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
261630 A. BUILDING __________
B. WING ______________ 		08/05/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ST CROIX HOSPICE 471 S SPRINGFIELD AVE, BOLIVAR, MO, 65613
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)
E0006      
38507 Based on policy review, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The agency failed to develop policies and procedures for staffing strategies during an emergency shortage of staff. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the undated policies titled, "Coronavirus COVID-19 Preparedness Policy" and "Pandemic Infectious Disease," failed to show a policy or procedure for staffing strategies during an emergency shortage of staff due to COVID-19. During an interview on 08/04/2020 at 3:30 PM, the administrator stated that he/she: - Was not aware of the COVID-19 focused survey for acute and continuing care providers that was released from CMS 03/23/2020; - Knows the agency is deficient in this area; and - The agency's corporation has COVID-19 policies and procedures that will become effective at the governing body meeting next month.
L0543      
38507 Based on review of standards of practice, clinical record review, and staff interview, the agency failed to ensure that physician orders were obtained and followed on the individulized written plan of care for one (RECORD/PATIENT #1) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Standards of Practice for Hospice Programs (2018) The National Hospice and Palliative Care Organization's (NHPCO) showed the following: Standard: JIF PFC 4.2 Verbal/telephone physician orders are received, immediately recorded, and read back by the licensed individual. The prescribing physician signs and dates the order in accordance with applicable laws and regulations. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 07/03/2020 for malignant neoplasm of pancreatic duct. The patient resided in the home with family caregivers. Review of the clinical record showed: - On 07/31/2020 during a routine skilled nursing visit, the patient started Roxanol (narcotic analgesic) at 5:00 P.M., no dosage or amount was documented; - The note failed to show documentation of contact with the physician or an order received; - A physician's order failed to be written for the Roxanol that was administered on 07/31/2020; and - The Roxanol failed to be documented on the plan of care. During an interview on 08/04/2020 at 5:30 P.M., the DON/RN A stated that he/she could not find a physician's order for the Roxanol that was administered on 07/31/2020.
L0577      
38507 Based on agency observation, policy review, home visit observation, and interviews, the agency failed to ensure an effective COVID-19 infection control program using the guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to: - Maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel (L578); - Follow accepted standards of practice to prevent the transmission of infections, including the use of standard precautions (L579); - Maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious diseases that includes a method for identifying infectious disease problems and a plan for implementing appropriate actions (L580); - Provide infection control education to patients and family members (L582); and - Include strategies for addressing emergency events identified by the risk assessment, including staffing shortages (E0006). The cumulative effect of these deficient practices has the potential to affect the health and safety of all the agency's patients.
L0578      
38507 Based on agency observation, policy review, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: On 08/03/2020 at 12:35 PM, the surveyor approached the outer doors of the agency's office. Observation failed to show any signage to visitors or staff to show visitation restrictions and screening procedures for COVID-19. There failed to be signs to individuals with symptoms of a respiratory infection to put on a mask, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions. After entering the agency, there failed to be any type of screening of visitors for COVID-19 signs and symptoms. The staff were not wearing masks or complying with social distancing requirements. Review of the undated policies titled, "Coronavirus COVID-19 Preparedness Policy" and "Pandemic Infectious Disease," failed to show procedures for identification and mitigation of infectious diseases in the office for visitors or staff. During an interview on 08/04/2020 at 3:30 PM, the administrator stated that he/she: - Was not aware of the COVID-19 focused survey for acute and continuing care providers that was released from CMS 03/23/2020; - Knows the agency is deficient in this area; and - The agency's corporation has COVID-19 policies and procedures that will become effective at the governing body meeting next month.
L0579      
38507 Based on policy review, home visit observation, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to follow accepted standards of practice to prevent the transmission of infections, including the use of standard precautions in one of one home visit conducted (RECORD/PATIENT #1). This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency's undated policy titled, "Bag Technique Procedure and Policy," showed, in part, the following: - Place the bag (nursing bag) on a clean surface at waist high or above, not on the floor; - Remove all bag items which will be needed for the visit; - If additional items are needed after care has started, wash the hands before re-entering the bag; - Clean any items from the bag which have become soiled; and - Wash hands and return equipment to the bag. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 07/03/2020 for malignant neoplasm of the pancreatic duct. The patient resided in the home with family caregivers. During a home visit observation on 08/04/2020 at 1:40 PM, the director of nursing/registered nurse (DON/RN) A failed to follow the standards of practice to prevent transmission of infections when the following bag technique protocols were not observed. DON/RN A: - Placed a barrier on the floor and then put the nursing bag on top of the barrier; - Failed to retrieve all needed equipment from the nursing bag that would be needed for the visit; - Failed to cleanse hands before re-entering nursing bag; and - Failed to cleanse equipment before returning it to bag. During an interview on 08/04/2020 at 5:00 PM, DON/RN A stated that he/she: - Usually wipes everything down before putting it back in the bag; and - Knows he/she should have cleaned hands before re-entering the bag.
