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
261554 A. BUILDING __________
B. WING ______________ 		10/24/2019
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)
L0536      
29559 Based on agency policy, home visit observation, clinical record review and interview, the agency interdisciplinary group (IDG) failed to ensure development of an individualized plan of care that reflects patient and family specific goals and interventions (L546). The effect of this practice has the potential to affect all patients receiving hospice services from this agency.
L0546      
29559 Based on policy review, record review, and interviews the hospice agency failed to ensure the plan of care included the interventions necessary to manage pain and symptoms. The patient had severe pain without effective intervention and coordination of the IDG (Interdisciplinary group/team = IDT/IDG) team in, but not limited to, one of three sampled cases (Patient/Record #1). The deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency policy titled "Interdisciplinary Teams", last updated in 2016 showed "The interdisciplinary Team is responsible for development and updating the patient's electronic plan of care". Review of the agency policy titled "Patient Rights", undated, showed "The right to receive quality hospice care and to receive pain management and symptom control". PATIENT/RECORD #1: Review of the initial comprehensive assessment completed by the hospice Registered nurse (RN) on 07/01/19 showed the following: - That the patient was admitted to hospice on 07/01/19 for end stage renal disease, with comorbitities of diabetes, pulmonary disease, seizures, and depression; - The patient was alert and orientated; - The patient required a mechanical lift for transfers; - The patient was chairfast, or bedfast, non-weight bearing; - The patient had a self reported pain level of "7" on a scale of 1-10 (10 being worst imaginable pain) in his/her back/hips; - The patient's acceptable level of pain was "5"; - "The patient comfortable with current treatment? yes"; and The assessment failed to address the discrepancy between the patient's current pain level above his/her self reported acceptable level of pain and "the patient being comfortable with current treatment". Review of a licensed practical nurse (LPN) visit on 07/02/19 showed the following:- The - The patient was alert and orientated; - The patient had a self reported pain level of "8" on a scale of 1-10 in his/her back; - The patient's acceptable level of pain was "4"; - The nurse contacted the hospice physician and received an new order for a Fentanyl 25 mcg/hr (micrograms/hour) transdermal patch and to increase Dilaudid (pain medication) 2 mg (milligrams) as needed (PRN) frequency to one tablet every six hours. The next nurse visit was 07/05/19. Review of the entire medical record showed no follow-up on the opioid prescribed/ new intervention on 07/02/19 to assess if pain control was effective. Review of a licensed practical nurse (LPN) visit on 07/05/19 showed the following:- The - The patient was alert and orientated; - The patient had a self reported pain level of "9" on a scale of 1-10 in his/her back; - The patient's acceptable level of pain was "4"; - "The patient comfortable with current treatment? yes"; The assessment failed to address the discrepancy between the patient's current pain level above his/her self reported acceptable level of pain and "the patient being comfortable with current treatment"; and - No documented contact with the physician or IDT (Hospice Interdisciplinary Team) regarding new interventions for the patient's pain. Review of a "RN supervisory visit" dated 07/09/19 showed the RN failed to asses the patient's pain. (The plan of care showed an intervention "assess effectiveness of medication and interventions each visit and PRN"). The next nurse visit was 07/09/19. Review of the entire medical record showed no follow-up on the severe pain that was identified on 07/05/19 (four days). Review of a licensed practical nurse (LPN) visit on 07/09/19 showed the following:- The - The patient was alert and orientated; - The patient had a self reported pain level of "9 - severe"on a scale of 1-10 in his/her back; - The patient's acceptable level of pain was "4"; - "The patient comfortable with current treatment? yes"; - The assessment failed to address the discrepancy between the patient's current pain level above his/her self reported acceptable level of pain and "the patient being comfortable with current treatment"; and - No documented contact with the physician or IDT (Hospice Interdisciplinary Team) regarding new interventions for the patient's uncontrolled pain. Review of a licensed practical nurse (LPN) "LPN Routine Visit" visit on 07/10/19 showed the following: - The patient was alert and orientated; - The patient had a self reported pain level of "10" - severe"on a scale of 1-10; - "Pt has lower abd (abdominal) pain"; and - No documented contact with the physician or IDT (Hospice Interdisciplinary Team) regarding new interventions for the patient's uncontrolled pain. A visit was attempted on 07/11/19, "no answer to door bell". Review of the 07/11/19 IDT team meeting note showed the typed discussion showed no mention of the patient refusing to have his/her pain medication increased, uncontrolled pain management, or any additional interventions for pain. Review of a licensed practical nurse (LPN) visit on 07/12/19 showed the following:- The - The patient was alert and orientated; - The patient had a self reported pain level of "8 - severe"on a scale of 1-10 in his/her back; - The patient's acceptable level of pain was "4"; - "The patient comfortable with current treatment? yes"; - "Has facial grimacing and moaning out at times during attempt at catheter placement" ; - No documented contact with the physician or IDT (Hospice Interdisciplinary Team) regarding new interventions for the patient's pain; and - The assessment failed to address the discrepancy between the patient's current pain level above his/her self reported acceptable level of pain and "the patient being comfortable with current treatment". During an interview with the patient's primary nurse (LPN-A) on 10/23/19, he/she stated the following: - The patient was alert and orientated; - The patient's pain was severe, the patient "always has some type of excuse why it was high" - "I don't think the patient understood the pain scale"; - "I spoke to the patient many times about increasing the pain medication"; - "The patient was non-compliant with taking medications"; - The patient had a Fentanyl (opioid) patch and Dilaudid tablets PRN; - When asked how many PRN Dilaudid tablets the patient used every day, the nurse responded, "I don't know, but never had to refill the bottle"; and - When asked if Dilaudid tablets were counted on the nurse visits, the nurse responded "no"; During an joint interview with the primary care giver and Patient #1 on 10/24/19 at 11:40 AM, he/she stated the following: - The patient is "bedridden" and needs help with bathing, dressing and toileting; - The patient transferred services to another hospice in September; and - When asked if the patient refused to have pain medication increased/changed, or was acceptable with the pain interventions to address the severe pain, the patient and caregiver responded "They did not discuss that with him/her".