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
261645 A. BUILDING __________
B. WING ______________ 		10/01/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CROSSROADS HOSPICE OF SAINT LOUIS, LLC 15450 SOUTH OUTER FORTY DRIVE, SUITE 100, CHESTERFIELD, MO, 63017
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)
L0524      
29559 Based on policy review, record review, home visit observation, and interview, the hospice nurse failed to perform a patient specific comprehensive assessment to identify the physical needs related to the terminal illness in one of five records reviewed for comprehensive assessment (Record/Patient #3). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the hospice policy titled " Comprehensive assessment", last revised 12/11/2018 showed in part the following: - The comprehensive assessment is a thorough evaluation of the patient's physical, psychosocial, emotional, and spiritual needs related to the terminal illness; and - The assessment should consider functional status, severity of symptoms. RECORD/PATIENT #3: Review of the initial plan of care plan showed that the patient was admitted on 07/13/2020 with a primary diagnosis of Parkinson's disease (a neurological disorder). Review of the comprehensive assessment, dated 07/13/2020 showed under the neurological assessment portion that the nurse assessed that the patient was "orientated to person". No additional neurological assessment specific to the patient's neurological terminal diagnosis was completed. The musculoskeletal section of the assessment was left blank. During a home visit observation on 09/29/2020, multiple holes in the homes sheet-rock walls were observed. When the patient's spouse/primary caregiver (PCG) was asked about the holes, he/she stated that the holes were caused by the patient attempting to walk, and leans forward into a run and goes head first into the wall due to lack of balance from the Parkinson's disease. The PCG stated that the holes occurred within the last year, but the patient primarily crawls on the floor now. The comprehensive assessment failed to include any findings regarding the patient's issues with balance and ambulation.
L0530      
29559 Based on policy review, clinical record review, home visit observation, and interview, the hospice failed to do a drug review on initial/comprehensive assessment to include the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with any laboratory monitoring in one patient (Record/Patient #1) and the hospice failed to maintain an accurate medication profile in one patient (Record/Patient #2) of three patients where a home visit was completed. This deficient practice has the potential to affect the accuracy of medication administration of all patients served by the hospice. Findings included: Review of the agency's policy titled, "Medication / Treatment Records / Medication Regimen Management," last revised 12/01/2018, showed in part the following: -Upon admission, the patient's medication regimen will be reviewed by a Registered Nurse (RN) for contradictions, duplication, and potential interactions; -Medication/treatment records will be continually updated in the system as changes occur. A copy of the updated record will be printed and filed within the medical record to ensure coordination of care; -Medication effects are monitored on a patient-specific and aggressive basis; -All medication profile(s) shall be reviewed by a pharmacist and assessed in relation to the patient's medication profile. RECORD/PATIENT #1: Review of the clinical record showed the patient's admittance to hospice on 08/12/20 with a terminal diagnosis of Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient resided in a nursing facility. Review of the initial/comprehensive assessment showed no drug review that included the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy currently associated with any laboratory monitoring. On 10/01/2020 at 10:00 AM, the findings from the record review for Patient #1 was reviewed with the Sr. Vice President of Clinical Operations and the Supervisory Nurse. No additional information was provided by the survey exit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 07/14/2019 with a terminal diagnosis of Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient resided in a nursing facility. The current hospice medication profile included the following treatment medications: - Losartan (blood pressure lowering medication) 100 milligrams (mg) by mouth (PO) every day (QD), started 7/14/2019; and - Lorazepam intensol 2 mg/1 milliliter (ml), 0.5 ml PO or sublingual (SL) as needed (PRN) for onset of seizures, started 8/25/2020. During a home visit observation on 09/29/2020 at 10:48 AM, review of the medication sheet located in the white hospice binder provided by RN-E, showed the patient was taking the medications as listed below: - No losartan on medication profile; - No lorazepam intensol on medication profile; and - Carrington moisture barrier topically to buttock area twice a day as needed. The current hospice medication profile did not match the medications as listed in the nursing facility. During interview on 9/29/2020 at 11:42 AM, RN E said medication sheets are updated with medication changes and the facility prints medication sheets every two weeks for RN-E. RN-E cannot access the nursing facilities computer system. On 10/01/2020 at 10:00 AM, the findings from the record review for Patient #2 was reviewed with the Sr. Vice President of Clinical Operations and the Supervisory Nurse. No additional information was provided by the survey exit.
