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
261626 A. BUILDING __________
B. WING ______________ 		11/22/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MEDI-PLEX HOSPICE, LLC 1470 SOUTH VANDEVENTER AVENUE, SAINT LOUIS, MO, 63110
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)
L0578      
29982 Based on agency observation, home visit observations, policy review, review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 focused Infection Control Survey Tool, and interview, the agency failed to screen two patients (Record/Patients #2 and #3) out of three home visits, the agency failed to notify a long-term facility that one patient (Record/Patient #5) had been exposed to COVID-19 prior to being admitted for respite care, and the agency failed to screen visitors as required in order to maintain and document an effective infection control program for COVID-19 that protects visitors and staff. This deficient practice has the potential to adversely affect the safety of all the agency's patients and the agency's visitors and staff. Findings included: Review of the agency policy titled, "COVID-19 Screening Employees and Guests," dated 04/01/2020, showed the following: -Policy: All employees will be monitored for signs and symptoms of COVID-19 prior to the start of work each day; -Purpose: To ensure the employee is COVID-19 free prior to working with others; -A staff nurse will conduct a temperature and pulse oxygen check upon entry into the building; and -Guest entering the building shall be required to wear a mask and have their temperature checked and recorded on the sign-in log. Review of the agency policy titled, "COVID-19 Patient Monitoring," dated 04/01/2020, showed the following: -Policy: All patient/caregivers will be monitored for signs and symptoms of COVID-19 prior to entering residence; -Purpose: To ensure the patient/caregiver is COVID-19 free prior to staff visit; -All staff shall actively monitor patient and caregivers prior to entering the residence at every visit for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat) and document findings. Ask patient/caregiver to report if they feel feverish or have symptoms of respiratory infection. Staff to notify the health department about patients with severe respiratory infection; and -Health department and CDC (Centers for Disease Control and Prevention) criteria will be followed for testing of symptomatic patients. Review of the CMS publication titled, "Revised COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care-QSO-21-08-NLTC," dated 12/30/2020, showed the requirement for a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure (for example: exposure to COVID-19 screening questions and assessment of symptoms/illness). On 11/16/2021 at 3:20 PM, two surveyors approached the agency entrance door. Observation showed that all that entered the building needed to wear a mask. Observation failed to show any signage to visitors or staff to show visitation restrictions and screening procedures for COVID-19. After entering the agency, there failed to be any type of screening for visitors for COVID-19 signs and symptoms. Again on 11/17/2021, 11/18/2021, and 11/19/2021 upon the two surveyors entering the agency, the agency failed to do any type of screening for COVID-19. RECORD/PATIENT #2: Review of the clinical record, showed the patient was admitted to hospice on 12/17/2020 with a terminal diagnosis of malignant neoplasm of the prostate. The patient lived at home. During a home visit observation and interview on 11/18/2021 at 10:15 AM, the agency nurse did not screen the caregiver or ask the patient about having any signs or symptoms of COVID-19. The caregiver denied the nurse screening him/her prior to the visit. RECORD/PATIENT #3: Review of the clinical record, showed the patient was admitted to hospice on 06/25/2021 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a condition involving constriction of the airways and difficulty or discomfort in breathing). The patient lived at home. During a home visit observation on 11/18/2021 at 11:50 AM, the agency social worker failed to screen the patient or caregiver for signs and symptoms of COVID-19 prior to entering the residence. RECORD/PATIENT #5: Review of the clinical record, showed the patient was admitted to hospice on 04/27/2021 with a terminal diagnosis of malignant neoplasm of unspecified part of the bronchus or lung. The patient lived at home until 10/15/2021, when he/she was admitted to a long-term care facility for respite care and the patient passed away at the facility on 10/19/2021. Review of social worker note, dated 10/14/2021, showed the patient's daughter had not been feeling well and requested respite care. Review of case communication note, dated 10/15/2021, showed the patient was to be picked up by ambulance and transported to a long-term care facility. Registered Nurse (RN) A called the long-term care facility and gave report. Also the patient's medical records had been sent to the facility. The documentation failed to show the patient had been exposed to COVID-19. Review of the agency's complaint log, showed on 10/19/2021 when the patient had passed away, it was found out then that the patient had been exposed to COVID-19 and that was why he/she was on respite. RN A had not informed the long-term facility of this and knew about the patient's exposure on 10/15/2021, prior to the patient being admitted to the long-term care facility. RN A was suspended following the investigation of the complaint. During an interview on 11/19/2021 at 10:30 AM, the director of clinical services stated that RN A should have shared information with the long-term care facility about Record/Patient #5's exposure to COVID-19 prior to admission to the facility and that all visitors should be screened upon entering the agency and patients/caregivers should be screened prior to staff entering the patient's residence.