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
261613 A. BUILDING __________
B. WING ______________ 		02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ALTERNATIVE HOSPICE, LLC 1749 GILSINN LANE, FENTON, MO, 63026
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)
L0533      
42078 Based on agency policy, facility record review, and agency record review, the agency failed to assure that the comprehensive assessment contained the patient's progress toward desired outcomes and reassessment of the patient's response to care in, but not limited to, one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect the comprehensive assessment of all of the agency's patients. Findings included: Review of the agency policy, revised 2017 and titled, "Reassessments/Update to the Comprehensive Assessment," showed that: - The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (IDG) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as, a reassessment of the patient's response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The update to the comprehensive assessment will include changes in physical, psychosocial, emotional, and spiritual needs; and - Staff will additionally reassess each patient with each home visit on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided. Such reassessments will be documented on discipline-specific visit notes. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a skilled nursing facility. Review of the facility documents dated 11/01/2021 to 11/30/2021 and titled, "eTAR," showed that a change in the plan of care occurred on: - 11/22/2021, and included treatment orders to check boot-style heel protector placement each shift; * The facility record showed documentation that the staff provided the treatment daily from 11/23/2021; and - 11/22/2021, and included treatment orders to monitor the left second toe for worsening bruise; * The facility record showed documentation that the facility staff monitored the area every shift until the order was discontinued on 01/13/2022, following surgical amputation of the digit. Review of the agency document dated 12/02/2021 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 11/22/2021 for the use of a foam dressing or waffle boot to left heel for prevention, and monitoring of the left second toe for worsening bruise. The IDT Plan of Care update documentation for problems with the skin showed, "Skin warm dry and intact without problems reported or assessed; will cont to assess." Review of the facility documents dated 12/01/2021 to 12/31/2021 and titled, "eTAR," showed that a change in the plan of care occurred on: - 12/21/2021, and included treatment orders to apply a foam dressing or waffle boot to the left heel for prevention; * The facility record showed documentation that the staff provided the treatment three times per day until the order was discontinued on 01/13/2022; and - 12/21/2021, and included treatment orders to cleanse the area on the left heel with wound cleanser, apply betadine (a topical antiseptic), and cover with Mepilex (a foam dressing) daily and as needed; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued on 01/06/2022. Review of the agency document dated 12/30/2021 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 12/21/2021 for the use of boot-style heel protectors and cleansing of the left heel with wound cleanser, application of betadine, and covering with Mepilex daily and as needed. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont [continue] to assess." Review of the facility documents dated 01/01/2022 to 01/31/2022 and titled, "eTAR," showed that a change in the plan of care occurred on: - 01/06/2022, and included treatment orders to cleanse the area to the left heel with wound cleanser and cover with Mepilex daily and as needed; * The facility record showed documentation that the staff provided the treatment until the order was discontinued 01/11/2022; - 01/10/2022, and included treatment orders to cleanse the second digit of the left toe with wound cleanser, and apply dry gauze dressing every other day; * The facility record showed documentation that the facility staff provided the treatment until the order was discontinued 01/17/2022; and - 01/11/2022, and included treatment orders to cleanse the area to the left heel with wound cleanser and cover with Mepilex daily and as needed. Review of the agency document dated 01/13/2022 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 01/10/2022, cleansing of the second digit of let toe with wound cleanser, apply a dry gauze dressing, change every other day and as needed, 01/11/2022 application of a Mepilex bandage to the left heel daily and as needed. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont to assess." Review of the facility documents dated 01/01/2022 to 01/31/2022 and titled, "eTAR," showed that a change in plan of care occurred on: - 01/14/2022, and included treatment orders to cleanse open area to coccyx with wound cleanser, and pat dry. Apply honey gel (a wound treatment that contains honey), Xeroform (a medicated gauze), 4x4, and island dressing once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/14/2022; - 01/14/2022, and included treatment orders to paint the necrotic (area of dead tissue) area to left heel with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/14/2022; - 01/14/2022, and included treatment orders to apply skin prep to shear wound (a wound caused by sliding against a surface) to left dorsal (top) foot once daily; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued 01/27/2022; - 01/21/2022, and included treatment orders to paint the left great toe with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment daily until the order was discontinued on 01/27/2022; and - 01/27/2022, and included treatment orders to paint left foot including toes with betadine once daily; * The facility record showed documentation that the facility staff provided the treatment beginning 01/27/2022. Review of the agency document dated 01/27/2022 and titled, "IDT Plan of Care Update," failed to contain updates to the hospice plan of care for facility orders dated 01/14/2022 for cleansing of open area to coccyx with wound cleanser, pat dry, apply honey gel, Xeroform, 4x4, and island dressing once daily and painting the necrotic area to left heel with betadine once daily. The IDT Plan of Care Updated documentation for problems with the skin showed, "skin warm dry and intact without problems reported or assessed; will cont to assess." The findings were reviewed with the administrator on 02/04/2022 at 04:00 PM and no further documentation was provided prior to the survey exit.
