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
261641 A. BUILDING __________
B. WING ______________ 		08/12/2020
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)
L0587      
05766 Based on policy review, clinical record review, long-term care facility record review, and interview, the agency failed to meet the requirements for the Condition of Participation: Core Services when the hospice failed to: - Ensure coordination of all changes in medications with the attending physician (L590); and - Ensure the registered nurse performed/documented a complete and/or accurate assessment of the patient to ensure that the nursing needs of the patient are met. This failure included medication usage, response to medications, description of agitation behaviors, fall reduction activities, and coordination of care with the long-term care facility and family (L591). The cumulative effect of these systemic practices resulted in the inability of the hospice to provide effective core services to meet the needs of all hospice patients.
L0590      
05766 Based on policy review, clinical record review, and interview, the hospice failed to ensure coordination of all changes in medications with the attending physician in two (Records/Patients #1 and #2) of three cases. This deficient practice has the potential to affect the effectiveness of medications prescribed for symptom management for all patients on service. Findings included: The hospice policy, "Scope of Services," last reviewed 02/22/19, stated in part: a) Physician Services - The medical director along with team physicians will: * Assure continuity and coordination of all medical services; * Provide medical services to a patient if the patient does not have an attending physician; * Consult with attending physicians regarding pain and symptom control, ethical issues, and concerns or conflicts; and * Ensure that the general medical needs of the patients are met to the extent that these needs are not met by the attending physician. b) Nursing Services - The registered nurse will: * Inform the attending physician, hospice physician and other team members of changes in the patient's condition and needs, including the patient's response to care, treatment and services; and * Document all findings in the patient's medical record. RECORD/PATIENT #1: During completion of the initial comprehensive assessment and plan of the care on 05/15/2020, the registered nurse (RN) contacted the patient's attending physician and coordinated orders for medications and establishment of the plan of care. The clinical record contained no documentation to show the attending physician wished the hospice physician to make decisions regarding changes in medications for pain and symptom management or wound treatments. On Monday, 07/06/2020, the RN case manager documented two new Stage 2 pressure ulcers between the toes of the left foot between the third and fourth toes and the fourth and fifth toes. The RN case manager documented new wound care orders obtained from the hospice physician. The clinical record failed to show communication with the attending physician regarding the new pressure ulcers or treatment ordered by the hospice physician. On Wednesday, 07/15/2020, the RN case manager documented changes in the patient's respiratory status that required a change in dosage and frequency of administration of morphine and lorazepam. The RN case manager documented contact with the hospice physician and obtained orders. The clinical record failed to show communication with the attending physician regarding the change in respiratory status and the changes in orders for the administration of morphine and lorazepam. RECORD/PATIENT #2: During completion of the initial comprehensive assessment and plan of the care on 01/08/2020, the registered nurse (RN) contacted the patient's attending physician and coordinated orders for medications and establishment of the plan of care. The clinical record contained no documentation to show the attending physician wished the hospice physician make decisions regarding changes in medications for symptom management. On Wednesday, 01/09/2020 at 12:45 PM, the RN case manager documented on the nurse visit note that the patient was agitated and required redirection frequently, and that an order for "lorazepam gel" was obtained from the hospice physician. The RN failed to document an unsuccessful attempt to contact the attending physician prior to contact with the hospice physician. The RN failed to document a written interim physician order for "lorazepam gel." The clinical record failed to show communication with the attending physician regarding the new medication ordered by the hospice physician to treat the patient's agitation. On Monday, 01/20/2020 at 12:45 PM, the RN case manager documented on the nurse visit note that the long term care facility (LTCF) staff reported agitation and disruptive behaviors had diminished with addition of Seroquel twice daily (anti-psychotic medication used to mental/mood disorders) and the use of lorazepam prn (as needed) for agitation. The RN documented that lorazepam BID (twice daily) for agitation was requested. The RN documented an interim physician order for lorazepam 0.5 milligrams (mg) oral, two times a day for agitation and sent this order to the hospice physician for signature. The RN failed to document an unsuccessful attempt to contact the attending physician prior to contact with the hospice physician. The clinical record failed to show communication with the attending physician regarding the new medications ordered by the hospice physician to treat the patient's agitation and disruptive behaviors. On Tuesday, 02/04/2020 at 10:00 AM, the LTCF nurse called the hospice RN regarding "agitation of patient and need for medication changes." The RN case manager documented an interim physician order from the hospice physician for Seroquel (quetiapine) Gel 25mg/1ml, apply 1 ml to inner wrist or other hairless area two times daily for agitation and Lorazepam Intensol 2mg/ml, 0.5 ml oral every 6 hours as needed and orders to discontinue the tablet forms of Seroquel and lorazepam previously ordered. The care coordination note documented by the RN failed to show why a change in dosage forms was requested. The RN failed to document an unsuccessful attempt to contact the attending physician prior to contact with the hospice physician. The clinical record failed to show communication with the attending physician regarding the new medications ordered by the hospice physician to treat the patient's agitation. Review of the clinical record findings occurred on 08/12/2020 at 9:00 AM with the director of clinical operations and executive director. The director of clinical operations stated and the executive director agreed that when an attending physician was involved in the care of the hospice patient, the attending physician should always be the primary contact for changes in medications or treatments. If the RN could not reach the attending the physician, then the hospice medical director or the hospice physician would be contacted. The RN should also document notification of the attending physician of any changes ordered by the hospice physician.
