Survey Report for 261593

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	261593	A. BUILDING __________ B. WING ______________	11/10/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
HOSPICE COMPASSUS-JOPLIN	2216 E 32ND STREET, SUITE 201, JOPLIN, MO, 64804
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
L0536	17006 Based on policy review, record review and interview the agency failed to: - Develop an individualized plan of care (L545); - Ensure the plan of care included accurate/updated medication orders and profile (L549); and - Provide care and services based on all assessments of patient and family needs (L556). The cumulative effect of these deficient practices has the potential to affect the delivery of safe, effective care for all agency patients.
L0545
L0545	17006 Based on policy review, record review, and interview, the agency failed to ensure the agency developed an individualized plan of care (POC) in two (Record/Patient #1 and #2) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Written Interdisciplinary Plan of Care," revised 09/27/2019, showed in part: - The agency utilized an interdisciplinary approach to the development, implementation, and evaluation of the individualized POC for each patient. The interdisciplinary group (IDG/IDT) will ensure the provision of care and services according to the POC and that the POC reflects updated patient and family/caregiver needs as determined in the updated comprehensive assessments; - Care is provided to the patient in accordance with the plan; - The content of the plan includes at a minimum an assessment of the patient and family's needs and goals, an identification of the services to be provided, including management of symptoms, detail of the scope and frequency of services necessary to meet the assessed needs safety measures, measurable goals and outcomes for planned interventions; - Staff assignments based on the plan of care will be managed by the director of clinical services or designee according to the identified needs of the patient/family as documented in the comprehensive POC; and - The IDG, in collaboration with the hospice physician and patient's attending physician reviews and updates the POC at least every 15 days or more often as needed as dictated by the patient's condition. Review of the agency policy titled, "Individualized Plan of Care," revised 01/20/2020, showed in part: - The initial POC is intended to address areas of immediate concern based on the initial assessment completed by the RN (registered nurse); - The comprehensive POC developed by the members of the IDG team upon completion of all elements of the comprehensive assessments as described in other policies/procedures; - The updated POC; revisions to the comprehensive POC based on assessment information gathered over the period of time between the last review and the current as well as documentation of the plan going forward for the next 14 days; and - The POC is the complete treatment plan that provides the pathway for the hospice IDG to follow in providing care that is based on the initial and comprehensive assessments of the patient by all of the members of the IDG team as well as input from the patient and/or caregiver as appropriate. Review of the agency policy titled, "Written and Verbal Orders," revised 08/22/2018, showed in part the agency ensures properly recorded orders are in place for the provision or administration of medications, biologicals, durable medical equipment, and treatments. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Co-morbidities included atrial fibrillation (heart arrhythmia) and long term use of anticoagulants (blood thinning medications); - The patient took an anticoagulant; - Hematopoietic assessment (evaluation of a patient's medications and risk factors for clotting or bleeding) showed no problems identified; and - No information regarding who was managing the patient's anticoagulant and PT/INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted, normal PT range 11.0-13.5 and normal INR range for patients on warfarin is 2.0 to 3.0) monitoring. Review of the POC dated 04/01/2021 showed: - The patient took warfarin (blood thinning medication) six milligrams (mg) daily; - Safety measures included bleeding/anticoagulant precautions; - No specific interventions regarding assessment for anticoagulant complications; and - No information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of the IDG comprehensive assessment and POC update report dated 04/09/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of the IDG comprehensive assessment and POC update report dated 04/23/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of a physician order dated 04/28/2021 showed an order to obtain a PT/INR per fingerstick and notify the physician of results. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 under the section for orders since last IDG showed the previous order for a PT/INR on 04/28/2021. On 04/28/2021 prothrombin time less than 23.2 and INR less than 1.9. Review of the RN recertification assessment note dated 06/17/2021 showed: - The patient had a diagnosis of hypertensive heart disease. Co-morbidities included long term use of anticoagulants; - No problems identified with the hematopoietic and integumentary assessment; and - No information regarding who was managing the patients anticoagulant monitoring. During an interview on 11/09/2021 beginning at 2:10 PM, when asked whether the assessments and POC should address who is monitoring the patient's anticoagulant, the director of quality outcomes stated that they got an order for a PT/INR on 04/28/2021. RECORD/PATIENT #2: Review of the physician certification dated 12/15/2020 showed the patient had a terminal diagnosis of hypertensive heart disease complicated by respiratory failure, chronic kidney disease and thromboembolic disease which contributes to the patient's decline. The patient is oxygen dependent on five liters of oxygen. Review of the RN start of care assessment dated 12/15/2020 showed: - The patient was on five liters of continuous oxygen; - No edema (swelling); - High risk for falls; - Had an indwelling urinary catheter (a tube inserted into the bladder to drain urine) 16 french (size of catheter)/10 milliliter (ml, the amount of water inserted into the catheter to inflate a balloon at the end of the catheter) that was inserted on 12/08/2020; - Date of scheduled catheter change - monthly; and - Interventions provided showed instructions on catheter care, initiated fall precautions with instruction given to patient/caregiver to minimize incidence of falls. Review of the POC dated 12/15/2020 showed: - Observe and assess genitourinary pattern and teach/reinforce care of catheter, instruct patient/caregiver regarding irrigation of catheter, instruct regarding catheter removal; - No orders regarding irrigation, changing of the catheter or catheter size; - Safety measures showed high fall risk precautions but no specific interventions to address fall risk; and - No oxygen order. Review of physician standing orders dated 12/16/2020 showed: - May insert a 16 french/30 ml balloon indwelling Foley catheter as needed for chronic urinary retention or incontinence with discomfort; - Change every 30 days or sooner due to occlusion or sign of infection; and - May irrigate Foley catheter with 60 mls saline (salt solution) as needed to maintain catheter patency. Review of the hospice IDG comprehensive assessment and POC update report dated 12/18/2020 showed: - The RN note showed the patient was on oxygen at six liters per minute (the start of care assessment and physician certification showed five liters per minute); - The patient was dependent on a Foley catheter for urination; and - No orders/interventions for irrigation, changing of catheter or catheter size. Review of a LPN visit note dated 12/29/2020 showed the patient was on six liters of oxygen per minute. Review of an RN visit note dated 01/08/2021 showed: - Indwelling Foley catheter size 16/10; - Indicate catheter insertion date - 01/08/2021 (unsure if this meant the original insertion date of 12/08/2020 as indicated on the start of care assessment or if this meant the catheter was changed this day. No further documentation to indicate that a catheter change was performed on 01/08/2021); - Indicate date of scheduled catheter change - 30 days from insertion date; - The patient used oxygen at four liters (the start of care assessment and physician certification showed five liters per minute) per minute. Review of a LPN visit note dated 01/13/2021 showed the patient used oxygen at three (another change from what was previously indicated) liters per minute. Review of the hospice IDG comprehensive assessment and POC update report dated 01/15/2021 showed: - No oxygen orders; and - No orders for catheter irrigation, catheter changes or size of the catheter. Review of a LPN visit note dated 01/19/2021 showed the Foley catheter was changed. Patient tolerated. No documentation regarding what size catheter was used. Review of a discharge-transfer summary report dated 01/25/2021 showed the patient and spouse requested to come off hospice. He/she discussed with their physician last week that the patient has improved and is now walking and doesn't feel they need hospice services any longer. The patient has a follow up appointment with his/her urologist on 02/05/2021 regarding the indwelling urinary catheter. The patient was on oxygen at four liters per minute and the oxygen orders will be managed by the patient's attending physician. During an interview on 11/09/2021 beginning at 3:30 PM the director of quality outcomes stated that the interventions provided for falls on the start of care assessment should have flowed to the POC. There should be an order for catheter changes. The regional director of operations stated that they have standing orders for catheter changes. They would need to write the order and it would update to the POC.
