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
261623 A. BUILDING __________
B. WING ______________ 		02/17/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE COMPASSUS-NORTH CENTRAL MISSOURI 303 NORTH KEENE STREET, SUITE 306, COLUMBIA, MO, 65201
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      
38507 Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an updated and accurate medication profile in two (Records/Patients #1 and #2) of five full record reviews completed. This deficient practice has the potential to adversely affect the safe and accurate administration of medications for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Reconciliation," dated revised 01/30/2019, showed, in part, the following: - Regardless of the setting, it is the responsibility of the registered nurse performing the admission visit to complete a comprehensive medication review and reconciliation; and - For nursing facility patients, it is the responsibility of the hospice nurse to perform the following each scheduled nursing visit: 1. Review the current MAR (medication administration record) and 2. Note whether there are any new or changed medications. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of senile degeneration of the brain (progressive dementia). Comorbidities included abnormal weight loss, diabetes mellitus type 2 with diabetic neuropathy (high blood sugars with numbness and tingling in extremities), and depression. The patient lived in a long-term care facility (LTCF). He/she required total care with activities of daily living, transferred to wheelchair by lift, and had bowel and bladder incontinence. The patient was refusing oral medications by tablet or capsule. During a home visit observation with the registered nurse on 02/09/2021 at 4:30 PM, the facility charge nurse made copies of the patient's current medication administration record (MAR) for the surveyor. Review of the facility MAR compared to the current hospice client medication report printed 02/10/2021 showed the following discrepancies: - The MAR showed Humulin 70/30 (a slow acting and fast acting combination of insulin for high blood sugar control) 20 units subcutaneous (subq) (given by injection into the fatty tissue) daily in the morning. The hospice medication report failed to show this medication; - The MAR showed Humulin N (a slow acting insulin) 15 units subq in the evening. The hospice medication report showed the medication listed but showed the Humulin N was to be given in the morning; - The MAR showed metoclopramide 10 milligrams (mg) (used to treat high blood pressure) orally every six hours as needed. The hospice medication report failed to show this medication; - The MAR showed Zofran 8 mg (for nausea and vomiting) orally every 8 hours as needed. The hospice medication report failed to show this medication; - The MAR showed muscle rub cream topically four times per day. The hospice medication report failed to show this medication; - The MAR showed nystatin powder (used to treat skin fungus) 100,000 units/gram topically three times per day. The hospice medication report failed to show this medication; and - The MAR showed oxygen two liters per nasal cannula (2 pronged tube placed in the nose) inhalation every shift. The hospice medication report failed to show this medication. During an interview while on the home visit observation on 02/09/2021 at 5:15 PM, the hospice registered nurse stated that she reviews the patient's LTCF electronic record during each nursing visit and checks for medications that need to be reordered. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of heart failure. Comorbidities included malnutrition. The patient lived in a long-term care facility (LTCF). He/she required total care. During a home visit observation with the chaplain on 02/09/2021 at 3:30 PM, the facility charge nurse made copies of the patient's current medication administration record (MAR) for the surveyor. Review of the facility MAR compared to the current hospice client medication report printed 02/10/2021 showed the following discrepancies: - The MAR showed digoxin 0.125 mg (milligrams) (Used to make the heart beat slower and stronger) orally every other day. The hospice medication report showed the medication to be taken daily; - The MAR showed Sinemet 25-100 mg (used for Parkinson's Disease- a neurological disease that causes tremors and problems with ambulation). The hospice medication report failed to show this medication; - The hospice medication report showed Keflex 250 mg (a broad spectrum antibiotic) orally daily. The MAR failed to show this medication; and - The hospice medication report showed Klor-Con M20 (a potassium supplement). The MAR failed to show this medication. During an interview on 02/17/2021 at 10:30 AM, the administrator stated that: - The agency receives a copy of the medication administrative record from the facilities at the beginning of every month and this should be reconciled with the patient medication report; and - The nurses should reconcile the hospice medications with the facility medications every visit.
