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
261602 A. BUILDING __________
B. WING ______________ 		11/08/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SEASONS HOSPICE, INC 1831 W MELVILLE ROAD, SPRINGFIELD, MO, 65803
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)
L0500      
31099 Based on policy review, record review, and interview, the agency failed to promote and protect the following patient rights: - If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law (507); and - To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of these deficient practices resulted in a finding of immediate jeopardy for one patient (Patient/Record #3) and has the potential to affect all patients served by the agency.
L0507      
31099 Based on policy review, record review and interview, the agency failed to obtain a copy of the durable power of attorney (DPOA) paperwork and ensure it was included in the patient's chart for the designated legal representative to exercise the patient's rights to the extent allowed by state law. This deficient practice has a potential to affect the exercise of the rights of all patients served by the agency. Review of agency's policy revised September 2021 titled, "Patients Rights And Responsibilities," showed patients have the right to designate a representative to act on his/her behalf, unless judged incompetent and a state appointed representative will act on his/her behalf and can exercise theses rights. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 07/16/2021 with a terminal diagnosis of cardiovascular disease and degenerative disease of nervous system (affect's many of your body's activities, such as balance, movement, talking, breathing, and heart function). Review of the hospice informed consent form showed: - Patient's spouse named as primary caregiver; - Signed and dated 07/16/2021 by the patient's spouse; - Patient unable to sign due to condition; and - I have or I have not executed a DPOA for health care boxes are left blank. Review of the communication note dated 11/03/2021, showed: - Call received from emergency medical system (EMS) requesting a copy of DPOA paperwork; - Primary caregiver cannot locate his/her copy at the moment; - Staff advised EMS that agency can provide a copy and would need to go to the office to get a copy (no copy of DPOA in clinical record); and - Agency staff reminded the EMS that the patient's spouse (caregiver) has every right to refuse transportation to hospital and that the spouse does not have to prove he/she is the DPOA. During an interview on 11/04/2021 at 2:10 PM, findings were reviewed and the administrator stated the patient's spouse repeatedly says he/she has the DPOA paperwork and can't find it.
L0512      
31099 Based on policy review, clinical record review, and interview the agency failed to assure that patients received effective pain management and symptom control from the hospice in one (Records/Patient #3) of three records reviewed. This deficient practice has the potential to affect the pain management of all patients served by the agency. Findings included: Review of agency's policy revised October 2019 titled, "Pain Assessment," showed: - All patients will receive pain assessments; - When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient's condition; - When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: * Pain intensity using a rating scale (on a scale of 0 - 10: 0 = no pain, 10 = unbearable pain). The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain; * Present pain management regimen and effectiveness; * Effects of pain. These include impact on daily life, function, sleep, appetite, relationship with others, emotions, concentration, etc; and - Pain assessments will be part of the comprehensive assessment and will be updated if significant changes occur. Review of agency's policy revised September 2021 titled, "Patients Rights And Responsibilities," showed: - Patients have the right to: *Receive care of the highest quality by receiving effective pain management and symptom control; *Be assured that all medically related hospice care is provided in accordance with the attending physician of their choice and hospice Medical Director orders. * Physician directed (ordered) cares will focus and be attentive to effective pain management and effective symptom control. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 09/30/2021 with a terminal diagnosis of degenerative disease of nervous system (affect's many of your body's activities, such as balance, movement, talking, breathing, and heart function). The patient resides in a long term care facility. Review of the admission physician orders to the long term care facility, dated 9/30/2021, showed the following: - Admission diagnoses: Failure to thrive and hospice admission; - Named (long term care facility) PRN'S (as needed): * Acetaminophen 325 milligrams (mg) two tablets by mouth every four hours as needed for general discomfort, restlessness, or temperature above 100.5; and * Acetaminophen 650 mg one rectally every four hours as needed for general discomfort, restlessness, or temperature above 100.5. Review of the long term care resident progress notes showed: - On 9/30/2021 at 3:47 PM, the patient arrived via emergency medical system (EMS) transfer from hospital at 2:30 PM. Transferred from stretcher to bed via EMS and staff assist. Resident shows signs and symptoms of pain upon turning; and - On 9/30/2021 at 11:36 PM, the patient states he/she has pain in his/her left leg. Gave Tylenol for pain. Will continue to monitor throughout the night. Review of the hospice nursing documentation showed that: - On 09/30/2021 the registered nurse (RN) initial comprehensive assessment showed that the patient was forgetful, confused, alert and oriented times one (to name), disoriented, no meaningful verbal communication, and no pain verbally expressed. The summary documentation showed the patient had pain on the back of his/her legs at times and used Voltaren (topical nonsteroidal anti-inflammatory for pain) gel when he/she had a flare up which usually lasted a