L0591      
05766 Based on policy review, hospice clinical record review, long-term care facility (LTCF) record review, and staff interview, the agency failed to ensure the hospice registered nurse (RN) performed/documented a complete and/or accurate assessment of the patient in, but not limited to, two (RECORDS/PATIENTS #1 and #2) of three record reviews when the RN failed to: - Provide the LTCF with a list of hospice comfort pack medications or the protocol to follow for use of these medications; - Perform/document an ongoing medication reconciliation between the hospice medication profile (HMP) and the LTCF medication administration record (MAR); - Perform/document assessment of blood sugars and diabetic management; - Assess/document frequency of falls, specific fall reduction activities and fall reduction instruction; - Increase visit frequency and/or document follow-up with LTCF staff in response to medication changes and patient behaviors; and - Document the specific person and/or specific content when the family and/or facility were notified of visit and care management activities. These deficient practices have the potential to adversely affect the nursing care and patient outcomes for all hospice patients. Findings included: Review of the agency's policy titled, "Scope of Hospice Services," effective 02/22/2019, showed nursing staff were to: - Coordinate services with the patient, family, and others involved in the plan of care; - Provide education and support to the patient and family; - Provide nursing services, medications, and treatments in accordance with physicians' orders and with the patient's interdisciplinary plan of care and according to the standards of nursing practice; - Document all findings in the patient's medical record; and - A registered nurse case manager will be assigned to each patient to coordinate the patient's care, and integrate and provide continuity of patient/family care in conjunction with other services to assure physician orders are followed. During an interview on 08/11/2020 at 10:34 AM the director of clinical operations stated that: - All medications that are included in the comfort pack are labeled as "***this is part of a comfort pack order***"; - Medications included in the comfort pack should not be used until the physician was notified of emergent symptoms and the RN obtained verbal orders to activate the medication; and - The practice for activating a comfort pack medication would be for the clinician to discontinue the comfort pack medication order for a specific medication, and then write a physician order for the medication that does not contain the statement that it is a comfort pack order. RECORD/PATIENT #1: The hospice admitted this patient on 05/19/2020 with a primary diagnosis of degenerative disease of the nervous system with a history of multiple strokes with loss of use of the right side of the body. The patient lived in his/her own home and was cared for by his/her spouse. Review of hospice clinical record for visit dated 05/20/2020 by the RN case manager (RN A) showed: - The comfort and pain assessment indicated that the patient takes Tylenol PM (combination drug for comfort and sleep) with no assessment/documentation of the dosage or frequency of use; - The gastrointestinal (GI) assessment indicated that if the patient did not have a bowel movement every two to three days the spouse would give him/her Metamucil (fiber medication to treat constipation); and - RN A failed to notify the physician of the use of these medications, obtain/document physician orders, or include them on the hospice plan of care. Review of hospice clinical record for visit dated 05/27/2020 by the RN case manager showed: - The patient's bowel routine included Miralax (over the counter medication used to treat constipation); and - RN A failed to notify the physician of the use of Miralax, obtain/document a physician order, or establish a plan of care for constipation. Clinical record findings for Patient #1 were reviewed with the director of clinical operations and executive director on 08/12/2020 at 9:00 AM. Both acknowledged the findings and no additional information was provided. RECORD/PATIENT#2: Review of the clinical record showed the patient was admitted to hospice on 01/08/2020 with a principle diagnosis of Alzheimer's disease and dementia, and other pertinent diagnoses of type 1 diabetes mellitus, acute kidney failure, major depressive disorder, dysphagia (difficulty swallowing), and muscle wasting and atrophy. This patient resided in an LTCF. Review of the comprehensive assessment performed on 01/08/2020 by the registered nurse (RN C) showed: - The patient was an insulin dependent diabetic and there were no assessments documented related to diabetes including frequency of blood sugar testing by facility staff, blood sugar ranges, and assessment of feet; - The patient had weakness in both arms and both legs; - The patient was at a high risk for falls and the RN requested placement of a hi/low bed, fall mat, and bedside table; and - Identified the responsible family member by name for coordination of care (family member #1) Review of durable medical equipment ordering records dated 01/08/2020 and delivery records dated 01/09/2020, showed delivery of the hi/low hospital bed was refused. The Synapse patient data integration report showed that the LTCF refused the hospital bed. The