L0579      
42078 Based on agency policy and home visit observation, the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one (Record/Patient #3) of one home visit observation performed. This deficient practice has the potential to affect infection control practices for all of the agency's patients. Findings included: Review of the agency policy revised in 2017 and titled, "Equipment Maintenance: Staff Equipment," showed that: - A sturdy canvas bag or a rolling duffel bag is often needed for housing and transporting patient care items such as stethoscope, blood pressure cuff, thermometer, etc.; - All items in the bag are considered clean and the principles of asepsis are followed in the delivery of care; and - A barrier such as a plastic bag or newspaper must be placed between the bag and the surface on which it is placed. RECORD/PATIENT #3: During a home visit observation on 02/04/2022 at 01:00 PM, the registered nurse: - Performed the patient assessment using the equipment (blood pressure cuff, stethoscope, thermometer, etc.); - Failed to clean the equipment before putting it into his/her uniform pocket; - Removed the equipment from his/her pocket; - Cleansed the equipment; and - Placed the equipment back into his/her soiled uniform pocket.
L0759      
42078 Based on policy review, clinical record review, and interview, the agency failed to ensure that coordination of care with the long term care facility (LTCF) was effective when the hospice failed to: - Ensure that the agency assumed responsibility for professional management of the resident's hospice services (L762); and - Ensure that changes in the plan of care were discussed with the patient or representative, and facility staff (776). The cumulative effect of these systemic practices resulted in the agency's inability to effectively provide care and services to hospice patients that reside in a LTCF.
L0762      
42078 Based on policy review, facility record review, agency record review, home visit observation, and interview the hospice provider failed to maintain professional management of hospice patient's plan of care in two (Records/Patients #2 and #3) of three records reviewed for patients residing in a skilled nursing facility (SNF). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy, revised March 2013, and titled, "Care to Residents of a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/MR (Intermediate Care Facility/Mental Retardation) showed, in part, that: - Hospice assumes responsibility for professional management of the resident's hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation; - The term professional management for a hospice patient who resides in a SNF/NF or ICR/MR has teh same meaning that it has if the hospice patient were living in his/her own home. Professional management involves assessing, planning, monitoring, directing, and evaluating the patient's hospice care across all settings; and - Hospice is responsible for providing all hospice services including ongoing assessment, care planning, monitoring, coordination, and provision of care by the hospice interdisciplinary group (IDG). Review of the agency's document dated 06/2009 and titled, "Hopice/LTC Coordinated Task Plan of Care" instructions, showed that: - The agency will coordiante services with each LTC [long-term care] provider. The agency and LTC provider will jointly ensure collaborative efforts between the LTC provider and the agency, by documenting which services will be provided, by whom, the frequency of services, updates when changes occur, dated signatures of both LTC provider and agency staff; - The Coordinated Task Plan will be initiated by the hospice provider upon start of care in the LTC and will be continuously updated with any chagnes as needed; At a minimum, the Coordinated Task Plan will be reviewed with recertification of the hospice resident; and - The procedure will include: * For the wound care schedule, circle the days of the week that hospice will provide the wound care. Update any on-going schedule changes on the next line. The LTC provider will be responsible for wound care on all other days * List each treatment planned and document frequency under each party responsible; and * Document a start date for each new or changed intervention and an end date for each discontinued intervention. