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
261581 A. BUILDING __________
B. WING ______________ 		07/22/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CROSSROADS HOSPICE OF KANSAS CITY, L C 14310 EAST 42ND STREET SOUTH, UNIT 600, INDEPENDENCE, MO, 64055
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)
L0505      
38507 Based on bill of rights documentation review, complaint log review, complainant letter review, and interviews, the agency failed to document a family's complaint and complete an investigation in one of three records (Record/Patient #3) selected from the agency's complaint file. This deficient practice has the potential to affect the rights of all the agency's patients. Findings included: Review of the bill of rights included in the patient admission packet, titled, "Registration and Consent Forms (Page 26) Patient/Family Bill of Rights," showed, in part, a patient /patient representative has the right to report violations of these rights to the agency's executive director. The agency executive director will: - Investigate all alleged violations and complaints; and - If the violations are verified, corrective action will be taken. Review of the complaint log for 2018 failed to show a complaint listed for Patient #3. During an interview on 07/21/2020 at 4:40 PM, the assistant clinical director stated that the family did not call in a complaint to the agency and no complaint investigation was found. Review of the complainant's letter dated 02/14/2020 showed: - The patient was on service with the agency 02/27/18 and 02/28/2018; - In the weeks following the patient's passing, the complainant played "phone tag" with an agency marketer; - He/she was "never available when he/she called, even if the (complainant) called right back"; and - Was never able to talk to the employee. During an interview on 07/21/2020 at 3:00 PM, RN A stated that he/she remembered an "unhappy family." He/she notified the supervisor that: - The family did not feel prepared to take care of the patient; and - The family complained that the patient was not as comfortable as he/she could have been at death.
L0512      
38507 Based on policy review, the patient's bill of rights documentation review, clinical record review, complainant letter review, and interviews, the agency failed to ensure the patient received effective pain management and symptom control interventions at the end of life in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to affect the patient's right to pain and symptom management of all agency patients. Findings included: Review of the agency's policy titled, "EvenMore Care (EMC)," revised 10/01/12, showed, in part, the use of EMC helps increase the likelihood that hospice personnel is at the patient's bedside at the time of death. This allows the hospice to ensure that the patient's symptoms are managed throughout the dying process, and to provide emotional support to the family during this difficult time. Review of the patient's bill of rights included in the patient admission packet, titled, "Registration and Consent Forms (Page 27) Patient/Family Bill of Rights," showed, in part, the patient has the right to receive competent, compassionate, and effective pain management and symptom control interventions from the agency to alleviate distress and discomfort to the fullest extent safely possible. RECORD/PATIENT #3: Review of the clinical record and the complainant letter showed the patient had a past medical history of pulmonary hemosiderosis (a rare disease characterized by repeated episodes of bleeding into the lungs, which can cause anemia and lung disease) and associated respiratory failure (the capillaries, or tiny blood vessels, surrounding the air sacs can't properly exchange carbon dioxide for oxygen). The patient was admitted to the hospital on 02/19/2018. The patient became progressively worse and the physicians suggested hospice or to let the patient die at the hospital. The hospice house could not take the patient with the high dose of oxygen needed to maintain the patient's oxygen level. The patient wanted to go home to die and the family decided to take the patient home on 02/27/2018. The physician told them that the oxygen set up in the hospital was the best and the home set up would not be as effective. The agency had a respiratory therapist (RT) that evaluated the patient's home and decided liquid oxygen could be set up on bipap (Bilevel Positive Airway Pressure-a machine with a face mask that assists with breathing) in the home. The patient was discharged from the hospital on 02/27/2018 and expired at home the next morning, 02/28/2018 at 4:50 AM. Review of the clinical record showed an admission visit conducted by registered nurse C (RN C) on 02/27/2018 at 8:00 PM to 02/28/2018 at 2:15 AM. The admission visit documentation showed that after the patient was transported home per ambulance and the bipap with oxygen was set up for patient, the patient's oxygen saturation (the amount of oxygen that's in your bloodstream, the normal range is 94 to 99 percent) was 48-49% throughout the visit. The family expressed "anxiety about patient's condition and all the equipment (bipap and liquid oxygen concentrators x 6)." RN C educated the patient's family to call the agency with questions or concerns at any time. The patient's oxygen saturation was still at 49% when RN C left the home. During an interview on 07/21/2020 at 4:35 PM, RN C vaguely remembered the patient having the liquid oxygen. He stated that he/she remembered that: - Respiratory therapist D (RT D) was there and set up the oxygen and bipap; - The family was expecting the patient to expire soon; - The visit was four and half hours, way longer than normal; - He/she messaged the night supervisor asking for someone to take his/her place; - No one was available to take his/her place; - He/she felt the family must have been alright with him/her leaving and waiting for the nurse to come in the morning or he/she wouldn't have left; and - The patient was at the end of life and he/she thought the patient would pass within 24 hours. Review of the complainant's letter dated 02/14/2020 showed: - When RN A (hospice nurse) completed the registration (for hospice) at the hospital on the morning of 02/27/2018, the