L0580      
38507 Based on policy review and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care". The hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious diseases that includes a method for identifying infectious disease problems and a plan for implementing appropriate actions. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the undated policies titled, "Coronavirus COVID-19 Preparedness Policy" and "Pandemic Infectious Disease," failed to show the following: - Procedures for an established surveillance plan; - A plan that includes early detection and management of a potential infectious, symptomatic patient; - A process for communicating the diagnosis, treatment, and laboratory test results when transferring patients to a facility or healthcare provider; and - Staff able to identify/describe the communication protocol with local/state public health officials. During an interview on 08/04/2020 at 3:30 PM, the administrator stated that he/she: - Was not aware of the COVID-19 focused survey for acute and continuing care providers that was released from CMS 03/23/2020; - Knows the agency is deficient in this area; and - The agency's corporation has COVID-19 policies and procedures that will become effective at the governing body meeting next month.
L0582      
38507 Based on policy review, home visit observation, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by the Centers for Medicare and Medicaid Services (CMS) dated 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care". The agency failed to provide infection control education to patients and family members in one of three records reviewed (RECORD/PATIENT #1). This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the undated policies titled, "Coronavirus COVID-19 Preparedness Policy" and "Pandemic Infectious Disease," failed to show a policy or procedure to instruct the patient and family regarding transmission of infectious diseases and specifically mitigating the transmission of COVID-19. Review of the admission packet that contained patient education materials failed to show any specific COVID-19 or pandemic disease written instructions to be given to the patient and family at the time of admission. RECORD/PATIENT #1: Record review showed the start of care date as 07/03/2020. Review of the initial/comprehensive assessment dated 07/03/2020 failed to show documentation that education regarding standard precautions as related to COVID-19 were given/taught. During a skilled nurse observation visit on 08/04/2020 at 1:40 PM: - The agency home binder was observed. The binder failed to show COVID-19 or pandemic disease written instructions; and - The family was interviewed and denied any specific COVID-19 education verbally provided by the agency staff. During an interview on 08/04/2020 at 3:30 PM, the administrator stated that the agency had: - Added a teaching tool to the admission packets titled, "Chronic Disease and COVID-19: What You Need to Know"; - The teaching tool must have been missed being put in to the surveyor copy of the admission packet; and - The administrator did not know if the teaching tool had been given to patients that did not get the tool in the admission process.
L0584      
38507 Based on policy review, State of Missouri statute review, employee file review, and interview, the agency failed to have an accurate policy and procedure (P&P) and to follow their policies and procedures to ensure the Employee Disqualification List (EDL) was checked prior to hire for two of two employee files reviewed (Director of Nursing/Registered Nurse (DON/RN) A and RN B). This deficient practice has the potential to affect the safe care of all the agency's patients. Findings included: Review of the agency's policy titled, "Background Checks," dated 07/2020, showed, in part, the following: -All Missouri staff, including contract staff, must be registered in good standing with the Missouri Department of Health and Senior Services Family Care Safety Registry (FCSR). Verification of good standing with the FCSR will be performed at the time of hire; and -At the time of hire, the agency will verify that the employee, is not included on the Missouri Employee Disqualification List. (The policy for the criminal background checks failed to include the correct information about when the EDL must be completed by law, prior to hire.) Review of Section 192.2495.3 (2), RSMo: Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider, make an inquiry to the department of health and senior services whether the person is listed on the employee disqualification list as provided in section 192.2490. Review of the employee file for registered nurse A (DON/RN A) showed: -DON/RN A was hired 09/23/19; -The employee's file failed to show EDL results; and -The agency failed to verify that the employee was not included on the EDL prior to hire. Review of the employee file for RN B showed: -RN B was hired 03/18/2020; -The employee's file failed to show EDL results; and -The agency failed to verify that the employee was not included on the Missouri EDL prior to hire. During an interview on 08/4/2020 at 12:45 P.M., the administrator stated that when he/she was reviewing the employee files, it was noted: - There was a problem with criminal background checks and EDL's; and - They should be completed at the time of hire. (The administrator was made aware at the time of the survey that the law requires EDL to be obtained prior to hire.)