agency failed to provide documentation in the clinical record to show refusal of delivery of the hi/low bed by the facility, discuss the reason for refusal with the LTCF, or notification of the family. During a telephone interview on 08/13/2020 at 10:30 AM, the patient's family member #1 stated he/she was upset because the patient did not receive a new hospital bed as promised by the hospice nurse. Family member #1 stated no one from the hospice notified him/her of the refusal of the bed by the LTCF. Review of the "IDT Care Plan" dated 01/08/2020 to 02/28/2020 showed: - An intervention to communicate with family member #1 after each visit with an update on patient condition and plan of care; - No orders/plan for fall reduction activities; and - No orders/plan for assessment of diabetic management or blood sugar readings. Review of the hospice medication profile (HMP) and physician orders compared to the LTCF medication administration record (MAR) and LTCF physician order sheets, showed the following discrepancies for the period of 01/08/2020 through hospice discharge on 02/07/2020: - HMP showed haloperidol 2 milligrams/milliliter (mg/ml) give 1mg by mouth or under tongue every 6 hours as needed for agitation (***this is part of a comfort pack order***), and MAR showed haloperidol 2mg/ml give 1mg by mouth or under tongue every 6 hours as needed for agitation with no designation as a comfort pack medication. The MAR showed doses of haloperidol administered to the patient 01/18/2020 at 12:00 PM, 01/27/2020 at 03:00 AM and 10:00 AM, 01/29/2020 at 08:00 AM, 02/04/2020 at 08:00 AM and 07:00 PM and 02/05/2020 at 08:00am. The HMP does not contain documentation that haloperidol was activated from the comfort pack and no skilled nurse (SN) documentation on clinical notes to show the hospice nurse was aware of the use of haloperidol by the facility; - HMP showed Levemir (long-acting insulin) 100units/ml, give six units subcutaneous one time per day (discontinued on 01/08/2020); and MAR showed Levemir 100units/ml, give six units subcutaneous one time per day as an active order, being administered per LTCF staff daily through discharge on 2/07/2020; - HMP showed lorazepam 0.5mg tablet, one tablet every six hours as needed for anxiety (***this is part of a comfort pack order***), and MAR showed lorazepam 0.5mg tablet, one tablet every six hours as needed for anxiety with no designation as a comfort pack medication . The MAR showed administration of lorazepam began on 01/16/2020. HMP showed that lorazepam as needed was not activated from the comfort pack. On 01/20/2020 the HMP showed orders to administer lorazepam 0.5mg twice per day and discontinue the lorazepam as needed comfort pack order. On 01/20/2020 the MAR included the order for lorazepam two times per day and the order for lorazepam as needed for agitation; - HMP showed memantine extended release capsule 28mg give three times per day for dementia beginning 01/08/2020, and MAR showed memantine extended release capsule 28mg give one time a day beginning 10/20/19 and continuing through discharge 02/07/2020; - HMP showed orders for aspirin 81mg one time per day, and MAR showed enteric coated aspirin 81mg one time per day; - HMP showed glucagon emergency 1mg/ml every 8 hours as needed for blood sugars below 60, and MAR showed glucagon 1mg/ml every 3 hours for blood sugars below 60; and - HMP showed prochlorperazine maleate, morphine sulfate, and hyoscyamine as part of the comfort pack order, but the MAR showed prochlorperazine maleate, morphine sulfate, and hyoscyamine as active medication orders with no comfort pack designation. Throughout the one time weekly visits from 01/09/2020 through 02/03/2020, the RN case manager (RN B) consistently documented and/or failed to document the following information: - Failed to document an assessment of blood sugars obtained by the LTCF and administration of sliding scale insulin (review of the MAR showed patient received daily and sliding scale insulin with blood sugar checks three times per day); - Answered the question, "Is the patient experiencing any Anxiety/Restlessness/Agitation beyond comfort level?" as "No"; - Documented patient had an anxious/anxiety behavioral status; - Documented patient was alert and oriented to person, but disoriented to place and time; - Documented patient's neuro symptoms included balance deficit, dysphagia (trouble swallowing), forgetfulness, and drowsiness; - Documented patient had weakness in both legs; - Documented patient required walker for ambulation but frequently did not use; - There was no documentation of assessment for patient falls, fall reduction activities, or equipment used to manage falls; - Routine/generic education, with no documented elaboration, provided to unidentified caregiver without documentation of caregiver level of understanding included disease process, pain and comfort control measures, medication management and administration, and safety/falls; - Documented that the facility staff were updated at the end of the visit with no specific contact person identified or documentation of the specific information given to the person notified; and - Documented that the family was updated at the end of the visit with no specific contact person identified or documentation of the specific information given to the person notified. Review of hospice clinical record for visit dated 01/09/2020 by RN B