family was assured that hospice would be with the family 24 to 48 hours before the the patient passed; - During the admission visit that evening at the home, RN C had attempted to get another nurse there as soon as possible and the nurse would be there by 7:00 AM; - The family told RN C and RT D several times they were not comfortable with their ability to care for the patient adequately and to keep her comfortable; - The patient's granddaughter had gone into labor that night and was on the way to hospital; - RN C said he/she would stay only if they had to leave to go to the hospital; and - The family stayed to care for the patient and RN C left. Further review of the complainant's letter dated 02/14/2020 showed: - At approximately 3:00 AM, the son called the hospice agency to see if someone would come and help them; - A nurse called back and said they would have someone to the house by 5:00 AM; - The patient was becoming more restless and indicated he/she hurt and had labored breathing; - They were trying to administer the morphine every hour but it didn't work; - The son called the agency again and the on-call nurse said someone would be there as soon as possible; - About 4:45 AM, RN B arrived and checked the patient, the patient had expired; and - The family was told the patient would be kept comfortable and pass peacefully but there was nothing peaceful about the patient's passing. On 07/22/2020 at 10:05 AM, the surveyor attempted to call the son's home telephone number and a message was left on the home answering machine. There was no return call from the family. Review of the on-call logs the morning of 02/28/2018 showed: - Call #1- Came in at 3:25 AM from the patient's son. The communication showed he told the operator that he had concerns for the patient and would like to speak to a nurse. RN E spoke with the son and forwarded the information to the clinical director. RN E told the son, he/she would get a nurse there "as soon as I can"; and - Call #2- Came in at 3:56 AM from the son. The operator's communication showed, "the patient is struggling (breathing) and he (son) would like for someone to come ASAP." The son also had questions about medication and "seems rather anxious." RN E spoke with the son and wife, "patient is struggling to breath, becoming agitated. Advised that I (RN E) will get a nurse there ASAP." RN E failed to document instruction on use of the medications to control symptoms or other interventions to assist the patient while the family awaited the nurse. During an interview on 07/22/2020 at 10:40 AM, the assistant clinical director stated that the on-call logs were the only documentation of RN E's communication with the family.
L0584      
38507 Based on policy review, clinical record review, review of the complainant's letter, and interview, the agency failed to ensure that the licensed professional services delivered by their health care professionals was practiced under the hospice's policies and procedures (P&Ps) in one (Record/Patient #3) of three records reviewed, when the following occurred: - Situation #1-An after hours urgent situation nursing visit did not occur within the time period of the P&P guidelines; and - Situation #2-The proper level of care was not provided to a patient according to the P&Ps. This deficient practice has the potential to affect the quality of care provided to all the agency's patients. Findings included: SITUATION #1: Review of the agency's policy titled, "Response and Care Time Protocol/After Hours/On Call Protocols and Timely Delivery of Medications, Supplies and DME for Hospice Patients," revised 12/03/2018, showed in an emergent or urgent situation, the visit should be made within one hour (or sooner) of receipt of the initial call/contact. RECORD/PATIENT #3: Review of the clinical record and the complainant letter showed the patient had a past medical history of pulmonary hemosiderosis (a rare disease characterized by repeated episodes of bleeding into the lungs, which can cause anemia and lung disease) and associated respiratory failure (the capillaries, or tiny blood vessels, surrounding the air sacs can't properly exchange carbon dioxide for oxygen). The patient was admitted to the hospital on 02/19/2018. The patient became progressively worse and the physicians suggested hospice or to let the patient die at the hospital. The hospice house could not take the patient with the high dose of oxygen needed to maintain the patient's oxygen level. The patient wanted to go home to die and the family decided to take the patient home on 02/27/2018. The physician told them that the oxygen set up in the hospital was the best and the home set up would not be as effective. The agency had a respiratory therapist (RT) that evaluated the patient's home and decided liquid oxygen could be set up on bipap (Bilevel Positive Airway Pressure-a machine with a face mask that assists with breathing) in the home. The patient was discharged from the hospital on 02/27/2018 and expired at home the next morning, 02/28/2018 at 4:50 AM. Review of the complainant's letter dated 02/14/2020 showed: - At approximately 3:00 AM, the son called the agency to see if someone would come and help them; - A nurse called back and said they would have someone to the house by 5:00 AM; - The patient was becoming more restless and indicated he/she hurt and had labored breathing; - They were trying to administer the morphine every hour but it didn't work; - The son called the agency again and the on-call nurse said someone would be there as soon as possible; - About 4:45 AM, RN B arrived and checked the patient, the patient had expired; and - RN A failed to arrive within the one hour time limit the P&P indicated. Review of the on-call logs the morning of 02/28/2018 showed: - Call #1- Came in at 3:25 AM from the patient's son. The communication note showed he told the operator that he had concerns for the patient and would like to speak to a nurse. RN E spoke with the son and forwarded the information to the clinical director. RN E told the son, he/she would get a nurse there "as soon as I can"; and - Call #2- Came in at 3:56 AM from the son. The operator's communication note showed, "the patient is struggling (breathing) and he (son) would like for someone