L0536      
29559 Based on agency policy, home visit observation, clinical record review and interview, the agency interdisciplinary group (IDG): - Failed to update the plan of care orders to specify the hospice care and services necessary to meet the patient's needs (L538); - Failed to ensure care and services were provided to meet the patient and caregiver needs in (L539); - Failed to ensure all hospice care and services on the plan of care (POC) were followed (L543); - Failed to ensure that each patient and the primary care giver (s) received education for services identified in the plan of care (L544); and - Failed to develop an individualized written plan of care for the patient (L545). The cumulative effect of these systemic practices, and the negative outcome identified at L539 resulted in the inability of the hospice provider to provide effective ongoing care and services to all hospice patients.
L0538      
29559 Based on policy review, observation and record review the interdisciplinary care group (IDG) failed to update the plan of care orders to specify the hospice care and services necessary to meet the patient in one of three patients where physician orders were given during the weekly IDG meeting (Record/Patient #16). The deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of the agency's policy titled, "IDG Hospice plan of care- Content, Plan, Goals, Interventions, and Outcomes, dated as revised, 12/08/18, showed in part the following: -The plan of care will identify all the services needed to address problems identified in the initial, comprehensive, and updated assessments; -The plan of care will integrate changes based on clinical, social, spiritual, and emotional assessment findings; -A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; -Coordination of services: Hospice will ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided. Hospice will ensure that the care and services are provided in accordance with the plan of care. RECORD/PATIENT #16: During an observation of the hospice provider's IDG meeting on 09/30/2020 at 1:40 PM, the patient's case manager provided an update on the patient's lung sounds, oxygen use and breathing patterns. The physician gave verbal orders to the patient's case manager nurse to check weights weekly, titrate oxygen flow rate to keep oxygen saturations above 90%, and obtain a baseline Creatinine level results. On 10/01/2020 at 11:00 AM, The patient's clinical records were requested, and specifically any physician orders or plan of care updates for the last week. Review of the plan of care showed no orders for weights weekly, titrate oxygen flow rate to keep oxygen saturations above 90%, or a baseline Creatinine level results. No additional information was provided by the survey exit.
L0539      
29559 Based on clinical record review, policy review, and interview the hospice interdisciplinary group (IDG/IDT) failed to ensure care and services were provided to meet the patient and caregiver needs in, but not limited to, one of one revocation records reviewed (Record/Patient #8) . This deficient practice occurred when the patient's caregiver voiced that he/she was "overwhelmed and needing help right now." The patient's caregiver ended up calling 911 the next day after voicing the need and sending the patient to the hospital. The agency then had the patient's caregiver sign revocation papers since he/she sent the patient to the hospital. This example contributed to 418.56 identified at a condition level due to the adverse affect of the patient being transferred to the hospital and losing the hospice benefit by revocation. The deficient practice has the potential to affect all patients on service with the hospice. Findings included: Review of the agency policy "Continuous Home Care", dated as revised 11/18/18, showed the following: -CMS states that Continuous Home Care (CHC) may be provided only during a period of crisis. A period of crisis is a period in which a patient requires continuous care which is primarily nursing care to achieve palliative or management of acute medical symptoms. If a patient's caregiver has been providing this care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver. RECORD/PATIENT #8: Review of RN-A's nurses note, dated 04/02/20 (Thursday), showed the caregiver reports concerns of not being able to take care of the patient and needing help right now. Caregiver continues to report no family will come in and help. Caregiver states he/she has own health concerns and is overwhelmed. RN A documented he/she had received a phone call from the patient's daughter and she stated to RN A that the patient's caregiver sounded overwhelmed and she wanted an update. Advised that would be best if one family member could assist with care to minimize risk of Covid-19 exposure. The patient's daughter reported she had a sibling in Louisiana that was willing to come up and help take care of the patient. The social worker was updated on the conversation with the patient's daughter as well. Review of the visit log for 04/02/20 showed RN-A was at the patient's house from 10:15 A.M. until 11:45 A.M. Review of MSW-B's note dated 04/02/20, showed the following: -At 1:52 P.M., the social worker spoke with the primary caregiver and reiterated that the agency could not place the patient in a nursing facility due to Covid-19 restrictions and the caregiver expressed an