few days. Review of the long term care resident progress notes showed: - On 10/04/2021 at 10:53 AM, the patient's son states Voltaren has always been effective at relieving pain and cramping in calf. Also informs on use of tens unit for pain relief. "Pads applied to posterior leg at the bottom of calf, unable to recall setting used", states "It had to be set pretty high before it offered him/her any relief". "Will convey to provider for orders". Review of the hospice nursing documentation showed that: - On 10/04/2021 the RN visit showed: * The Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain Scale was used with pain of 0 (range of 0-10 with 0 representing no pain; * In and out (I&O) catheter (a sterile tube inserted through the urethra into the bladder to drain urine) performed earlier today due to urine retention (inability to completely empty the bladder) of greater than 500 milliliters by facility staff; * Appetite very poor. Patient ate only 10% for lunch; - On 10/07/2021 (no follow up for three days) the RN visit showed: * FLACC pain scale = 9 and pain all the time; * Appetite very poor; * New order for Roxanol (opiod to treat the symptoms of moderate-to-severe acute and chronic pain) 5-10 mg every two hours as needed for pain; * New order for Ativan (anxiety) 0.5 mg (0.25 ml) orally every four hours as needed for anxiety; * Patient continues to have intermittent difficulty voiding; * Assessment documentation showed patient lying in bed with complaint of severe pain in lower back and bilateral legs with any movement. Patient had no pain medications ordered at this time. Physician contacted and orders received for the Roxanol and Ativan. ( No Roxanol was given at visit and the agency failed to follow up with the facility staff and check effectiveness of Roxanol); * Assess and monitor patient's pain level; * Evaluate effectiveness of pain medication; - On 10/11/2021 (no follow up for four days) the RN visit showed: * FLACC pain scale = 9 and pain all the time; * Pain medications (Roxanol and Ativan) ordered on 10/7/2021 and faxed to the pharmacy, but were not put in the facility computer system. Patient had not had any Roxanol or Ativan until 10/11/2021. Will continue to monitor pain management; * Appetite very poor; * Foley catheter placed by facility staff on 10/07/2021 for repeated episodes of urine retention; * Assessment documentation showed patient having a lot of pain at this time. Just touching legs, creates high levels of pain. Spoke with facility staff to see when dose of last pain medications were given. No doses of pain medications were given since being ordered. It was found that orders were faxed to pharmacy and not placed in facility computer. "Dose given during visit with good results"; - On 10/14/2021 (no follow up visit for four days) the RN visit showed: * FLACC pain scale = 10 severe; * Appetite very poor; * Spoke with facility staff. Patient still having a lot of pain and not being given medications as needed. Instructed to monitor patient closely for pain control. Facility staff gave morphine and Ativan during visit; and * Assessment documentation showed patient having pain all over that increases with minimal movement. No pain medications have been given today per the facility staff. Instructions given to make sure patient is being evaluated for pain every two hours and call the hospice agency if current dosage or dosing times are not sufficient. Review of the long term care resident progress notes showed: - On 10/14/2021 at 11:08 AM, the patient showing signs and symptoms of pain. As needed meds given prior to care by hospice. Will continue to monitor. Review of the hospice nursing documentation showed that: - On 10/18/2021 (no follow up visit for four days) the RN visit showed: * FLACC pain scale = 4; * Pain daily but not constantly; * Pain is much better controlled now that patient has been getting as needed doses of pain medication; * Appetite very poor; * Assessment documentation showed patient resting more comfortable in bed since he/she is getting as needed pain medications. Continues to have pain with movement, but much more tolerable; - On 10/21/2021 the RN visit showed: * FLACC pain scale = 10, severe; * Pain all of the time; * Patient has not received any as needed pain medication doses since last visit. Spoke with facility staff. Facility staff administering dose now; * Appetite very poor. Patient eating less than 20 percent of meals; * Assessment documentation showed patient lying in bed with complaint of pain. Unable to turn patient at this time due to the amount of pain he/she has in bilateral legs. Spoke with facility staff concerning patient pain level. After review of medication administration record (MAR) it was noted that patient has not had an as needed dose of pain medication in over two days. Facility staff was instructed that patient needs to be evaluated every two hours for pain. Patient also has Ativan that can be given as well. Facility staff stated that he/she will report this and also add to his/her report sheet to make sure patient is getting his/her medication as needed. Patient was comfortable after medication received. Patient had a FLACC of five by end of visit; - On 10/25/2021 (no follow up visit for four days) the RN visit showed: * FLACC pain scale = 10, severe; * Pain all of the time; * Patient has not received any as needed pain medication doses since Saturday. Spoke with facility staff and he/she administered pain medication; * Appetite very poor. Patient eating less than 20 percent of meals; and * Assessment documentation showed patient lying in bed complaint of pain in bilateral legs. Patient yelling out in pain when turned to clean him/her. Per facility nurse, patient has not received as needed pain medication since Saturday. Per facility director of nursing, he/she will talk with patient's primary care physician about getting scheduled pain medications so patient's pain can remain under control. Patient is cooperative with assessment. Alert and orientated with self and son. Poor short term memory. Pain level had decreased to a FLACC of five and appears