L0549
L0549	17006 Based on policy review, record review, and interview, the agency failed to ensure the plan of care was updated and the medication profile was accurate in two (Record/Patient #1 and #2) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Written and Verbal Orders," revised 08/22/2018, showed in part: - The agency ensures properly recorded orders are in place for the provision or administration of medications; - If the order is verbal the individual receiving the order must record and sign it immediately and have the prescribing person sign it in accordance with state and federal regulations; and - When a standing order is implemented, the nurse notifies the physician of the start date and documents this in the clinical record. Review of the agency policy titled, "Nursing Services," revised 09/16/2021, showed in part: - The agency provides nursing care and services under the supervision of a registered nurse (RN). Nursing services ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments; - Nursing services include evaluation and review of medication regimen including inventory, management and disposal; and - Implementation of the plan of care (POC) and recommendations for revision to the POC based on assessment data. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Review of a licensed practical nurse (LPN) visit note dated 04/09/2021 showed the patient had mucus in his/her throat that he/she could not clear. Used standing orders for Mucinex (thins mucus to make it easier to clear). Review of the physician orders showed no order for Mucinex. Review of the IDG comprehensive assessment and POC update report dated 04/09/2021 showed no update of the POC or medication profile to include an order for Mucinex. Review of a coordination note report dated 05/06/2021 showed a follow up pain note because the patient was still having pain and went to the walk in clinic on 05/05/2021. The caregiver told the nurse the clinic thought the pain was due to arthritis. The patient was using Voltaren (nonsteroidal anti-inflammatory) cream and Aleve (nonsteroidal anti-inflammatory) for pain and inflammation. The caregiver said the patient did not want to use anything stronger right now and the pain was a little better. Review of the physician orders showed no order for the Voltaren gel and Aleve. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 showed: - The patient injured his/her arm around 05/02/2021 by trying to brace a door. The patient went to the walk in clinic and they informed him/her it was arthritis. The patient was using Voltaren gel and Aleve to manage pain. The patient doesn't want to take any opioids (narcotic pain medication) for the pain; and - No update to the POC/medication profile to include an order for the Voltaren gel or Aleve. During an interview on 11/09/2021 beginning at 2:10 PM, the director of quality outcomes stated that when the clinician writes an order the medication profile is updated at that time. The RN updates the orders on the POC. He/she did not see an order to update the medication profile. RECORD/PATIENT #2: Review of an RN visit note dated 12/22/2020 showed: - The patient had 4+ edema (when the skin is pressed it leaves a deep indentation) to the right and left lower extremity/ankle; - The patient voiced he/she was concerned about the edema; and - The family voiced they would like to change to warfarin (blood thinning medication) instead of Eliquis (blood thinning medication). The nurse voiced he/she would call the physician's office. Review of a coordination note dated 12/22/2020 showed the nurse called in regards to transferring from Eliquis to warfarin. Message left. Review of a coordination note dated 12/23/2020 showed the nurse called to update about medications. No documentation of what medications he/she referred to. Review of the physician orders showed an order dated 12/29/2021 to draw a monthly INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted). Review of a LPN visit note dated 12/29/2020 showed no changes in medication. Review of the hospice IDG comprehensive assessment and POC update report dated 01/01/2021 showed: - The patient was switched from Eliquis to warfarin and the patient was also on a diuretic due to edema; and - The POC medication list/medication profile was not updated with a new order for warfarin or a diuretic. Review of the physician orders showed no orders to discontinue the Eliquis and start warfarin or an order for a diuretic. Review of an RN visit note dated 01/08/2021 showed refills of furosemide (diuretic, helps to decrease edema) and potassium chloride (supplement) called into the pharmacy. Review of the hospice IDG comprehensive assessment and plan of care update report dated 01/15/2021 showed the POC medication list continued to show the patient took Eliquis and no update or orders for warfarin, furosemide or potassium chloride. During an interview on 11/09/2021 beginning at 3:30 PM the director of quality outcomes stated that he/she would expect there to be an order for medication changes and the changes should flow to the medication profile and POC. He/she did not see orders for the medication changes or updates to the POC.
