Survey Report for 261554

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	261554	A. BUILDING __________ B. WING ______________	09/01/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SERENITY HOSPICECARE	5272 FLAT RIVER ROAD, PARK HILLS, MO, 63601
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)
L0552
L0552	29559 Based on policy review, record review, and interview, the hospice failed to ensure that the hospice interdisciplinary group (IDG) was involved in level of care changes, and followed the Serenity care hospice policy regarding continuous care. This deficient practice occurred in three of three sampled patient records (Record/Patient #1, #2, and #3). This deficient practice has the potential to affect all patients served by the hospice. Findings included: Review of the agency's policy titled, "Procedure for Initiation of Continuous Care Service and Documentation", last revised in 2019 stated in part the following: - Continuous care is a specific level of hospice care authorized "under orders of the patient's physician"; - The medical record must show the reason why the level of care changed; - Document the patient's condition in respect for need of continuous care; - Document the patient's level of pain, and interventions and response to interventions; and - Document interventions in response for need of the continuous care. RECORD/PATIENT #1: Review of the list of billed continuous care, provided by the hospice administrator on 08/30/2021, showed that the patient received continuous care on 07/31/2021 for eight hours. Review of the nurse visit and all available clinical documentation in the electronic medical record (EMR) showed the staff failed to document the reason for continuous care, document any interventions provided during the continuous care. The staff failed to document response to any new interventions during this period. The medical record failed to show the reason why the level of care changed. On 07/31/2021 the nurse documented the only narrative regarding the need of continuous care "Lying in bed on right side, no observable distress at this time, patient in active phase of dying. Family coping well with condition. Receiving Roxanol, Ativan and hyosyne every four hours for discomfort". Review of the hospice plan of care showed no new orders, no new interventions during the continuous care period on 07/31/2021. Review of all interim orders, and plan of care orders showed no physician orders for changing the patient's level of care to continuous care as the Serenity hospicecare policy requires. Review of all IDG notes, nurses notes, and communication notes showed no evidence that the IDG was involved or informed that the patient was advanced in hospice level of care to continuous care. During an interview with the hospice administrator and clinical manager on 08/31/2021 at 10:45 AM, they stated that the nurse should have clearly documented the need for continuous care and interventions during that time. They stated that there was no physician order for the patient to receive continuous care in the medical record. He/she stated that there was no evidence in the medical record that the IDG team was involved in the determination of changing the patient's level of care to continuous care. The decision for continuous care was made by nursing only. The IDG was notified after, by secure text, which cannot be retrieved for review, because the text messages "drop off". RECORD/PATIENT #2: Review of the list of billed continuous care, provided by the hospice administrator on 08/30/2021, showed that the patient received continuous care on 06/23/2021 for twelve hours. Review of all interim orders, and plan of care orders showed no physician orders for changing the patient's level of care to continuous care on 06/23/2021 as the Serenity Hospicecare policy requires. Review of all IDG notes, nurses notes, and communication notes showed no evidence that the IDG was involved or informed that the patient was advanced in hospice level of care to continuous care. During an interview with RN-A on 08/30/2021 at 3:00 PM, he/she stated that continuous care was started on hospice patients with a verbal okay from the hospice nurse practitioner. No physician orders are written. The physician or IDG are not involved in the decision. RECORD/PATIENT #3: Review of the list of billed continuous care, provided by the hospice administrator on 08/30/2021, showed that the patient received continuous care on 06/09/2021 for ten hours. Review of all interim orders, and plan of care orders showed no physician orders for changing the patient's level of care to continuous care on 06/09/2021 as the Serenity hospicecare policy requires. Review of all IDG notes, nurses notes, and communication notes showed no evidence that the IDG was involved or informed that the patient was advanced in hospice level of care to continuous care. During an interview with RN-B on 08/31/2021 at 10:20 AM, he/she stated that continuous care was started on hospice patient with a collaboration from the hospice nurse clinical manager. The IDG is informed after the fact by "matrix communicate" texting application, but the decision for level of care change is made solely by nursing.