Survey Report for 261616

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	261616	A. BUILDING __________ B. WING ______________	02/20/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE CORPORATION MIDWEST	1801 PARK 270 DRIVE - SUITE 150, SAINT LOUIS, MO, 63146
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)
L0554
L0554	38507 Based on policy review, record review, and interview, the agency failed to maintain a system of communication and integration, to ensure the interdisciplinary group (IDG) maintains responsibility for directing, coordinating, and supervising the care and services provided when the agency transitioned care from one IDG to another and services were interrupted, in one of three records reviewed. (Records/Patient #3) This deficient practice has the potential to adversely affect all the agency's patients that are transferred to another care team within the agency. Findings included: Review of the agency's policy titled, "VS Care Planning," updated 06/19/18, showed, in part, the following: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC) established by the IDG; - The POC will include the frequency of services necessary to meet the specific patient and family needs; - The hospice must develop and maintain a system of communication and integration to ensure the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided; and - The IDG must ensure the care and services are provided in accordance with the POC. RECORD/PATIENT #3: Review of the clinical record showed: - The patient's planned visit schedule according to the Visit Frequency Grid showed the nursing visits were scheduled for one time per week on 01/21/2020 and two times per week on 01/29/2020; - Documented nurse visit notes were provided for 01/21/2020, 01/24/2020, 02/10/2020, and 02/17/20; - On 02/14/2020, team manager 1(TM1) documented that the agency did not receive documentation of the RN visit scheduled for 01/29/2020, and that several attempts were made to obtain the documentation. RN1 is no longer an employee of this agency; and - The IDG failed to ensure nurse visits were provided as ordered two times per week on the week of 01/29/2020 (no nurse visit) and the weeks of 02/05/2020 and 02/11/2020 (only one nurse visit per week). Review of the agency generated report, "Daily Itinerary Summary by Employee," dated between 01/01/2020 and 02/19/2020 for RN1, showed, in part, the following: - On 01/28/2020 a telephone visit was made to the patient; - On 01/29/2020 a Superv. Vis. RN (supervisory visit RN) was made to the patient; - The agency failed to show documentation for the visit; and - Without the visit note, there is not conclusive evidence that the visit was completed. During an interview on 02/19/2020 at 4:30 PM, the administrator stated that: - RN1 resigned and walked out suddenly on 02/04/2020; - RN1 patients were transitioned the same day to care team 333 (South); - The patient's care should have been continued per the POC; and - The chart should have been hand delivered to the south office within one to two days. During an interview on 02/19/2020 at 4:40 PM, TM1 stated that: - On 02/04/2020, RN1 resigned and walked out that day; - All RN1 patients were on care team 334 (north) and were reassigned on 02/04/20; - Patient #3 was reassigned to care team 333 (South); - The visit frequency on the Visit Frequency Grid is from IDG meeting to the next IDG meeting; - He/she talked to the receiving team manager (TM2) and verbalized the transition of care - Normally, the RNCM (Registered Nurse Case Manager) gives report to the accepting RNCM when a team transition is performed; and - The agency does not expect to find documentation of the verbal report given from RNCM to RNCM in the medical record. During a telephone interview on 02/20/2020, TM2 stated that: - He/she remembers getting a telephone call regarding the transition of care; - Care team 333 (south) picked up the care for the patient; and - He/she is not sure why the frequency of visits was not accurate.
L0555
L0555	38507 Based on policy review, record review, and interview, the agency failed to ensure that the care and services were provided in accordance with plan of care (POC) when the interdisciplinary group (IDG) failed to ensure the visit frequency was followed, in three of three records reviewed. (Records/Patients #1, #2, and #3) This deficient practice has the potential to adversely affect the care provided to all the agency's patients. Findings included: Review of the agency's policy titled, "VS Care Planning," updated 06/19/18, showed, in part, the following: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care (POC) established by the IDG; - The POC will include the frequency of services necessary to meet the specific patient and family needs; - The hospice must develop and maintain a system of communication and integration to ensure the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided; and - The IDG must ensure the care and services are provided in accordance with the POC. RECORD/PATIENT #1: Review of the clinical record showed: - The patient's planned visit schedule according to the Visit Frequency Grid showed the nursing visits were scheduled for three times per week on 01/14/2020, 01/29/2020, and 02/05/2020; - Documented nurse visit notes were provided for 01/22/2020, 01/24/2020, 01/27/2020, 02/05/2020, and 02/07/2020; -On 02/14/2020, team manager 1(TM1) documented that the agency did not receive documentation of the RN visit scheduled for 01/30/2020, and that several attempts were made to obtain the documentation. RN1 is no longer an employee of this agency; and - The IDG failed to ensure nurse visits were provided as ordered three times per week on the weeks of 01/29/2020 (only one nurse visit) and 02/05/2020 (only two nurse visits). RECORD/PATIENT #2: Review of the medical record showed the following: -The patient's planned visit schedule according to the Visit Frequency Grid showed the nursing visits were scheduled for one time per week on 01/14/2020 and 01/28/2020; - The record failed to show documentation of nursing visits for the week of 01/29/2020 to 02/04/2020; - On 1/28/2020 the social worker documented that the patient was transitioned from care team 333 (South) to 334 (North) secondary to a change in address and placement in a care facility; - On 1/28/2020, registered nurse 1 (RN1) documented a phone call with client's son introducing the new care team and staff members. This note also included that RN1 planned to visit the next morning and discuss care with the facility staff; and - On 02/14/2020, team manager 1(TM1) documented that the agency did not receive documentation of the RN visit scheduled for 01/29/2020, and that several attempts were made to obtain the documentation. RN1 is no longer an employee of this agency. Review of the agency generated report, "Daily Itinerary Summary by Employee," dated between 01/01/2020 and 02/19/2020 for RN1, showed, in part, the following: - On 01/28/2020 a telephone visit was made to the patient and documentation was provided; - On 01/29/2020 a Superv. Vis. RN (supervisory visit RN) was made to the patient; - The agency failed to show documentation for the visit; and - Without the visit note, there is not conclusive evidence that the visit was completed and therefore, the POC visit frequency was not followed the week of 02/05/2020. RECORD/PATIENT #3: Review of the clinical record showed: - The patient's planned visit schedule according to the Visit Frequency Grid showed the nursing visits were scheduled for one time per week on 01/21/2020 and two times per week on 01/29/2020; - Documented nurse visit notes were provided for 01/21/2020, 01/24/2020, 02/10/2020, and 02/17/20; -On 02/14/2020, team manager 1(TM1) documented that the agency did not receive documentation of the RN visit scheduled for 01/29/2020, and that several attempts were made to obtain the documentation. RN1 is no longer an employee of this agency; and - The IDG failed to ensure nurse visits were provided as ordered two times per week on the week of 01/29/2020 (no nurse visit) and the weeks of 02/05/2020 and 02/11/2020 (only one nurse visit per week). During an interview on 02/19/2020 at 4:40 PM, TM1 stated that: - Patients #1, #2, and #3 were transitioned from care team 334 (north) to care team 333 (south) on 02/04/2020 when an RN resigned and walked out; - Both care team 333 (south) and care team 334 (north) team meetings are on Tuesdays; -The visit frequency on the Visit Frequency Grid is from IDG meeting to the next IDG meeting and if the frequency is not changed at the IDG meeting, it continues as previously ordered; - Report was called to team manager 2 (TM2) at the south office; - Normally, the RNCM (Registered Nurse Case Manager) gives report to the accepting RNCM when a team transition is performed; and - The agency does not expect to find documentation of the verbal report given from RNCM to RNCM in the medical record.