understanding. The social worker gave an update to the caregiver on the plan that one of the patient's children from Louisiana would be coming to help care for the patient. The social worker told the caregiver that as soon as he/she knew when, he/she would let the caregiver know; -At 2:29 P.M. the social worker spoke with the patient's daughter and she had informed the social worker that her sibling from Louisiana would be at the patient's home on Monday morning to help care for the patient. There was no further documentation showing that anyone had notified the primary caregiver of the plans. Review of a phone call report, dated 04/03/20 (Friday), showed RN-C documented the following: -At 8:39 P.M., he/she received a phone call that the primary caregiver had called 911 due to the patient having increased weakness and the patient was transported to the hospital; -At 9:01 P.M., call placed to primary caregiver to discuss revoking hospice to cover hospitalization, the caregiver stated, "he/she had not slept in 20 hours and cannot sign tonight, and requested a visit tomorrow, but not early so that he/she can sleep." Review of the Hospice Benefit Revocation, dated 04/04/20, showed the primary caregiver signed the revocation paper for the following reason: Went to the hospital for treatment and then leaving the service area and moving to the daughter's house out of state. During an interview on 09/30/20 at 4:50 P.M., RN-A said the following: - He/she thought that a family member from out of state was coming to help the primary caregiver care for the patient; - He/she did not follow-up to see if the family member from out of state arrived to help the primary caregiver (PCG); - He/she did not offer continuous care as the patient did not need it and did not feel the patient was at risk of harm by being left with the primary caregiver; and - He/she had told the social worker about the primary caregiver feeling overwhelmed and needing help. During an interview on 10/01/20 at 9:11 A.M., MSW-B said the following: - The patient did not want to go to the nursing home, he/she wanted to stay at home; - The hospice did not offer continuous care to the patient's family; - One of the patient's children from out of state was coming to help the primary caregiver in the home take care of the patient; and - The patient revoked because the patient ended up going to the hospital and then was moving out of the service area. During an interview on 10/01/20 at 10:29 A.M., the Sr. Vice President of Clinical Operations said he/she would have expected the agency to do continuous care until another family member could help provide care for the patient.
L0543      
29559 Based on policy review, clinical record review, and interview, the agency failed to ensure all hospice care and services on the plan of care (POC) were followed when visits were not completed as ordered in one (Record/Patient #1) out of five full record reviews conducted. This deficient practice has the potential to adversely affect the care provided to all patients served by the agency. Findings included: Review of the agency's policy titled, "IDG Hospice plan of care- Content, Plan, Goals, Interventions, and Outcomes, dated as revised, 12/08/18, showed in part the following: -The plan of care will identify all the services needed to address problems identified in the initial, comprehensive, and updated assessments; -The plan of care will integrate changes based on clinical, social, spiritual, and emotional assessment findings; -A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; -Coordination of services: Hospice will ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided. Hospice will ensure that the care and services are provided in accordance with the plan of care. RECORD/PATIENT #1: Review of the record showed the patient's admittance to hospice on 08/12/20. The admitting diagnosis was Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient resided at a long-term care facility. Review of the plan of care showed that the patient was assigned hospice nurse visits twice a week on Monday and Thursday and chaplain visits once a month. Review of Interdisciplinary Group (IDG) notes, dated 08/26/20, showed the chaplain has increased visits to two times per month in order to spend time with the patient's spouse and the nurse visits to continue twice a week on Monday and Friday. Review of the clinical record showed no hospice nurse visits were made 08/20/20, 08/27/20, 09/18/20, 09/21/20, and 09/25/20. Review of the long-term care facility record of hospice nursing visits also showed no hospice nurse visits were made 08/20/20, 08/27/20, 09/18/20, 09/21/20, and 09/25/20. Review of the chaplain visits, showed only one visit for August on 08/14/20 and only one visit for September on 09/28/20. An interview was conducted with the memory care director where the patient lived on 09/29/20 at 2:11 P.M. He/she stated that the facility had been allowing visits from the hospice agency and had not restricted any hospice staff from doing their scheduled visits. He/she did say that they required the screening of all staff and that they required the hospice nurse to document each time he/she made a visit in their record. Findings were reviewed with the Sr. Vice President of Clinical Operations and the hospice supervisory nurse on 10/01/20 at 10:00 A.M.. No additional information was provided by the survey exit.
