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
261574 A. BUILDING __________
B. WING ______________ 		01/28/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE 12101 WOODCREST EXECUTIVE DRIVE, SUITE 102, SAINT LOUIS, MO, 63141
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)
L0759      
31099 Based on policy review, record review, and interview, the agency failed to promote and protect the following care to patient of a SNF/NF or ICF/MR (now called ICF/IID): - 418.112 (e)(3) Provide the SNF/NF or ICF/IID with the following information: - (ii) Hospice election form and any advance directives specific to each patient. (L781) The cumulative effect of this deficient practice resulted in a finding of immediate jeopardy for one patient (Patient/Record #1) and has the potential to affect all patients served by the agency.
L0781      
31099 Based on policy review, record review, and interview, the agency failed to provide an updated coordinated plan of care (POC) to the nursing facility where the patient resided, that identified the advance directive showing the patient's desired full code status in the event of cardiac arrest, in one (Record/Patient #1) of one discharged record reviewed. This deficient practice has the potential to affect care of all patients served by the agency. Findings included: Review of agency's policy 510 titled, "DO NOT RESUSITATE," dated 07/2009, showed: Through written or verbal statements, patients exercise their right to accept or refuse life-prolonging procedures. A patient is not required to have a do not resuscitate (DNR) order to be admitted to Heartland Hospice (AKA Promedica Hospice). PROCEDURE: - The registered nurse meets with the patient/family to explain and discuss patient's right to self-determination and review heartland's policy on Advanced Directives/DNR; - Copies of Advanced Directives and/or DNR orders are placed in the patient record; and - Original "Do Not Resuscitate" order written by patient's physician is kept in patient record. Review of the agency's policy titled, "Coordination and Communication," dated 2021, ProMedica Hospice Facility Guidebook showed: - A designated hospice registered nurse (RN) will coordinate the integration and implementation of the plan of care. The facility must identify a representative from their interdisciplinary team to collaborate with the hospice RN in developing the integrated plan of care; - Care plans are implemented, evaluated and updated to meet identified needs of the patient as changes occur. Changes are discussed with the patient, family, caregiver and facility staff. Procedures are in place to ensure patients receive medication and treatments for optimal palliation. Hospice and facility staff coordinate care to assure the patient does not experience a delay in receiving needed medications and treatment. Hospice and facility staff determine the process by which information is exchanged when developing and evaluating outcomes and updating the plan of care to assure patients receive necessary care and services. Both teams seek input from the patient and caregiver on desired goals; - For optimum patient and family care, the facility and hospice work closely together in the following: - Collaboratively developing and implementing an interdisciplinary plan of care; - Jointly participating in the patient's care conference; - Frequent communication with any change of condition, new orders or family needs; - Time-of-death notification and communication; and - The hospice and facility must have a process for shared communication between both entities. Review of the agency's undated policy titled, "Individualizing the Hospice Plan of Care Guidebook," showed: - The mission of hospice is to provide quality hospice care to patients with a terminal illness and to support their caregivers; - The plan of care (POC) is one of the most important items the hospice team develops and guides the care provided to each patient. Agencies comply with policies, federal and state regulations and accreditation standards; - The hospice interdisciplinary group (IDG) creates the POC in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs; - Development of the POC begins with the comprehensive assessment; - Needs may be identified in the comprehensive assessment that are not related to the terminal illness and related conditions. The assessment documents that the hospice is aware of these needs and if warranted, notes who is addressing them. The hospice ensures that each patient and the primary caregiver(s) receive education and training as appropriate to their responsibilities for the care and services identified in the POC; - The IDG reviews and revises the POC based upon review of the updated comprehensive assessment and the patient's changing needs. Each discipline involved in the patient's care contributed to each IDG discussion and participates in updating the POC based on the patient and family's current needs. The POC is a "work in progress"; - The initial POC includes, but is not limited to: * Drugs and treatments necessary to meet the needs of the patient; * End-of-life care preferences; - A POC must be established before care is provided and periodically reviewed by the attending physician, the hospice physician, and the IDG group; - Patient preferences for end of life care are assessed and included in the POC. This includes funeral home preferences, advance directives, and living wills; - Like home patients, facility patient's POC's are individualized according to each patient's needs. The hospice team and facility staff communicate, establish, and agree upon a coordinated POC for both providers which reflects the hospice philosophy, and is based on an assessment of the patient's needs and unique living situation in the facility; - The integrated plan identifies care and services which the facility and hospice are going to provide. The POC is revised and updated as necessary to reflect the patient's current status; and - Critical thinking skills are essential when developing a POC. The hospice POC is individualized based upon the comprehensive assessment. Each time a patient is admitted or recertified, a POC is developed or updated based upon the current needs. RECORD/PATIENT #1: Review of the clinical records showed the following: - An "Outside the Hospital Do-Not-Resuscitate Order" signed in the box for revocation of DNR status on 05/03/2021 by the patient, and signed by the physician on 05/07/2021; - Patient was admitted to hospice services on 06/03/2021; - Admitted with a terminal diagnosis of severe protein-calorie