to be much more comfortable even with movement. Educated facility staff on the importance of pain control and assessments. Review of the physician progress note on 10/25/2021 showed the patient is having enough pain to require frequent use of sublingual morphine. He/she is still remaining in bed and not demonstrating much functional capacity at all. Plan is since he/she appears to be uncomfortable and he/she states "all over", we will add a single starting dose of morphine 15 mg extended release at bedtime and see how well he/she tolerates this. If this is well tolerated and he/she still requires frequent sublingual dosing during the day, we will then increase to every 12 hours. Review of the physician's nurse practitioners progress note on 10/28/2021 showed chronic pain-uncontrolled and plan to increase morphine ER 15 mg from ever HS (bedtime) to twice a day as patient is still in significant pain. Review of the hospice nursing documentation showed that: - On 10/28/2021 (no follow up visit for three days) the RN visit showed: * FLACC pain scale = 10, severe; * Pain all of the time; * Patient continues to have increased pain even with morphine sulfate ER 15 mg at bedtime. New orders received. As needed morphine and Ativan given by facility nurse; * Appetite very poor. Patient eating less than 20 percent of meals; * Assessment documentation showed patient lying in bed complaint of extreme pain with minimal movement. Patient drowsy and falls asleep easily when not being moved. Spoke with nurse practitioner for patient's physician about patients continued pain issues, new orders received. After patient received pain medications, pain level decreased to a FLACC of five. Educated facility nurse on frequent monitoring of pain control and giving appropriate pain medications; * New orders for routine pain medication of morphine sulfate extended release 15 mg twice a day, narcan 0.4 mg as needed for over sedation and gabapentin 100 mg twice a day for nerve pain in legs; - On 11/01/2021 (no follow up visit for four days) the RN visit showed: * FLACC pain scale = 10, severe; * Pain all of the time; * Patient continues to moan and grimace with movement. Patient not responsive to verbal stimuli. As needed pain medications given at this time by facility nurse; * Patient not eating at this time. Patient did cough with fluids that were given by facility staff and family; and * Assessment documentation showed patient lying in bed with son at bedside. Son states that patient was slightly more alert earlier and he gave him/her some thickened water and patient coughed afterwards. Patient not responding to verbal or tactile stimulation, but does respond to pain. Patient's pain level decreased to FLACC of six by end of visit. Requested to facility staff that patient receives another dose of as needed pain medication when it is due to help further control pain. Facility nurse agreed to pain plan. Review of the physician progress note on 11/01/2021 showed the patient appears to be transitioning in that he/she is really just not eating or drinking. He/she exhibits a pain response with a minimal amount of movement. Plan is to discuss with the patients son, but hold his medications by mouth except for comfort medications and going to have to switch him from the extended-release morphine to fentanyl patch. Review of the long term care resident progress notes showed: - On 11/01/2021 at 4:20 PM, new order received and noted from the patient's physician. Discontinue meds by mouth except Roxanol, Ativan and atropine. Discontinue Morphine SR 15 and switch to Fentanyl 25 microgram (mcg) patch every 72 hours, increase as needed Roxanol to 10 mg (0.5 ml) sublingual every one hour as needed, increase as needed Ativan Intensol to 0.25-0.5 ml (0.5-1 mg) every two hours as needed restlessness. Review of the hospice nursing documentation showed that: - On 11/02/2021 the RN visit showed: * FLACC pain scale = 5, medium; * Pain all of the time; * Patient continues to moan and grimace with movement. Patient not responsive to verbal stimuli; * Assessment documentation showed patient moaning intermittently during assessment, wet secretions in upper airway auscultated. Foley catheter has about 50 cc dark tea colored urine. Patient has pulse 95-101 and does not appear to be comfortable. Discussed medications with facility nurse and he/she agrees to administer comfort medications including atropine at this time. Patient appears comfortable at end of visit, facility nurse denies any new needs or concerns; - On 11/03/2021 the RN visit showed: * FLACC pain scale = 7; * Pain all of the time; * Patient continues to moan and grimace with movement. Patient not responsive to verbal stimuli. Patient given as needed morphine and as needed Ativan at this time; and * Assessment documentation showed patient lying in bed on right side. Pressure sore noted on left ear, left hip and left foot. Patient moans loudly even when just moving the sheets off legs. Patient's physician at bedside to assess patient. No new orders at this time. Patient's pain level is FLACC of 4 by end of visit. Patient is now in active dying process. Will continue to keep patient on daily visits. Review of the long term care resident progress notes showed on 11/04/2021 at 11:18 AM, this nurse called to the patient's room by RN from hospice. The patient passed away as evidenced by cessation of vital signs at 11:14 AM. During an interview on 11/04/2021 at 11:18 AM, the administrator stated the following: - The case manager talks to the patient's physician to order pain medications; - The case manager collaborates with the facility where patient resides; - The hospice staff ensure medications are on site and effective with visit, collaborating with the facility staff; and - Hospice staff should have followed up the same day or the next day after ordering pain medications. During an interview on 11/04/2021 at 12:45 PM, the administrator stated it was an effort to work with the facility and it was missed by the case manager to follow up. There was no documentation of follow-up and no other visits other than what was given.