L0591      
38507 Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the nursing needs of the patients were met as identified in the initial, comprehensive, and updated assessments in one (Record/Patient #1) out of five full record reviews completed. This deficient practice has the potential to adversely affect the nursing care provided to all the agency's patients. Review of the agency's policy titled, "Initial and Comprehensive Assessment," dated revised 01/22/2021, showed, in part, the following: - The agency will conduct and document in writing patient-specific initial and ongoing comprehensive assessments that identify the patient's clinical needs; - The assessment will include all areas of hospice care related to the palliation and management of the terminal illness and related conditions; - A nursing assessment is the holistic evaluation of an individual's response to changes in their health status; and - The collected data will be used to formulate a nursing diagnosis, develop a plan of care, implement nursing interventions, and the evaluation of the effectiveness of these interventions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of senile degeneration of the brain (progressive dementia). Comorbidities included abnormal weight loss, diabetes mellitus type 2 with diabetic neuropathy (high blood sugars with numbness and tingling in extremities), and depression. The patient lived in a long-term care facility (LTCF). He/she required total care with activities of daily living, transferred to wheelchair by lift, and had bowel and bladder incontinence. The patient was refusing oral medications by tablet or capsule. Review of the hospice start of care patient medication report dated 11/02/2020 showed the patient was on metformin (an oral drug used to treat type 2 diabetes, a condition in which the body does not use insulin normally) and glimepiride (an oral drug used to treat type 2 diabetes). Review of the facility physician order report showed Accucheck (a type of finger stick blood sugar monitor) 3 times per day when resident allows, dated 10/14/2020 to an open ended date. Review of the hospice initial plan of care dated 11/02/2020 failed to show endocrine or diabetes as a problem and failed to show an intervention for assessment of blood glucose (sugar) levels. Review of the nursing visit note dated 12/09/2020 showed the physician was called and orders were received to discontinue metformin and glimepiride. Review of the nursing visit notes dated 12/10/2020 and 12/14/2020 failed to show any mention of anti-diabetic medications being discontinued or assessment of the endocrine system including signs and symptoms of hypo/hyperglycemia (low or high blood sugar levels) or blood glucose monitoring results from the facility. Review of the LTCF (long term care facility) MAR (medication administration record) showed that Humulin N (a slow acting insulin) 15 units subcutaneous (subq) in the evening was started on 12/20/2020 and Humulin 70/30 (a combination insulin that includes slow and fast acting insulin) 15 units subq in the morning was started 12/28/2021. Review of the hospice client medication record showed the hospice registered nurse (RN) failed to show the Humulin N being started until 12/28/2020 and had no record of the Humulin 70/30 being started at all. Review of the interdisciplinary group (IDG) meeting dated 12/30/2020 failed to show: - Documentation of the RN reporting the new medication Humulin N started 12/28/2020; and - The medication review by the medical director failed to include Humulin N in the review of current medications. The RN failed to: - Assess for changes in medication on an on-going basis and as a result of that failure, failed to assess the patient for endocrine changes or signs and symptoms when the patient was started on insulin 12/20/2020; - Report medication changes to the IDG; and - Include the changes on the updated plan of care. During an interview on 02/11/2021 at 4:00 PM, the administrator stated that: - The plan of care should have included endocrine assessment, interventions, and goals from the beginning of care; - The discontinuation of the oral anti-diabetic medications on 12/09/2020 and the start of Humulin N documented on 12/28/2020 should have been discussed in the IDG meetings; and - The nursing staff should have documented an endocrine assessment that included blood sugars and any signs and symptoms of changes in condition on the follow-up visits. During an interview on 02/17/2021 at 10:30 AM, the administrator stated that: - The agency receives a copy of the medication administrative record from the facilities at the beginning of every month and this should be reconciled with the patient medication report; and - The nurses should reconcile the hospice medications with the facility medications every visit.