L0544      
29559 Based on policy review and record review, the hospice failed to ensure that each patient and the primary care giver(s) received education for services identified in the plan of care in one of five full records reviewed. A patient was given a bolus of intravenous fluid without specific education to the family regarding precautions (Patient/Record #4). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: 1) Review of policy/procedure, Number 299-37: STANDARDS OF PRACTICE FOR INTERDISCIPLINARY GROUP, last revised 11/11/19, showed in part: - Crossroads ensures that each and every discipline within the hospice interdisciplinary group follows the standards of practice for each professional discipline, to ensure that the safety of the patient is maintained and that highly qualified professionals are hired and retained by the hospice; - This policy encompasses all staff including registered nurse, nurse practitioner, and licensed practical nurse; - All licensed staff must meet all qualifications and follow standards of practice for their specific discipline including ...documentation; - Clinical staff will be supervised by and report to a designated supervisor; - All clinical staff will document all visits, interactions, phone calls with patient/family within the patient's medical record; - All documentation must be timely, concise, detailed, legible (if handwritten) and complete; - All clinical staff will ensure coordination of care and timely communication to ensure patient/family needs are met and that all State, Federal and CHAP guidelines are met. RECORD/PATIENT #4: Review of the initial plan of care showed that the patient was admitted on 06/05/2020 with a terminal diagnosis of breast cancer. Review of an interim physician order dated 06/05/2020 at 11:15 AM showed an order to administer intravenous fluids of one liter of normal saline over two hours (500 ml/hr). Review of the medication profile showed to administer intravenous fluids of one liter of normal saline over two hours daily starting on 06/05/2020. Review of a nurse visit noted dated 06/05/2020 (unable to determine time) showed that the patient's lungs were clear in all lobes. Review of another nurse visit note on 06/05/2020 (unable to determine time) showed a visit to the patient's home and the patient's implanted intravenous port was used to start intravenous fluids of one liter of normal saline over two hours. The note stated coordination occurred with the patient's caregiver. The visit had no documentation that specific education was provided to the patient or caregivers regarding the IV fluid bolus at 500ml/hr. (A fluid bolus runs the risk of fluid overload) Review of an interim physician order dated 06/05/2020 at 9:00 PM showed an order to discontinue IV fluids. Review of a communication note, documented on 06/05/2020 at 11:20 PM, showed that a caregiver called and reported that the patient was "gurgling", "guppy breathing" and oxygen saturations were in the "70's". The agency nurse failed to provide education to the caregivers regarding what symptoms or risks are associated with giving a fluid bolus.
L0545      
29559 Based on policy review, record review and interview, the agency failed to ensure an accurate plan of care/medication profile/treatment profile for each patient to include treatments necessary to meet the needs of the patient in two (Record/Patient #1 and #2) of two records reviewed who resided in a long-term care facility (LTCF). This deficient practice has the potential for incomplete medication orders and adverse medication events for patients in LTCF. Findings included: Review of the hospice policy titled "IDG HOSPICE PLAN OF CARE-CONTENT, PLAN, GOALS, INTERVENTIONS AND OUTCOMES", last revised 12/08/2018 v2 showed in part, the following: - Policy statement: The hospice agency and palliative care ensures patient and family needs are met by establishing, following, updating an individualized plan of care that clearly meets the scope of needs; - Purpose: To provide information and guidance regarding the interdisciplinary group (IDG) hospice plan of care and the comprehensive assessment which contribute to the plan of care and required and completed for hospice and palliative care patients; - Procedures: The IDG written plan of care is based on initial and updated patient- specific comprehensive assessments by members of the IDG and is developed with measurable goals and outcomes for planned interventions; - The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: name, dosage, route, frequency and indication of medication/treatments ordered; plans of care will be individualized and patient-specific; the plan of care will integrate changes based on clinical, social, spiritual and emotional assessment findings; the plan of care will be documented, will support that the development of the plan of care was a collaborative effort involving all members of the IDG, the patient/family and as appropriate, the attending physician; - The hospice interdisciplinary group must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days; - A revised plan of care will include information from the patient's updated comprehensive assessment and will note of the patient's progress toward outcomes and goals specified in the plan of care; and - The hospice will ensure systems are in place to facilitate the exchange of information and coordination of services among staff and with other non-hospice healthcare providers. PATIENT/RECORD #1: Review of the clinical record showed the patient's admittance to hospice on 08/12/20. The admitting diagnosis was Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient had secondary diagnosis of hypertension (elevated blood pressure) and