showed: - Per the visit narrative, the patient spoke in a nonsensical fashion and ambulated with a walker but was unsteady on his/her feet, the LTCF staff reported that patient was frequently agitated and required redirection; - The RN failed to document the specific behaviors exhibited by the patient or when periods of agitation occurred; and - The RN obtained an order from hospice physician for "lorazepam gel" for patient agitation but no written physician order found and this medication was not listed on the hospice medication profile or LTCF MAR. The RN failed to assess the patient response to the documented medication change made for treatment of agitation on 01/09/2020 by phone or by visit until the next scheduled skilled nurse visit on 01/13/2020. Review of hospice clinical record for visit dated 01/13/2020 by RN B showed: - Per the visit narrative, the patient was up all night, had a shower the morning of the visit and was tired at the time of the visit, lying in bed sleeping during visit, and goes back to sleep during the visit; - Primary reason for this visit included assessment of agitation and effectiveness of "lorazepam gel" but this was not performed/documented; - The RN failed to assess/document whether prescribed medications for treatment of anxiety and agitation were administered as ordered by the LTCF; and - RN received orders to discontinue the quetiapine fumarate (Seroquel - used to treat mental/mood disorders) 12.5mg every morning and start quetiapine fumarate 12.5mg two times per day on 01/13/2020. The RN failed to assess the patient response to the documented medication change made for treatment of agitation/anxiety on 01/13/2020 by phone or by visit until the next scheduled skilled nurse visit on 01/20/2020. Review of hospice clinical record for visit dated 01/20/2020 by RN B showed: - The RN documented that the facility staff reported agitation and disruptive behaviors diminished with the addition of Seroquel two times per day used in conjunction with lorazepam as needed for agitation, - The RN failed to document the specific behaviors exhibited by the patient or when periods of agitation and disruptive behaviors occurred; and - RN documented a request and subsequent physician order to increase lorazepam to two times per day to manage agitation. The RN failed to assess the patient response to the documented medication change made for treatment of agitation on 01/20/2020 by phone or by visit until the next scheduled skilled nurse visit on 01/27/2020. Review of hospice clinical record for visit dated 01/27/2020 by RN B showed: - Per the visit narrative, the facility staff reported that patient spit out medication at times and was agitated in the evenings; - The RN failed to document the specific patient behaviors that demonstrate agitation or the frequency of occurrence; and - The RN failed to assess/document whether prescribed medications for treatment of anxiety and agitation were administered as ordered by the LTCF Review of hospice clinical record for visit dated 02/03/2020 by RN B showed: - The plan for the visit was to assess the effectiveness of the Seroquel and lorazepam on patient's reported agitation and the hi/low bed and fall mats ordered previously; - Per the visit narrative, LTCF staff reported patient's behavior varied - at times agitated and others calm; - The RN failed to assess/document the specific behaviors displayed by the patient when agitation occurred or the frequency of agitation episodes; - The RN failed to assess/document whether prescribed medications for treatment of anxiety and agitation were administered as ordered by the LTCF Review of the communication notes from 02/04/2020 showed a telephone call from the facility nurse to the hospice nurse (RN B) reporting the patient had increased agitation and requesting a change of medications. The hospice nurse obtained orders to increase quetiapine (Seroquel) dosage to 25 mg gel applied to the wrist twice daily and the and change the lorazepam dosage to 0.5ml every six hours as needed for agitation. There was no documentation in the record that family member #1 was notified of the changes. There were no additional telephone calls to the LTCF documented to follow up on the effectiveness of the medication changes nor visits made to the patient after these changes were made to plan of care. According to the LTCF record obtained on 08/12/2020, the LTCF transferred the patient to the hospital on 02/07/2020 at the request of family member #1 after repeated falls that day. The LTCF failed to notify the hospice of the falls or transfer. The hospice documented a telephone call from family member #1 on 02/07/2020 that stated the hospice was fired. Family member #1 declined to talk with the hospice when a follow-up phone call was attempted. During an interview on 08/11/2020 at 09:08 AM the director of clinical operations stated that they would expect the hospice nurse to follow up with a telephone call or extra visit to assess the patient's response to medication changes made for pain or symptom management. During an interview on 08/11/2020 at 10:34 AM the director of clinical operations stated that they would expect to have physician orders for monitoring and oversight of blood sugars for an insulin dependent individual and that monitoring of the diabetic status would be part of the hospice plan of care in order to promote patient comfort.