Survey Report for 261641

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	261641	A. BUILDING __________ B. WING ______________	10/07/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ACCENTCARE HOSPICE & PALLIATIVE CARE OF MISSOURI	3660 S GEYER ROAD - SUITE 120, SAINT LOUIS, MO, 63127
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)
L0500
L0500	38507 Based on policy review, clinical record review, and interview, the agency failed to ensure: - Alleged violations involving misappropriation of the patient property are reported immediately to hospice administrator (L508); - Violations are immediately investigated (L509); and - Verified violations were reported to State and local bodies having jurisdiction within five working days (L511). The cumulative effect of these deficient practices has the potential to adversely affect the protection of patient rights and the safety of all the agency's patients.
L0508
L0508	38507 Based on policy review, record review, and interview, the agency failed to ensure that alleged violations involving misappropriation of patient property were reported immediately to the agency administrator in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to adversely affect the patient's right to be free from misappropriation of property for all the agency's patients. Findings included: Review of the agency's policy titled, "Suspected Abuse, Neglect, or Exploitation," dated 03/22/2019 showed, in part, the following: - Any employee, volunteer, or contracted staff who discovers any exploitation will immediately (as soon as possible, but not more than (24) hours after discovery of the incident) report their observations to the team director or administrator-on-call, who will then inform the executive director; - The executive director will immediately (as soon as possible, but not more than (24) hours after being notified of the incident) initiate an investigation of all alleged violations; - The executive director will make sure that verified violations are reported to State and local bodies having jurisdiction (including to the State Survey and Certification agency) within 5 days of becoming aware of the violation; -Documentation of the investigation should be made in an adverse event report; and - The definition of exploitation is the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 05/29/2020 with a terminal diagnosis of end-stage renal disease (kidney disease that leads to death). The patient lived alone at home but had children that lived close and helped with care. Review of the record showed a nurse visit note dated 09/19/2020 by registered nurse (RN) A. The narrative note showed an FYI (for your information) The patient does not have a comfort pack. During an interview on 10/07/2020 at 11:10 AM, the on-call registered nurse, RN A, stated that: - When he/she made the visit on 09/19/2020, it was on a weekend and he/she noticed the patient did not have a comfort kit (package of medications frequently needed for end-of-life care); - He/she "checked" and found out it had never been ordered for this patient; and - Was not concerned that it was not in the home. Continued review of the clinical record showed a nurse visit note dated 09/24/2020 completed by registered nurse (RN) B. The documentation showed: - The comfort kit was not in the refrigerator and was apparently missing; - The patient also stated that her purse was stolen yesterday (09/23/2020) and all of her identification cards and medicines were in the purse; - The patient also stated he/she had the Percocet (combination drug with narcotic for pain control) in his/her sweater pocket and was not stolen; and - A new comfort kit order was requested from attending physician. During an interview on 10/07/2020 at 11:30 AM, the case manager registered nurse (RN) B stated that: - He/she received a report from the weekend nurse, RN A, that on 09/19/2020, the comfort kit was not found in the patient's home; - The comfort kit was delivered to the patient's home, RN B checked on it, and knew it was in the refrigerator prior to 09/19/2020; - On the 09/24/2020 skilled nurse visit, the comfort kit was not found in the refrigerator; - The patient reported that his/her purse containing medications was also stolen; - The patient also reported that other items were missing from the home; - The patient had two children that had opioid addiction; - The daughter was at the home during the visit and was aware of the missing items and was sure the purse was misplaced and they would find it; - He/she was unsure if the team leader was informed of the missing items; - As of 10/01/2020, the items had not been found; and - The patient requested to not have a comfort kit in the home "since it would just come up missing, too." During an interview on 10/07/2020 at 2:30 PM, the team leader registered nurse (RN) C stated that: - The patient missing a comfort kit and purse, sounded familiar and he/she may have heard about it on the end-of-day report or someone may have called and reported it; - He/she checked the end-of-day reports and did not find it mentioned on 09/24/2020; - He/she did not remember RN B calling and reporting missing items; - If this had been reported, he/she would have responded by initiating an adverse event report which would go to the clinical director and then to the executive director; and - RN B should have reported this to the team leader. An interview was conducted with the executive director on 10/07/2020 at 2:54 PM. He/she stated that: - Misappropriation of property was exploitation of the patient; and - "You would think the employee would have reported this to a supervisor"; and - The staff were trained at orientation and yearly on abuse and neglect, mandatory reporting, and agency procedures. The agency's employee failed to report misappropriation of the patient's property to the agency executive director.