L0591      
38507 Based on policy review, record review, visit observation, and interview, the agency failed to ensure the nursing needs of the patient were met when agency staff failed to document subsequent wound assessments and failed to care plan the wound for one patient (RECORD/PATIENT #1) of three record reviews completed. This deficient practice has the potential to adversely affect the wound care and healing of all the agency's patients. Findings included: Review of the agency's policy titled, "Wound Assessment and Documentation," dated as revised 03/2019, showed, in part, the following: -Wound assessment to be completed upon initial assessment of wound and subsequent skilled nurse visits; -Wound progression or lack thereof will be reported to the physician and treatment will continue as ordered; -Assess the wound location and its size; measure the length, width, and depth; -Consult with the physician, and revise the plan of care as needed if the wound is not healing satisfactorily; and -Document instructions, any abnormal findings, and compliance on visit report. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 07/03/2020 for malignant neoplasm of the pancreatic duct. The patient resided in the home with family caregivers. Review of the clinical record showed: -On 07/20/2020 during a skilled nursing visit, documentation showed the spouse advised the registered nurse (RN) B that the patient had a wound to his/her buttocks. The area was assessed. RN B documented that the patient had a flat, reddish-purple discoloration approximately 0.5 centimeters (cm) by 0.8 cm to his/her right upper gluteal (buttock). Wound care documented was applied skin prep and foam dressing. Hospital bed and low loss air mattress was offered and refused at this time. RN B will order Roho type cushion (pressure relief cushions for wheelchairs, toilet seats, and mattresses that are made of soft, flexible air cells connected by small channels) and shower bench, as the patient is accepting of bath aide at this time; -Physician's order, dated 07/21/2020, showed durable medical equipment (DME) to include hospital bed, low air loss mattress, shower bench, and roho type cushion; -Physician's order, dated 07/22/2020, showed apply skin prep to discoloration on upper right buttock at each visit twice weekly until resolved. Cover area with a foam dressing. Caregiver may provide wound care daily and as needed; -A comprehensive/ongoing plan of care, failed to show documentation or interventions for the wound; - Skilled nursing visits, dated 07/22/2020 and 07/24/2020, failed to show documentation of the wound; and -On 07/27/2020 during a skilled nursing visit, DON/RN A documented the patient's skin was currently intact. During a skilled nurse visit observation on 08/04/2020 at 1:40 PM, DON/RN A was observed providing care and instruction to the patient and family. DON/RN A failed to do a wound assessment on the patient's buttocks. After the visit was completed, DON/RN A was questioned about the absence of the skin assessment. DON/RN A stated that: - The patient was resting comfortably and he/she did not want to disturb the patient (who had been recently turned by the family); - He/she had done a skilled nursing visit the previous day, 08/03/2020, and had helped the family clean an incontinent episode and turn the patient; and - The patient's buttocks were observed then and there was no skin breakdown noted. During an interview on 08/04/2020 at 11:15 AM, DON/RN A stated that wounds should be documented on every scheduled visit and include interventions and treatment on the up-dated plan of care.
L0796      
38507 Based on policy review, State of Missouri statute review, employee file review, and interview, the agency failed to have an accurate policy and procedure (P&P) and failed to follow their policies and procedures (P&P) to ensure the criminal background check was completed prior to patient contact for one of two employee files reviewed (RN A). This deficient practice has the potential to affect the safe care of all the agency's patients. Findings included: Review of the agency's policy titled, "Background Checks," dated 07/2020, showed, in part, that all Missouri staff, including contract staff, must be registered in good standing with the Missouri Department of Health and Senior Services Family Care Safety Registry (FCSR). Verification of good standing with the FCSR will be performed at the time of hire. (The policy for the criminal background checks failed to include the correct information about when the checks must be completed by Missouri State statute, prior to patient contact) Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the provider's duty to conduct employee criminal background checks pursuant to this section ..." Review of the employee file for registered nurse A (DON/RN A) showed: -DON/RN A was hired 09/23/19; -His/her criminal background check was completed on 12/10/2019 (78 days after hire); and -The agency failed to obtain a criminal background check prior to patient contact. During an interview on 8/4/2020 at 12:45 P.M., the administrator stated that when he/she was reviewing the employee files, it was noted: - There was a problem with criminal background checks: and - They should be completed at the time of hire. (The administrator was made aware at the time of the survey that the law requires the criminal background check to be obtained prior to patient contact.)