diabetes (elevated blood sugar). The patient resided in a long-term care facility. Example #1 Review of the patient's Initial/Comprehensive assessment, dated 08/12/20, showed the following: -The patient was incontinent of bowel and bladder; -The patient had diabetes; -The patient needed to be fed; -The patient had recent weight loss; -The patient was at risk for falls; -No teaching was provided for dehydration. Review of the medication profile showed the following: -Amiloride HCl (diuretic used for hypertension) 5 milligram (mg) one-half a tab once a day; -Hydrochlorothiazide (diuretic used for hypertension) 25 mg one tab once daily; -Metformin (anti-diabetic agent) 500 mg one tab twice a day; -Memantine (cognition-enhancing medication) 10 mg one tab daily. Review of patient's plan of care contained duplicate medication therapy (diuretic), was not individualized to include interventions for potential for dehydration since on duplicate diuretics, individualized interventions for incontinence as to what to use and if to try and toilet or check and change, safety interventions for the patient since has Alzheimer's, and no individualized interventions regarding the patient's diabetes. Example #2 Review of phone call report, dated 08/22/20, showed the hospice nurse received a phone call from the patient's child stating that the patient had a fall. Review of Interdisciplinary Group (IDG) meeting note, dated 08/26/20, showed the interventions for falls were not updated or individualized. Review of comprehensive assessment, dated 09/22/20, showed the hospice nurse documented that the patient's child reported the patient had another fall. Review of Interdisciplinary Group (IDG) meeting note, dated 09/23/20, showed no documentation of the fall in the notes and the interventions for falls were not updated or individualized. Findings were reviewed with the Sr. Vice President of Clinical Operations and the hospice supervisory nurse on 10/01/20 at 10:00 A.M. No additional information was provided by the survey exit. PATIENT/RECORD #2: Review of the clinical record showed the patient's admittance to hospice on 07/14/19. The admitting diagnosis was Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient had secondary diagnosis of hypertension (elevated blood pressure) and diabetes (elevated blood sugar). The patient resided in a long-term care facility. Example #1 Review of the patient's Initial/Comprehensive assessment, dated 07/14/2019, showed the following: - The patient was disorientated to person, place, time and situation; - The patient was on a bowel regimen; - The patient had generalized weakness, unable to feed self and unable to make needs known; - The patient was total care for activities of daily living (ADLs); - Aspiration precautions taken to ensure patient safety; and - Fall precautions to ensure patient safety. Review of patient's plan of care was not individualized to include interventions for constipation, individualized interventions for incontinence as to what to use and if to try and toilet or check and change, no safety interventions for the patient since has Alzheimer's, and no individualized safety interventions regarding the patient's risk for falls and aspiration precautions. Example #2 Review of comprehensive assessment, dated 08/09/20, showed the hospice nurse documented that the patient was one to two assist with transfers, stand to pivot and the patient does not bear any weight. Review of a face to face visit patient assessment report, dated 08/11/20, showed the APRN documented the patient was a Hoyer lift (mechanical lift) or one to two person transfer as the patient does not bear any weight. Review of Interdisciplinary Group (IDG) meeting note, dated 08/12/20, showed the interventions for transfers were not updated or individualized. Findings were reviewed with the Sr. Vice President of Clinical Operations and the hospice supervisory nurse on 10/01/20 at 10:00 A.M.. No additional information was provided by the survey exit.
L0619      
29559 Based on review of employee files and interview, the agency failed to show documentation that demonstrated completion of the required hospice aide basic skills testing in one employee/hospice aides (E1) of one hospice aide personnel files reviewed. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of E1's employee file showed the aide was hired on 11/11/19. The file included an exam for the basic skills test which is used to document registered nurse (RN) observation and competency evaluation of the aide's ability to perform the hands-on skills and tasks associated with caring for the patient. The test dated 12/02/19 failed to include documentation of specific comments regarding the skills, tasks, and the aide's performance of the following items: - Measurement of: * Oral and axillary temperature; * Radial pulse; * Respirations; and * Blood pressure; - Bed, sponge, shower, and tub bath; - Shampoo of the hair in bed; - Nail care including filing and cleaning; - Skin care including lotion/powder and protective barrier, and observation of skin and correct identification of any changes to be reported to the registered nurse; - Oral care including dentures and/or natural teeth; - Peri-care, incontinent care, and use of the bedside commode; - Patient and aide safe transfer techniques; - Ambulation using a walker or cane; - Active and passive range of motion; and - Bed and chair positioning technique. During an interview on 10/01/2020 at 10:00 AM, the supervisory nurse stated that he/she was not familiar with the requirement to document specific comments regarding the competency and the aide's performance of the tasks on the Missouri state approved basic skills test. No further information was provided.