L0509
L0509	38507 Based on policy review, record review, and interview, the agency failed to: - Immediately investigate the alleged violations and immediately take action to prevent further potential violation while the alleged violation was being verified; and - Conduct the investigation and the documentation of the violations in accordance with established procedures. These failures occurred in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to adversely affect the patient's right to be free from misappropriation of property for all the agency's patients. Findings included: Review of the agency's policy titled, "Suspected Abuse, Neglect, or Exploitation," dated 03/22/2019 showed, in part, the following: - Any employee, volunteer, or contracted staff who discovers any exploitation will immediately (as soon as possible, but not more than (24) hours after discovery of the incident) report their observations to the team director or administrator-on-call, who will then inform the executive director; - The executive director will immediately (as soon as possible, but not more than (24) hours after being notified of the incident) initiate an investigation of all alleged violations; - The executive director will make sure that verified violations are reported to State and local bodies having jurisdiction (including to the State Survey and Certification agency) within 5 days of becoming aware of the violation; -Documentation of the investigation should be made in an adverse event report; and - The definition of exploitation is the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 05/29/2020 with a terminal diagnosis of end-stage renal disease (kidney disease that leads to death). The patient lived alone at home but had children that lived close and helped with care. Review of the record showed a nurse visit note dated 09/19/2020 by registered nurse (RN) A. The narrative note showed an FYI (for your information) The patient does not have a comfort pack. During an interview on 10/07/2020 at 11:10 AM, the on-call registered nurse, RN A, stated that: - When he/she made the visit on 09/19/2020, it was on a weekend and he/she noticed the patient did not have a comfort kit (package of medications frequently needed for end-of-life care); - He/she "checked" and found out it had never been ordered for this patient; and - Was not concerned that it was not in the home. Continued review of the clinical record showed a nurse visit note dated 09/24/2020 completed by registered nurse (RN) B. The documentation showed: - The comfort kit was not in the refrigerator and was apparently missing; - The patient also stated that her purse was stolen yesterday (09/23/2020) and all of her identification cards and medicines were in the purse; - The patient also stated he/she had the Percocet (combination drug with narcotic for pain control) in his/her sweater pocket and was not stolen; and - A new comfort kit order was requested from attending physician. During an interview on 10/07/2020 at 11:30 AM, the case manager registered nurse (RN) B stated that: - He/she received a report from the weekend nurse, RN A, that on 09/19/2020, the comfort kit was not found in the patient's home; - The comfort kit was delivered to the patient's home, RN B checked on it, and knew it was in the refrigerator prior to 09/19/2020; - On the 09/24/2020 skilled nurse visit, the comfort kit was not found in the refrigerator; - The patient reported that his/her purse containing medications was also stolen; - The patient also reported that other items were missing from the home; - The patient had two children that have opioid addiction; - The daughter was at the home during the visit and was aware of the missing items and was sure the purse was misplaced and they would find it; - He/she was unsure if the team leader was informed of the missing items; - As of 10/01/2020, the items had not been found; and - The patient requested to not have a comfort kit in the home "since it would just come up missing, too." During an interview on 10/07/2020 at 2:30 PM, the team leader registered nurse (RN) C stated that: - The patient missing a comfort kit and purse, sounded familiar and he/she may have heard about it on the end-of-day report or someone may have called and reported it; - He/she checked the end-of-day reports and did not find it mentioned on 09/24/2020; - He/she did not remember RN B calling and reporting missing items; - If this had been reported, he/she would have responded by initiating an adverse event report which would go to the clinical director and then to the executive director; and - RN B should have reported this to the team leader. An interview was conducted with the executive director on 10/07/2020 at 2:54 PM. He/she stated that: - Misappropriation of property was exploitation of the patient; - "You would think the employee would have reported this to a supervisor;" and - There have been no complaints or grievances since the prior survey in August. The agency failed to investigate misappropriation of the patients property and medications and failed to immediately take action to prevent further potential violations from occurring.
