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
261598 A. BUILDING __________
B. WING ______________ 		01/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
LEGACY HOSPICE, LLC 607 BILLINGTON, KENNETT, MO, 63857
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)
L0530      
31099 Based on policy review, record review, home visit observation, and interview the agency failed to maintain a complete/accurate medication profile in one of four records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency medication profile policy showed in part the following: -The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications; -A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication; and -During home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: Using the medication profile to evaluate the use of the drugs in the home settings. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. Using the medication profile as a communication tool for other clinicians involved in care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice service on 11/26/2018. The patient resided in a long term care facility (LTCF). Review of the LTCF medication administration record (MAR), dated January 2021, showed the following discrepancies with the current hospice medication profile: -The hospice medication profile showed an order dated 07/24/2019 for Lexapro (used to treat depression and generalized anxiety) 5 milligram (mg) daily. The LTCF MAR showed no order for Lexapro; -The hospice medication profile showed an order dated 09/02/2020 for Ativan (sedative) 0.5 mg daily. The LTCF MAR showed no order for Ativan; -The hospice medication profile showed an active order dated 11/03/2020 for Cefdinir (antibiotic) 300 mg twice a day for 7 days; and -The LTCF MAR showed an order dated 11/17/2020 for Nystatin (antifungal) 100,000 units powder apply to buttocks three times a day and as needed. The hospice medication profile did not include the order for the Nystatin. During an interview on 01/12/2021 at 9:15 A.M., hospice RN A said the following: -Medications should be reconciled at least weekly; and -The patient was no longer on Cefdinir and it should have been discontinued from the hospice medication profile. During an interview on 01/13/2021 at 4:40 P.M., hospice branch manager said the following: -The medication list should be reconciled at every interdisciplinary team meeting (IDT) meeting, which is every two weeks. During an interview on 01/14/2021 at 11:00 A.M., the hospice administrator said the following: -Medications should be reconciled with every visit.
L0578      
31099 Based on agency observation, policy review, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: On 01/11/2021 at 03:40 PM, the surveyor approached the outer doors of the agency's office. Observation failed to show any signage to visitors or staff to show visitation restrictions and screening procedures for COVID-19. There failed to be signs to individuals with symptoms of a respiratory infection to put on a mask, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions. After entering the agency, there failed to be any type of screening of visitors for COVID-19 signs and symptoms. The staff were not wearing masks or complying with social distancing requirements. Review of the "Center for Medicare and Medicaid Services (CMS), Ref: QSO-20-16-Hospice," dated March 9, 2020 provided by the agency for the COVID-19 policy, showed in part the following: - Screen visitors and patients by asking if there has been any international travel within the last 14 days to countries with sustained community transmission; - Screen for signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat; - Ask, in the last 14 days, has had contact with someone with or under investigation for COVID-19, or are ill with respiratory illness; - Ask if residing in a community where community-based spread of COVID-19 is occurring; and - Monitoring or restricting staff or hospice volunteers should be completed by performing the same screening for patients and visitors. During an interview on 01/13/202 at 10:11 AM, RN B said staff check their temperatures when they arrive for work every day, but they do not keep a log. During an interview on 01/13/2021 at 10:50 AM, the administrator stated: - Staff (nurse and aides) screen themselves at home and self-report any abnormalities to the office; - Visitors are screened with a temperature check in the front office and it is reported if any abnormalities; - There is a screening tool on the agency's website the employees use to document date, temperature, if they have a cough, any shortness of breath, and if a sore throat; - Each office has a COVID-19 binder and the employees call in each morning and office manager or administrator documents the screening; - Staff call in if they have any abnormalities such as a temperature of 99 degrees Fahrenheit or above; - Visitors that enter the office should have temperature and same screening tool completed as the staff; - The surveyors were not screened on Monday due to some staff at front desk and branch administrator were gone on training and the aide at the facility did not know to complete the screening; - He/she did not have an answer to why the surveyors were not screened on Tuesday when entered the building; - He/she would expect staff to wear mask at all times in the agency unless in the office and maintain six foot distance apart; and - He/she would expect signage on the office door about COVID-19 and not to enter with any symptoms.
L0677      
31099 Based on policy review, record review, and interview the hospice provider failed to ensure each patient's record included accurate advance directives in one of two records reviewed (Record/Patient #1). Patient that elected a Do-Not-Resuscitate (DNR) status at a long term care facility (LTCF) was incorrectly identified as Full Code on hospice agency orders. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Advance Directives," dated as revised April 2020, showed in part the following: -To support the implementation of the Patient Self-Determination Act within the framework of state and federal law and organization policies; -The agency recognizes that all adult persons have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. It is the policy of the agency to encourage individuals and their family/caregivers to participate in decisions regarding care, treatment, and services; and -It is the organization's policy that: "In the event of cardiac or pulmonary arrest, cardiopulmonary resuscitative measures will be promptly initiated unless a Do Not Resuscitate/Do Not Intubate (DNR/DNI) order has been written by the physician in charge and documented in the patient's clinical record. RECORD/PATIENT #1: Review of clinical record showed the patient was admitted to hospice services on 11/26/2018. The patient resided in a long-term care facility. This patient signed a Full Code order on 11/26/2018. Review of the patient's LTCF records showed the patient as a DNR. During an interview on 01/12/2021 at 9:15 A.M., hospice RN A said the patient was a DNR and she was unsure why the hospice records showed the patient as a Full Code. Review of the LTCF patient's Advance Health Care Directive Form showed the patient as a DNR signed and dated on 06/13/2019. During an interview on 01/13/2021 at 11:00 A.M., the hospice administrator said the hospice agency record should be accurate and reflect the patient's wishes.