L0556
L0556	17006 Based on policy review, record review, and interview, the agency failed to ensure that care and services were coordinated and provided based on all assessments of the patient and family needs for one (Record/Patient #1) of four records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Continuation of Care and Services," revised 12/03/2021, showed in part, the agency maintains a consistent approach to the delivery of care and services necessary to meet the needs of the patients on a 24 hour basis seven days per week. Nursing services, physician services, and drugs and biologicals are routinely available 24/7. Other services are made available to the patient and family when necessary to meet identified needs. Review of the agency policy titled, "Nursing Services," revised 09/16/2021, showed in part: - The agency provides nursing care and services under the supervision of a registered nurse (RN). Nursing services ensure that the nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment and updated assessments; - The RN conducts nursing assessments for all patients at the time of admission and routinely as part of the comprehensive assessment and plan of care process. The Licensed Practical/Vocational Nurse (LPN, LVN) conducts focused assessments intended to gather patient data to support the RN in the ongoing management of the patient's plan of care. An RN is available by phone anytime an LPN/LVN is providing patient care services; - Nursing services are available 24 hours per day, 7 days per week; - Nursing services provided outside of normal business hours will be prioritized based on the urgency of patient/family need. It is expected that all care is delivered in a timely manner and that communication is provided to the patient/family regarding an estimated arrival; and - Nurses will maintain a complete and accurate record of all care provided including assessments, clinical notes, and updates to the POC. RECORD/PATIENT #1: Review of the RN start of care assessment dated 04/01/2021 showed in part the patient had a primary diagnosis of hypertensive heart disease without heart failure (heart disease caused by high blood pressure). Co-morbidities included atrial fibrillation (heart arrhythmia) and long term use of anticoagulants (blood thinning medications); - The patient took an anticoagulant; - Integumentary (skin) assessment showed no problems identified; - Hematopoietic assessment (evaluation of a patient's medications and risk factors for clotting or bleeding) showed no problems identified; and - No information regarding who was managing the patient's anticoagulant and PT/INR (a laboratory test to determine if your anticoagulant is working the way it should, whether your blood is clotting normally and whether your anticoagulant dosage needs to be adjusted, normal PT range is 11.0-13.5 and normal INR range for patients on warfarin is 2.0 to 3.0) monitoring. Review of the plan of care (POC) dated 04/01/2021 showed: - The patient took warfarin (blood thinning medication) six milligrams (mg) daily; - Safety measures included bleeding/anticoagulant precautions; - No specific interventions regarding assessment for signs of anticoagulant complications; and - No information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of an RN visit note dated 04/06/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae (tiny round brown-purple spots due to bleeding under the skin which may be in a small area due to minor trauma or widespread due to a blood clotting disorder). The assessment failed to include any specific information regarding the petechiae. Review of a LPN visit note dated 04/09/2021 and 04/16/2021 showed no problems identified with the hematopoietic or integumentary assessment. Review of an RN visit note dated 04/20/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information regarding the petechiae. Review of an LPN visit note dated 04/23/2021 showed no problems identified with the hematopoietic and integumentary assessment. Review of the IDG comprehensive assessment and POC update report dated 04/23/2021 showed no information regarding who was managing the patient's anticoagulant and PT/INR monitoring. Review of a physician order dated 04/28/2021 showed an order to obtain PT/INR. Review of an LPN visit note dated 04/28/2021 showed: - No problems identified with the hematopoietic and integumentary assessment; and - PT/INR performed and results (no documentation of what the results were) called to the physician. Review of an LPN visit note dated 04/30/2021 showed no problems identified with the hematopoietic and integumentary assessment and no medication changes. Review of an RN visit note dated 05/04/2021 showed: - The patient told the nurse the day before he/she hurt his/her right arm biciep area trying to brace a lock bar against the door that led to the garage. The patient rated his/her pain a seven (pain is rated on a scale of zero to ten with zero meaning no pain and ten meaning the worst pain). We applied a heating pad and the patient took Tylenol. Before the nurse left the patient stated that he/she had relief from his/her pain and was comfortable. No description of what the arm looked like or whether any bruising present; - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; - Integumentary