication with the complainant regarding resolution of the complaint; and * Documentation of the resolution of the complaint. Complaint #2: Review of complaint #2 with report date of 10/02/2020 showed the complaint form failed to contain documentation of: - The efforts of the AECS/D to comply with the policy regarding: * The investigation of the complaint, * The corrective actions taken to resolve the complaint, * Communication with the regional vice president, regional executive of clinical operations, vice president of human resources and/or compliance office for further decision making for an investigation that revealed actions that violate agency policy; and * Documentation of the resolution of the complaint. During an interview on 01/06/21 at 12:20 PM the administrator stated that the grievance process had not been completed or documented per agency policy on either record.
L0513      
17006 Based on policy review, record review, and interview the agency failed to ensure that the patient/legal guardian was involved in developing his or her hospice plan of care and failed to inform the patient/legal guardian of a change in the plan of care in advance of the change in one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect the rights of all patients served by the agency. Findings included: Review of agency policy dated 07/05/19 and titled, "Policy C5 - Patients' Rights," showed: - The rights of the patient are exercised by the person appointed pursuant to state law to act on the patient's behalf; - The patient has the right to be involved in developing his or her hospice plan of care including notice of changes to the plan; and - The patient has the right to be informed in advance of the services to be provided. Review of the patient rights information, included in the admission packet, dated August 2019, and titled, "Patients' Bill of Rights," showed that the patient has the right: - To participate in the planning of his/her care, and to be informed of such right in advance of implementation of changes to the plan of care; and - The patient's guardian may exercise the patient's rights when the patient is unable to do so. RECORD/PATIENT #1: Review of the court order dated 08/03/2020 showed that: - The patient was by reason of total physical, mental, and cognitive incapacity, unable to manage the essential requirements for food, clothing, shelter, safety or other care, or financial resources and lacked the capacity to vote, marry, or drive an automobile; - The appointed guardian may act in the patient's behalf with full powers as provided by law; and - The guardian shall allow the visiting child (VC) to visit the patient at the guardian's home subject to the following conditions: *The VC may visit Monday, Wednesday, and Friday only at such time when a hospice worker shall also be present. Review of the hospice start of care visit dated 08/24/2020 showed: - The patient resided in the guardian's home; and - The patient exhibited abnormal attention, did not follow conversation, or answer questions appropriately. Review of the informed consent and notice of patient rights form dated 08/24/20 showed: - A statement that the patient understood that he/she had a choice of hospice providers, and would be involved in the planning of his/her care (including the right to review the plan of care, set goals, make suggestions, and refuse a particular treatment or service); - A statement that the patient received a copy of the hospice bill of rights; and - The signature of the guardian as the patient's representative. During an interview on 01/06/2021 at 09:40 AM, the social worker stated that: - The guardian was "a little strange" and had a "do it my way" attitude; - The guardian had a screening station on the porch of their residence, and even had tape on the floor to mark the boundaries for social distancing; - The VC voiced concerns that the guardian would not allow him/her to touch the patient during the supervised visit. The social worker stated that the VC was directed to contact his/her attorney if they were dissatisfied with the visitation arrangements; - The VC reported to the social worker that his/her attorney had suggested writing up a list of ground rules for the supervised visitation; - The social worker notified director of clinical services (DCS) of the VC's request for a list of ground rules for the supervised visitation; - The DCS developed a list of ground rules for the supervised visitation; and - The DCS did not speak with the guardian about the development of the supervised visitation protocol. During an interview on 01/05/2021 at 4:25 PM, the guardian stated that he/she: - Was very concerned about exposing his/her fragile family member, and his/her self to the Coronavirus; - Put a sign on the front of the house to tell people about the Centers for Disease Control (CDC) guidelines, and a table so people could be screened before anyone, regardless of purpose for visit, entered the house; - Asked every person to wear a mask and sit behind the tape marker on the floor (to assure social distancing); and - On October 2, 2020 the chaplain made the visit with the visiting child (VC). The chaplain and VC came into the guardian's home; - The chaplain entered my house rather forcefully, shoved a piece of paper in my face, and told me to read it; while at the same time the VC moved past us, and into the room with my parent; - The VC then proceeded to hug and kiss the patient; - The VC then held up the piece of paper in front of the patient's face and read it to him/her line by line; and - The guardian stated that he/she felt that they should have been given the paper before a visit was made so it could be read in advance of any changes to the plan of care. Review of the undated and unsigned letter presented to the guardian during the visit on 10/02/2020 showed the following: - Hospice supervisory visit outline and expectations are as follows; - If visiting person have no signs or symptoms of being ill, they must wear a mask and gloves in the patient's home and near the patient; - If visiting person has signs and symptoms of being ill, visits need to be rescheduled when visitor has no signs and symptoms of illness. Phone visit must be allowed in place of physical visit on court ordered days; - Visitor may sit near patient and touch patient's hand and/or face as long as proper PPE (personal protective equipment) is worn; - Visitor must be allowed allotted full hour inside the home as court ordered to visit with patient; - Hospice staff will only supervise visits as court ordered three times per week for one hour. After the one-hour mark, hospice staff is released of all supervisory duties for that day and may leave the home regardless of whether visitor has left the premises; Caregiver must allow visitor to have uninterrupted conversation and contact with patient during court ordered visits; - Hospice staff may call 911 if they feel at any time that their safety or the patient's safety is at risk. Once police are in the home, hospice staff are permitted to leave the premises even if visit time allotted by the court has not been completed for that day. Visit requirements are considered null and void at that point and will reconvene the next scheduled day instead; Visitor must notify caregiver and agency at least one hour in advance of canceled visits for any reason; - Patient has the right to refuse visits; - Patient's needs must be met by caregiver and/or visitor during visit; and - If you have any questions please contact the agency administrator. During an interview on 01/05/21 at 3:30 PM, when asked to summarize the events of 10/02/20 the chaplain stated that: - They (the agency) developed a supervised visitation protocol and that he/she took three copies of the protocol to the patient's home on the 10/02/2020 visit. The chaplain stated that he/she gave the VC a copy of the supervised visitation protocol outside of the patient's home prior to entering for the supervised visitation; and - He/she gave a copy of the supervised visitation protocol to the guardian upon entering the home and told the guardian to read it. The chaplain stated that the VC proceeded to visit the patient, sitting beside the patient and did touch the patient's hands and face. Review of the document dated 10/05/2020 and titled, "Court Ordered Supervisory Visit," showed that the VC had a mask and gloves on during the visit. During an interview on 01/06/21 at 12:20 PM, the administrator stated that: - Changes in the plan of care are discussed with the patient and caregiver; - The changes in the plan of care were not discussed with the guardian; and - They had tried to discuss change in the supervised visitation with the guardian, but the guardian would not listen.