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a SNF. Example 1: Review of the facility record showed that: - The facility had received new orders for the patient to use a foam dressing or waffle boot to the left heel on 11/22/2021; - The facility had received new orders for the patient to use a boot-styled heel protector two times per day on 12/21/2021; - The facility had received new orders for facility staff to cleanse the ares of the left heel with wound cleanser, apply betadine, and cover with Mepilex (a wound dressing that provides a moist enviroment for wound healing) daily and as needed on 01/11/2022; - The facility had received new orders for the facility staff to paint the necrotic (area of dead tissue) area on left heel with betadine once daily on 01/14/2022; Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care related to the formation of a wound on the left heel and identified on the facility treatment administration record for the dates of 11/22/2021, 12/21/2021, 01/11/2022, and 01/14/2022. Example 2: Review of the facility record showed that: - The facility had received new orders for the patient to monitor the left second toe for worsening of a bruise; and - The facility had received new orders for facility staff to cleanse the left second toe with wound cleanser, apply a dry gauze dressing, changes every other day and as needed for soiling. Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care identified on the facility treatment administration record for the dates of 11/22/2021, 12/21/2021, 01/10/2022, 01/11/2022, 01/14/2022. Example 3: Review of the facility treatment administration record (TAR) and nurses notes showed: - The facility had received new orders for facility staff to cleanse the open area on the coccyx (tailbone) with wound cleanser and pat dry, apply honey gel, xeroform, gauze, and an island dressing one daily on 01/14/2022; Review of the agency document signed by facility staff beginning 09/28/2021 and titled, "Hopice/LTC Coordinated Task Plan of Care" showed that: - The document failed to contain updates for the changes in the patient's plan of care identified on the facility treatment administration record for the date of 01/14/2022. During an interview on 02/02/2022 at 2:58 PM, the patient's durable power of attorney (DPOA) stated that he/she had noticed that there was not much communication between the facility and hospice, and it seemed like they weren't communicating about the patient's needs. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of metastatic breast cancer (cancer of the breast that has spread to other parts of the body). He/she used a urinary catheter (a tube placed in the bladder to drain urine). The patient resided in a SNF. During a home visit observation on 02/04/2022 at 01:00 PM, the regisered nurse: - Cleansed the tubing on the patients urinary catheter; and - Applied Calmoseptine to the skin on the buttocks. During an interview on 02/04/2022 at 01:00 PM, the facility nurse stated that: - Either the agency or the facility staff can change the catheter; - When the facility changes the catheter they put a date on the drainage bag; - There was not a date on the drainage bag; - Review of the facility records showed a facility nurse had changed the catheter two weeks ago, and the facility clinical record failed to contain documentation of the procedure: and - When asked to see the Coordinated Task Plan, the facility nurse gave the surveyor a, "blank look." Review of the document last updated 12/20/2021 and titled, "Hospiice/LTC Coordinated Task Plan of Care," showed that the document failed to contain: - The responsible party for the change of the urinary catheter monthly; - Specific parameters for the change of the urinary catheter monthly to include the size of catheter and balloon volume; - Interventions for cleaning the urinary catheter tubing; and - Interventions and identification of who would apply, and, the frequency of application, of the Calmoseptine to the patient's buttocks.