assessment included petechiae but no specific information related to the petechiae; and - No medication changes. Review of a coordination note report dated 05/06/2021 showed a follow up pain note because the patient was still having pain and went to the walk in clinic on 05/05/2021. The caregiver told the nurse the clinic thought the pain was due to arthritis. The patient was using Voltaren (nonsteroidal anti-inflammatory) cream and Aleve (nonsteroidal anti-inflammatory) for pain and inflammation. The caregiver said the patient did not want to use anything stronger right now and the pain was a little better. Review of the IDG comprehensive assessment and POC update report dated 05/07/2021 under the section for orders since last IDG showed the previous order for a PT/INR on 04/28/2021. The vital sign summary report showed on 04/28/2021 prothrombin time less than 23.2 and INR less than 1.9. No information or orders regarding when the next PT/INR would be due. Review of an LPN visit note dated 05/07/2021 showed: - No problems identified with the hematopoietic assessment; - The clinician documented the integumentary was not assessed due to not appropriate at time of evaluation (unsure of what this means); - No medication changes; - The patient denied pain and ambulated independently; and - No specific information regarding the injury to the right arm. Review of an RN visit note dated 05/11/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information related to the petechiae. Review of an LPN visit note dated 05/13/2021 and 05/18/2021 showed no problems identified with the hematopoietic and integumentary assessment. On 05/18/2021 the patient and caregiver agreed that once a week visits would be better for them. Review of an LPN visit note dated 05/25/2021 showed: - The section for endocrine/hematopoietic assessment showed diabetes was assessed but no documentation related to a hematopoietic assessment; and - Integumentary assessment included petechiae but no specific information related to the petechiae. Review of an RN visit note dated 06/03/2021 and 06/10/2021 showed no problems identified with the hematopoietic and integumentary assessment. Review of an RN recertification assessment note dated 06/17/2021 showed: - The patient had a diagnosis of hypertensive heart disease. Co-morbidities included long term use of anticoagulants; - No problems identified with the hematopoietic and integumentary assessment; and - No information regarding who was managing the patients anticoagulant. Review of the physician orders showed an order dated 06/22/2021 for an emergent prn (as needed) visit. Review of an LPN prn (as needed) visit dated 06/22/2021 showed: - The visit was initiated by the caregiver; - Chief complaint or problem as presented by patient and/or caregiver - Bruising; - Endocrine/hematopoietic assessment - Excessive bleeding or bruising right upper arm and left hand; - Care coordination - Indicate if you communicated with other disciplines involved in this case - No; - The narrative portion showed the patient had bruising on the right arm. Ribs sore like may be bruised. Last PT/INR was 3.2 (unsure of when this referred to); - Will return in the AM to complete PT/INR due to clinic not being able to get patient in; and - No documentation that the physician or RN case manager was notified of the bruising or whether orders were obtained for the PT/INR. Review of the record showed a physician order dated 06/23/2021 at 11:49 AM for a PT/INR related to Coumadin (anticoagulant) use. Review of a client coordination note report dated 06/23/2021 documented by the director of clinical services (DCS, who no longer worked for the agency) showed: - 10:30 AM - Spoke to family member this AM regarding the patient's PT/INR. The patient to have PT/INR done by hospice nurse. The family member stated that he/she thought the nurse would be there first thing that morning. Explained that the staff had a brief meeting, then the nurse was going to pick up lab supplies, then would be out; - 12:30 PM the family member called the RN case manager and was upset the nurse had not made it to do the lab draw. The RN explained he/she was on his/her way as he/she had to wait for an order and pick up the supplies. The family member stated that he/she could take care of the patient his/herself and wanted to revoke (discontinue) services immediately. He/she said he/she was going to take the patient to the clinic. The DCS attempted to call the family member but no answer. The RNCM will take the revocation paperwork to the patient this day. During an interview on 11/09/2021 beginning at 1:00 PM LPN A stated that he/she saw the patient on 06/22/2021. The caregiver had tried to get the patient in to see the doctor. LPN A stated that he/she notified the DCS. When asked if he/she documented that anywhere, he/she could not recall but it should have been that day. The patient was supposed to have a PT/INR every 30 days (there was no physician order for this). He/she did not notify the physician or clinic because they already had an order for PT/INRs. During an interview on 11/09/2021 beginning at 2:10 PM, the director of quality outcomes stated that on 06/22/2021 he/she would have expected the nurse to notify the physician of the patient's bruising.