L0511
L0511	38507 Based on policy review, record review, and interview, the agency failed to ensure that the verified violations were reported to the State body having jurisdiction (including the State Survey and Certification Agency) within five working days of becoming aware of the violation in one (Record/Patient #3) of three records reviewed. This deficient practice has the potential to adversely affect the patient's right to be free from misappropriation of property for all the agency's patients. Findings included: Review of the agency's policy titled, "Suspected Abuse, Neglect, or Exploitation," dated 03/22/2019 showed, in part, the following: - Any employee, volunteer, or contracted staff who discovers any exploitation will immediately (as soon as possible, but not more than (24) hours after discovery of the incident) report their observations to the team director or administrator-on-call, who will then inform the executive director; - The executive director will immediately (as soon as possible, but not more than (24) hours after being notified of the incident) initiate an investigation of all alleged violations; - The executive director will make sure that verified violations are reported to State and local bodies having jurisdiction (including to the State Survey and Certification agency) within 5 days of becoming aware of the violation; -Documentation of the investigation should be made in an adverse event report; and - The definition of exploitation is the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 05/29/2020 with a terminal diagnosis of end-stage renal disease (kidney disease that leads to death). The patient lived alone at home but had children that lived close and helped with care. Review of the record showed a nurse visit note dated 09/19/2020 by registered nurse (RN) A. The narrative note showed an FYI (for your information) The patient does not have a comfort pack. During an interview on 10/07/2020 at 11:10 AM, the on-call registered nurse, RN A, stated that: - When he/she made the visit on 09/19/2020, it was on a weekend and he/she noticed the patient did not have a comfort kit (package of medications frequently needed for end-of-life care); - He/she "checked" and found out it had never been ordered for this patient; and - Was not concerned that it was not in the home. Continued review of the clinical record showed a nurse visit note dated 09/24/2020 completed by registered nurse (RN) B. The documentation showed: - The comfort kit was not in the refrigerator and was apparently missing; - The patient also stated that her purse was stolen yesterday (09/23/2020) and all of her identification cards and medicines were in the purse; - The patient also stated he/she had the Percocet (combination drug with narcotic for pain control) in his/her sweater pocket and was not stolen; and - A new comfort kit order was requested from attending physician. During an interview on 10/07/2020 at 11:30 AM, the case manager registered nurse (RN) B stated that: - He/she received a report from the weekend nurse, RN A, that on 09/19/2020, the comfort kit was not found in the patient's home; - The comfort kit was delivered to the patient's home, RN B checked on it, and knew it was in the refrigerator prior to 09/19/2020; - On the 09/24/2020 skilled nurse visit, the comfort kit was not found in the refrigerator; - The patient reported that his/her purse containing medications was also stolen; - The patient also reported that other items were missing from the home; - The patient had two children that have opioid addiction; - The daughter was at the home during the visit and was aware of the missing items and was sure the purse was misplaced and they would find it; - He/she was unsure if the team leader was informed of the missing items; - As of 10/01/2020, the items had not been found; and - The patient requested to not have a comfort kit in the home "since it would just come up missing, too." During an interview on 10/07/2020 at 2:30 PM, the team leader registered nurse (RN) C stated that: - The patient missing a comfort kit and purse, sounded familiar and he/she may have heard about it on the end-of-day report or someone may have called and reported it; - He/she checked the end-of-day reports and did not find it mentioned on 09/24/2020; - He/she did not remember RN B calling and reporting missing items; - If this had been reported, he/she would have responded by initiating an adverse event report which would go to the clinical director and then to the executive director; and - RN B should have reported this to the team leader. An interview was conducted with the executive director on 10/07/2020 at 2:54 PM. He/she stated that: - Misappropriation of property was exploitation of the patient; - The employee should have reported this to a supervisor; and - There have been no complaints or grievances since the prior survey in August. The agency failed to investigate misappropriation of the patients property and medications and failed to inform the State of Missouri Survey and Certification Agency.