L0776      
42078 Based on agency policy review, record review, and interview, the agency failed to assure that any changes in the hospice plan of care were discussed with the patient or representative, and facility staff in one (Record/Patient #2) of three facility records reviewed. This deficient practice has the potential to affect the care of all the agency's patients. Findings included: Review of the agency's policy revised 2017 and titled, "IDG Care Planning Process," showed that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG (interdisciplinary group) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's needs. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/27/2021 with a terminal diagnosis of colon and rectal cancer. The patient resided in a skilled nursing facility (SNF). Review of the hospice start of care forms dated 09/27/202 titled, "Informed Consent Electing Hospice Care, Medicare Hospice Benefit Election, Hospice Election Statement, and Admission Checklist, " were signed by the patient's durable power of attorney. Review of the agency's document dated 09/27/2021 and titled, "Informed Consent Electing Hospice Care," showed that an individualized plan of care would be developed with input from the patient and family. Review of licensed practical nurse's (LPN) documentation for the visit dated 10/04/2021, showed that the patient was having increased nausea and vomiting. A physician order was received on 10/04/2021 for Zofran (a medication used to treat nausea and vomiting) as needed. The record failed to contain documentation that the durable power of attorney (DPOA) was notified of the new medication order or the increased nausea and vomiting. Review of the LPN's documentation for visit dated 11/24/2021 showed that the patient had developed new pain on the lateral aspect of his/her left foot. The foot had no signs of trauma. The record failed to contain documentation that the DPOA was notified the patient reporting pain in a new area. Review of the facility nursing documentation showed that: - On 11/28/2021, the patient was able to transfer with minimal assist of one person and did not require repositioning in bed; and - On 12/02/2021 the patient needed one person to assist with transfers and was non-weight bearing on his/her left lower extremity. Review of the LPN's documentation for visit dated 12/06/2021 showed that the patient had increased weakness, continued episodes of nausea and vomiting, utilized as needed pain medication more frequently, and had constipation. The record failed to contain documentation that: - The hospice was aware that the patient had become non-weight bearing on the left lower extremity, and - The DPOA was notified of the new or worsening symptoms of increased weakness, continued episodes of nausea and vomiting, had increased use of pain medication, and constipation. Review of the LPN's documentation for visit dated 12/20/2021 showed that: - The patient stated that his/her left foot hurt and that the pain was getting worse; - The nurse removed the patient's sock and found the patient's second toe was black in color with a bandaid, "wrapped tightly," around it; - The bandaid was removed and the,"toenail came off as well;" - The director of nursing, facility administrator, and physician were notified and the patient was sent to the local emergency room; - The record failed to contain documentation that the DPOA was notified of the above information. Review of facility nursing documentation showed that on 12/21/2021 a new order was received to apply betadine and Mepilex (foam dressing that maintains a moist wound environment). Review of the LPN's documentation for visit dated 12/20/2021 showed that: - The wound on the left heel had eschar (brown/black colored dead tissue); - The LPN reapplied the heel protector and dressing; - The left second toe remained black in color, cool to touch, and hard; and - The record failed to contain documentation that the DPOA was notified of the above information. Review of the LPN's documentation for visit dated 12/27/2021 showed that: - The patient had a low level of oxygen in his/her blood; - The patient refused to wear oxygen; - The patient stated that he/she did not feel short of breath; - The above symptoms were discussed with the facility charge nurse (CN); - The patient continued to have: * Intermittent nausea and vomiting that was relieved with Zofran (a medicine used to treat nausea and vomiting); * A decreased appetite; and * Increased fatigue; - The record failed to contain documentation that the DPOA was notified of the above information. Review of LPN telephone progress note documentation dated 12/30/2021 showed that the: - LPN called the facility to check on the patient's condition, "d/t [due to] a recent COVID 19 outbreak;" - The patient continued to have: * A decreased appetite; * Increased fatigue; * He/she was spending the majority of the day in bed; and The record failed to contain documenation that the DPOA was notified of the above information. Review of the agency's document dated 01/07/2022, and titled, "After Visit Summary," showed that the patient underwent surgery on 01/07/2022 for amputation (surgical removal) of left second toe. During an interview on 02/02/2022 at 01:36 PM, the complainant stated that: - The communication between the nursing home, hospice, and family was not good; - The agency should have updated the family once a week with changes to the plan of care and what they were seeing; - The patient's care didn't stop just because he/she was terminal; and - The family could advocate for the patient if they were kept updated on the patient's condition. During an interview on 02/02/2022 at 2:58 PM the patient's child and DPOA stated that: - There was not much communication between the facility, hospice, and the family; - Communication was really lacking; and - The facility would say that the agency was responsible for care, and then the agency nurse would come in and look "stumped" when we asked questions. During an interview on 02/04/2022 at 04:09 PM, the administrator stated that, when the DPOA signs the consent forms, then the DPOA and patient should be notified of changes in the patient's condition and plan of care.