L0594      
38507 Based on policy review, record review, and interview, the agency failed to ensure social work services were based on the patient's psychosocial assessment to ensure the patient's and family needs were met when the visit frequency failed to be followed, in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to adversely affect the psychosocial care provided to all the agency's patients. Findings included: Review of the agency's policy titled, "Missed and Omitted Visits," updated 04/16/19, showed, in part, the following: - A missed visit is a visit that was scheduled and was not completed for any reason other than the patient/caregiver requested the visit be changed or canceled; - A omitted visit is a visit that was scheduled and was not completed because the patient/caregiver requested the visit be changed or canceled; and - When it is identified that a scheduled visit was missed, the director of clinical services (DCS) will determine whether or not a re-scheduled visit can be made timely (within the medicare week). The DCS will also contact the individual who missed the scheduled visit to have them contact the patient/caregiver to reschedule and complete the visit. Review of the agency's policy titled, "Individualized Plan of Care," updated 01/20/20 showed, in part, the following: - 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 the members of the IDG team as well as input from the patient and/or caregiver as appropriate; - The POC is a working document and is intended to be a guide for the hospice team in delivery of care based on identified problems and according to patient-directed goals; and - The POC should be reviewed and revised as often as the needs of the patient indicate but not less than every 15 calendar days. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 05/08/20 with a terminal diagnosis of malignant neoplasm of the colon. The patient lived at home with his/her spouse. Review of the IDG notes dated 11/05/20 showed the social work visits/phone calls were to be once a month. Review of the clinical record showed: - Documented social work phone call on 12/15/20; - A coordination noted dated 01/18/2021 showed the patient would be at the doctor on the date of scheduled visit (01/15/2021). The medical social worker to follow up with the patient next week. There was no documentation the follow up with the patient was completed; and - The IDG failed to ensure social work visits were provided as ordered once a month for the month of January (no social work visit). During interview on 02/11/2021 at 3:30 PM., the administrator stated: - The social worker visit was missed due to the patient had a doctor appointment. The social worker failed to follow up with the patient the next week due to illness; - He/she would have expected the social worker to follow up with the patient and complete the visit; and - The agency identified this as an issue today and started disciplinary actions and a performance improvement project.
L0674      
38507 Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the staff documented responses to medications, symptom management, treatments, and services based on the problems identified in the updated comprehensive assessments in two (Record/Patients #1 and #4) out of five full record reviews completed. This deficient practice has the potential to adversely affect the care provided to all the agency's patients. Review of the agency's policy titled, "Initial and Comprehensive Assessment," dated revised 01/22/2021, showed, in part, the following: - The agency will conduct and document in writing patient-specific initial and ongoing comprehensive assessments that identify the patient's clinical needs; - The assessment will include all areas of hospice care related to the palliation and management of the terminal illness and related conditions; - The comprehensive assessment will be updated as often as the patient's condition requires and it must consider changes that have taken place since the initial assessment; - A nursing assessment is the holistic evaluation of an individual's response to changes in their health status; and - The collected data will be used to formulate a nursing diagnosis, develop a plan of care, implement nursing interventions, and the evaluation of the effectiveness of these interventions. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of senile degeneration of the brain (progressive dementia). Comorbidities included abnormal weight loss, diabetes mellitus type 2 with diabetic neuropathy (high blood sugars with numbness and tingling in extremities), and depression. The patient lived in a long-term care facility (LTCF). He/she required total care with activities of daily living, transferred to wheelchair by lift, and had bowel and bladder incontinence. The patient was refusing oral medications by tablet or capsule. Review of the start of care patient medication report dated 11/02/2020 showed the patient was on metformin (an oral drug used to treat type 2 diabetes, a condition in which the body does not use insulin normally) and glimepiride (an oral drug used to treat type 2 diabetes). Review of the facility physician order report showed Accucheck (a type of blood sugar monitor for finger sticks) 3 times per day when resident allows, dated 10/14/2020 to open ended date. Review of the hospice initial plan of care dated 11/02/2020 failed to show documentation of endocrine or diabetes as a problem and failed to show documentation of an intervention for assessment of blood glucose (sugar) levels. Review of the nursing visit note dated 12/09/2020 showed the physician was called and orders were received to discontinue metformin and glimepiride. Review of the nursing visit notes dated 12/10/2020 and 12/14/2020 failed to show documentation of any mention of anti-diabetic medications being discontinued or assessment of the endocrine system including signs and symptoms of hypo/hyperglycemia (low or high blood sugar levels) or blood glucose monitoring results from the facility. Review of the updated plan of care dated 12/16/2020 failed to show documentation of changes related to discontinuation of the oral anti-diabetic medications or interventions to monitor endocrine related to the change in medication. Review of the IDG notes dated 12/16/2020 failed to show documentation of discontinued oral anti-diabetic medications. During an interview on 02/11/2021 at 4:00 PM, the administrator stated that: - The plan of care should have included endocrine assessment and interventions from the beginning of care; - The discontinuation of the oral anti-diabetic medications should have been discussed in the IDG meeting; and - The nursing staff should have documented in the nursing notes the changed medications and follow-up with an endocrine assessment that included blood sugars and any signs and symptoms. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 11/17/2020 with a terminal diagnosis of spreading cancer of the colon and of the lung. The patient lived in his/her home and had an adult child that assisted with care when needed. There was no full time caregiver in the home. Review of the clinical record showed a nursing visit note dated 11/24/2020 by an LPN (licensed practical nurse). The patient was wondering if he/she needed to take aspirin (a mild blood thinning agent) and Eliquis (a medication used to thin the blood) because he/she was bruising easily. The physician was called and the LPN was awaiting a call back. Review of the IDG (interdisciplinary group) meeting notes dated 12/01/2020 failed to show documentation of a discussion of any follow up regarding use of aspirin and Eliquis and both medications remain on the medication record. When communicating with the administrator by email, he/she responded to a question from the surveyor regarding if any communication notes were found from the physician about the aspirin and Eliquis. The administrator returned the email on 02/18/2021 at 4:18 PM and stated, "I spoke to the nurse, who reported the attending physician did not respond. The RN case manager ended up speaking with the medical director for advisement." There was no corresponding documentation provided to show how the medical director responded.
L0774      
38507 Based on policy review, record review, home visit observation, and interview, the agency failed to provide a plan of care that identified the care and services that are needed and specifically identified which provider is responsible for performing the respective functions that have been agreed upon by the long term care facility (LTCF) and the hospice agency in two (Records/Patients #1 and #2) of two patients visited in a LTCF. This deficient practice has the potential to adversely affect the care provided to all the agency's facility patients. Findings included: Review of the agency's policy titled, "Care in the Nursing Facility," revision date 05/17/2018 showed, in part, the following: - The agency collaborates with the facility to establish a coordinated plan of care and the plan of care is maintained by both the facility and agency. Care is provided according to the plan of care; - The hospice plan of care identifies the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care; and - The plan of care reflects the participation of agency representatives, the LTCF, and the patient and family to the extent possible. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of senile degeneration of the brain (progressive dementia). Comorbidities included abnormal weight loss, diabetes mellitus type 2 with diabetic neuropathy (high blood sugars with numbness and tingling in extremities), and depression. The patient lived in a long-term care facility (LTCF). He/she required total care with activities of daily living, transferred to wheelchair by lift, and had bowel and bladder incontinence. A home visit observation at the LTCF was completed with the registered nurse (RN) on 02/09/2021 at 4:30 PM. During the home visit observation, the RN was questioned about the use of the coordinated facility plan of care. He/she stated that: - The previous assistant director of nursing (ADON) at the LTCF had quit; - The old ADON had the coordinated facility plan of cares for all the hospice patients in the facility; - When that person left, the coordinated facility plan of cares could not be found; and - He/she is in the process of making new coordinated facility plan of cares for the hospice patients in the facility. The RN was asked if the floor staff were able to access the coordinated facility plan of cares. The RN stated that: - Not now as they are missing since the ADON left; - He/she didn't see how they could be if they were in the ADON's office; - He/she knows all the staff well as she is case manager for all the agency's hospice patients living at the facility and he/she verbally keeps the staff updated on any changes; - The staff emails him/her with any changes in the patient's condition including falls and medication changes. The RN also stated that: - The facility has access to the electronic medical record (EMR) portal and can access certain documents on the hospice record but she is not sure who can access the EMR portal or if it is used by the floor staff; and - The hospice no longer uses the paper binders since the facility has access to the EMR portal. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 with a terminal diagnosis of heart failure. Comorbidities included malnutrition. The patient lived in a long-term care facility (LTCF). He/she required total care with activities of daily living and needed assistance when transferred to a wheelchair. During a home visit observation with the chaplain on 02/09/2021 at 3:30 PM, the chaplain showed the surveyor the nurse's station where the hospice binders were kept. The binders failed to show any information regarding patient #2. The facility charge nurse stated that she did not normally work at this unit and was just filling in for that day. She was not aware of where the patient's hospice information was but thought it could be located on the facility EMR. She did not know how to access it. During an interview on 02/09/2021 at 4:15 PM. the LTCF director of nursing stated that: - He/she did not have much time to talk; - He/she was able to access the EMR portal and show the surveyor the documents available to view; and - The facility coordinated plan of care failed to be shown. During an interview on 02/11/2021 at 4:00 PM, the hospice administrator stated that: - The coordinated task plan is called the CTPOC on the portal and was there; - He/she will communicate with the facility DON to make sure they are able to get on the portal and that the LTCF and hospice staff know how to access the portal; and - A copy of the hospice/LTC Coordinated task plan of care for Patient #2 will be provided for the surveyor to review. Review of the hospice/LTC Coordinated task plan of care with the earliest date recorded of 12/03/2020 failed to show the LTCF staff signatures and it is unknown if they were aware of the coordinated task plan of care.
L0798      
38507 Based on State of Missouri regulation review, record review, and interview, the agency failed to provide services in compliance with all applicable State laws and regulations when the agency failed to ensure that standing orders were specific and did not allow for non-prescribers choice and were individualized in, but not limited to, two (Patient/Records #3 and #5) of five full records reviewed. The deficient practice has the potential to affect all patients on service with the hospice agency. Findings included: Review of the hospice state regulations 19 CSR 30-35.010, tag ML 163, showed a standing order shall be in compliance with all applicable state statutes and regulations and shall: (I) Include the purpose or conditions under which standing order will be implemented. (II) Be drug, treatment, or procedure specific and not allow for non-prescriber's choice. (III) Be individualized, signed and dated by the prescriber and included in the patient's record. PATIENT/RECORD #3: Review of the clinical record showed the patient was admitted to hospice on 05/08/20 with a terminal diagnosis of malignant neoplasm of the colon. The patient lived at home with his/her spouse. Review of the medication profile showed the following orders: - Morphine 0.25 milligrams (mg) to one mg every hour as needed; and - Acetaminophen 500 mg one to two tablets every four hours as needed for pain/fever. The orders are not specific and allows for non-prescribers choice. PATIENT/RECORD #5: Review of the clinical record showed the patient was admitted to hospice on 10/16/2020 with a terminal diagnosis of malignant neoplasm of connective and soft tissue. The patient lived at home with his/her spouse. Review of the medication profile showed an order for morphine 0.25 mg to one mg every hour as needed. The order for morphine is not specific and allows for non-prescribers choice. During interview on 02/11/2021 at 3:25 PM., the administrator stated he/she was unaware variable doses were not allowed.