to come ASAP." The son also had questions about medication and "seems rather anxious." RN E spoke with the son and wife, "patient is struggling to breath, becoming agitated. Advised that I (RN E) will get a nurse there ASAP." During an interview on 07/22/2020 at 10:40 AM, the assistant clinical director stated that the son's call at 3:25 AM was when the time period started for a nurse to get to the patient's home for an emergent or urgent visit. SITUATION #2: Review of the agency's policy titled, "EvenMore Care (EMC)," revised 02/15/13, showed, in part, the following: - EMC is provided to patients when the patient requires additional care, increased visits or around the clock care; - The patient may be placed on EMC at any time deemed necessary by any member of the interdisciplinary group (IDG), but must have authorization from the team leader, triage nurse or on-call/after hours ACD (assistant clinical director?); - EMC increases the likelihood that hospice personnel is at the patient's bedside at the time of death; and - Symptoms that may warrant EMC are, in part, severe agitation, abnormal breathing patterns, and cyanosis. Review of the agency's policy titled, "Crossroads Watch Care," revised 10/01/12, showed, in part, the following: - Any member of the interdisciplinary group (IDG) can initiate a Watch Status. The staff member initiating this change should notify the team leader or on-call triage nurse/on-call ACD (assistant clinical director?) of the need for change; and - Symptoms warranting a Watch Status change in level of care, are in part, a recent discharge from the hospital and early signs/symptoms that death may be imminent. See RECORD/PATIENT #3 clinical record review of past medical history as above. Review of the clinical record showed an admission visit conducted by registered nurse C (RN C) on 02/27/2018 at 8:00 PM to 02/28/2018 at 2:15 AM. The admission visit documentation showed that after the patient was transported home from the hospital per ambulance and the bipap with oxygen was set up for patient, the patient's oxygen saturation (the amount of oxygen that's in your bloodstream, the normal range is 94 to 99 percent) was 48-49% throughout the visit. The family expressed "anxiety about patient's condition and all the equipment (bipap and liquid oxygen concentrators x 6)." RN C's assessment of the patient during the visit included skin cool to touch especially in peripheral extremities, some cyanosis present around lips/mouth, heartrate 70 and irregular, and oxygen is set on 32 liters per minute on a bipap machine (normal dose is 2-3 liters). The patient's oxygen saturation was still at 49% when RN C left the home. The patient was receiving Roxanol 0.25 ml (milliliters) (highly concentrated solution of the narcotic analgesic morphine sulfate for oral administration used for the treatment of severe pain or shortness of air) every one hour orally/sublingual (under tongue) administered by the family. During an interview on 07/21/2020 at 4:35 PM, RN C vaguely remembered the patient having the liquid oxygen. He stated that he/she remembered that: - Respiratory therapist D (RT D) was there and set up the oxygen and bipap; - The family was expecting the patient to expire soon; - The visit was four and half hours, way longer than normal; - He/she messaged the night supervisor asking for someone to take his/her place; - No one was available to take his/her place; - He/she felt the family must have been alright with him/her leaving and waiting for the nurse to come in the morning or he/she wouldn't have left; and - The patient was at the end of life and he/she thought the patient would pass within 24 hours. During an interview on 07/21/2020 at 3:00 PM, RN A stated that RN C wanted to put the patient on EMC and the primary on-call nurse told him no. During an interview on 07/22/2020 at 10:40 AM, the assistant clinical director stated that even though the first visit took place in the morning (at the hospital) and the patient did not go home until that evening: - He/she would not have expected to have continuous staffing set up to be available to assist through the night; - The admitting nurse would assess the situation and let the primary (triage) nurse and the physician know if the patient/family needed an increase in the level of care; and - It is the triage nurse's "call" to send out the next available staff person. The agency failed to provide an increased level of care to the patient/family when the P&Ps indicated the situation warranted the care.
L0672      
38507 Based on clinical record review and interview, the agency failed to ensure the patient's record included updated comprehensive assessments and clinical notes in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to affect adequate follow-up and clear documentation of care provided to all the agency's patients. Findings included: RECORD/PATIENT #3: Review of the clinical record and the complainant letter showed the patient had a past medical history of pulmonary hemosiderosis (a rare disease characterized by repeated episodes of bleeding into the lungs, which can cause anemia and lung disease) and associated respiratory failure (the capillaries, or tiny blood vessels, surrounding the air sacs can't properly exchange carbon dioxide for oxygen). The patient was admitted to the hospital on 02/19/2018. The patient became progressively worse and the physicians suggested hospice or to let the patient die at the hospital. The family elected to take the patient home on 02/27/18. The patient expired at home the next morning, 02/28/2018 at 4:50 AM. Review of the clinical record failed to show the following documentation: - A respiratory therapist note from 02/27/2018 by RT D; - Final visit note (death) on 02/28/2018 from RN A; and - The initial assessment note dated 02/27/2018 by RN C failed to show the time in and out for the visit. During an interview on 07/21/2020, the assistant clinical director stated that: - The missing documentation could not be found; - The record had to be obtained from the stored off-site area: - The agency was doing paper documentation at that time and there were no other documents to be found; and - The time in and out for the 02/27/2018 was provided from a scheduling log from February 2018.