malnutrition; and - Patient resides in a long-term care facility. Review of the RN comprehensive assessment dated 06/03/2021, showed: - DNR preference confirmed with patient; - Alert and orientated to person, place and time; and - No abnormal cognitive functions identified. Review of the master of social worker (MSW) comprehensive assessment dated 06/08/2021, showed patient alert and oriented to person, place and time. Review of the hospice POC dated 06/02/2021 to 08/30/2021, showed: - Start of care 06/02/2021; - Skilled nurse twice a week times one week, one time a week times 12 weeks and as needed; - Hospice nurse to coordinate POC with long-term care facility [LTCF] staff; and - Advance directives - Do Not Resuscitate. Review of the RN comprehensive assessment dated 10/23/2021, showed: - DNR preference confirmed with patient; - Alert and orientated to person, place and time; - No abnormal cognitive functions identified; - Lives in a long-term care facility/nursing home; - Readmitted to Heartland [Promedica] hospice on 10/23/2021 with a diagnosis of protein calorie malnutrition. Patient had a fall out of bed on 10/20/2021 and was sent to the emergency room, where he/she was diagnosed with a right femoral fracture. He/she was subsequently discharged from Heartland [Promedica] hospice to receive surgery. Surgery was then declined by patient. The patient returned to the LTCF on 10/22/2021; and - Received report from the LTCF charge nurse and obtained copy of recent hospitalization records and copy of code status form dated 09/13/2021, indicating the patient is a full code. Review of the POC dated 10/23/2021 to 12/01/2021, showed: - Start of care 10/23/2021; - Skilled nurse once a week times one week, two times a week times one week, once a week times seven weeks and as needed; - Hospice nurse to coordinate POC with LTCF staff; and - Advance directives - Do Not Resuscitate; None. Review of the hospice MSW documentation showed that: - On 10/25/2021 the MSW visit showed: * Patient reports "I'm not gonna die. I hope for a miracle. One part of my life is to have miracle." Licensed clinical social worker (LCSW) spoke with patient regarding code status and patient reports a preference to remain a full code at this time. LCSW advised LTCF nurse, hospice RN case manager and hospice spiritual counselor coordinator, of the above mentioned details. Patient will likely benefit from ongoing hospice support and education; and - On 12/01/2021 the MSW visit showed: * "I am not afraid to die. We are all going to do it. I don't want to die but I am not afraid." Patient deceased at LTCF on 12/12/2021. Review of the hospice agency, "Investigation Report," dated 12/13/2021 to 12/14/2021 showed: - On 12/12/2021, hospice notified that patient had passed away; - On 12/13/2021, hospice Senior Director of Professional Services (DPS) spoke to the LTCF administrator and he/she was informed the LTCF agency nurse had not initiated CPR [cardiopulmonary resuscitation - an emergency procedure that can help save a person's life if their breathing or heart stops] on the patient, and he/she was a full code. The LTCF agency nurse had not looked at the facility chart, but had looked at "hospice paperwork" that showed patient was a DNR; - Conclusion: There was conflicting documentation in the patient's clinical record regarding the Outside Hospital DNR form that was signed in LTCF in May 2021 (prior to first hospice admission), and a code status form indicating full code that was signed on 09/17/2021. The hospice POC order for hospice admission date of 10/23/2021 indicated "Do Not Resuscitate" and this was signed by the hospice physician and attending physician, but there was also documentation by the RN and MSW (found in their comprehensive assessments) that the patient's wish was to be a full code. The LTCF agency nurse did not perform CPR, and hospice was notified after patient was already noted to be deceased; and - The discrepancies in the patient's medical record brought to light the urgent need to clarify all patients/responsible parties' wishes for resuscitation or full code, and to ensure that all wishes are communicated to all hospice caregivers and facility staff. Review of the "Witness statement," dated 12/14/2021, showed: - The MSW that completed the admitting assessment on 10/25/2021 was aware the patient was a full code, and he/she documented the patient's wishes in his/her comprehensive assessment, and documented that he/she had informed the hospice team and the [LTC] facility staff was aware; - The RN that made the death visit on 12/12/2021 was not aware the patient was a full code. The documentation in hospice record reflected DNR. He/she was completing paperwork and looking through the facility chart and noticed that the patient was a full code. He/she did not expect the patient's death. He/she had visited the patent on 12/11/2021, because he/she had nausea and obtained new orders and provided interventions. The patient was alert and stable at that time with no signs that he/she would pass away the next day; and - The RN that admitted the patient to hospice on 10/23/2021 was aware the patient wanted to be a full code and he/she documented it in his/her assessment narrative. He/she reviews the facility chart and looks for any advance directives or DNR forms. If the patient is a full code and they don't have another advance directive (DPOA- durable power of attorney) then he/she would indicate "None" in the Advance Directives screen. He/she would not have indicated Do Not Resuscitate if he/she wasn't a DNR when completing the admission. During interview on 01/25/2022 at 1:15 PM, the hospice DPS stated that: - There was a DNR in the patient's chart from May 2021; - After the patient returned from the hospital in October 2021, he/she changed to a full code; - He/she had made hospice staff aware that he/she was a full code after the hospital stay, but it never got changed in the hospice electronic medical record (EMR); and - He/she was a new admit in October, but some things carry over in the EMR, and his/her DNR status carried over and never got changed. During a telephone interview on 01/27/2022 at 1:23 PM, the MSW stated that: - The patient was a full code on admission and wanted to remain a full code on his/her second admission; - When a patient wants to be a full code, he/she talks to the nurse at the LTC facility and tells the hospice nurse the patient wants to be a full code; - He/she saw the nurse had also documented the patient wanted to be a full code; and - He/she doesn't know why the patient slipped through the cracks.