L0625      
29559 Based on clinical record review and staff interview, the hospice failed to prepare a complete and accurate hospice aide assignment in, but not limited to, one (Records/Patients #5) of four patients reviewed for hospice aide services. This deficient practice may adversely affect the quality of aide services provided to all the agency's hospice patients. Findings included: RECORD/PATIENT #5: Review of the initial comprehensive assessment of the patient, performed on 08/11/2020, showed that the patient wanted aide services three times weekly. Review of the initial interdisciplinary comprehensive hospice care plan showed the visit frequency for the hospice aide was three times per week. Review of the hospice aide care plan visit notes showed the hospice aide performed a visit and provided care to the patient on 08/14/2020 at 2:00 PM. Review of the hospice aide assignment sheet showed that the initial aide assignment sheet was created on 08/18/2020. A review of the clinical record findings was completed with the hospice administrator and supervisory nurse on 10/01/2020 at 10:00 AM. The supervisory nurse confirmed that the hospice aide did not have an assignment sheet for performance of the visit and tasks on 08/14/2020. No additional information was provided.
L0629      
29559 Based on record review and interview, the agency failed to ensure the registered nurse (RN) documented an accurate hospice aide on-site supervisor visit every 14 days in one (Record/Patient #2) of five complete record reviews completed. This deficient practice has the potential to affect the personal care and services of all the agency's patients with hospice aide services Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 7/14/2019. The primary diagnosis was Alzheimer's (progressive brain disorder that slowly destroys memory and thinking skills). The patient resided at a long-term care facility. Review of the hospice aide plan of care dated 7/14/2019, showed the certified hospice aide was to visit two times a week and complete the following task: - The patient required total care; - Shower, comb/brush hair, oral care/dentures, nail care, apply lotion/moisturizer, dress, perineal care, change adult brief, ambulation, wheelchair, up as tolerated, up in chair, reposition, make bed, change bed linens, straighten room and feed patient twice a week; and - Shampoo once a week. Review of the hospice aide care plan for inter disciplinary group (IDG) on 3/25/2020, showed no hospice aides allowed in the building as of 3/23/2020 per the administrator. Review of the hospice aide care plan visit, dated 7/1/2020 and 7/14/2020, showed supply delivery only due to COVID. Review of the hospice aide care plan visit, dated 7/16/2020 showed phone call only due to COVID. Review of the plan of care report showed the hospice aide was to make one phone call per week and one supply delivery per a week due to COVID-19, starting 7/21/2020. Review of the hospice aide care plan visit, dated 7/23/2020 and 7/30/2020 showed phone call only due to COVID. Review of the clinical record supervisory visit patient assessment report dated 7/30/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: N/A; - Exhibited positive rapport with patient/family: N/A; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored Health Insurance Portability and Accountability Act (HIPAA) (a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) and confidentiality: yes. Review of the hospice aide care plan visit, dated 8/6/2020 and 8/13/2020 showed phone call only due to COVID. Review of the hospice aide care plan visit, dated 8/20/2020, showed one phone call and one supply delivery. Review of the clinical record supervisory visit patient assessment report dated 8/21/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: yes; - Exhibited positive rapport with patient/family: yes; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored HIPAA and confidentiality: yes. Review of the hospice aide care plan visit, dated 8/27/2020 showed supply delivery only due to COVID. Review of the clinical record supervisory visit patient assessment report dated 8/29/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: yes; - Exhibited positive rapport with patient/family: yes; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored HIPAA and confidentiality: yes. Review of the hospice aide care plan visit, dated 9/3/2020 showed supply delivery only due to COVID. Review of the clinical record supervisory visit patient assessment report dated 9/7/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: N/A; - Exhibited positive rapport with patient/family: yes; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored HIPAA and confidentiality: yes. Review of the clinical record supervisory visit patient assessment report dated 9/8/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: N/A; - Exhibited positive rapport with patient/family: N/A; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored HIPAA and confidentiality: yes. Review of the hospice aide care plan visit, dated 9/10/2020, showed supply delivery only due to COVID. Review of the clinical record supervisory visit patient assessment report dated 9/12/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: yes; - Utilized safety precautions: yes; - Provided comfort measures: N/A; - Exhibited positive rapport with patient/family: yes; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: N/A; and - Followed/honored HIPAA and confidentiality: yes. Review of the hospice aide care plan visit, dated 9/17/2020, showed supply delivery only due to COVID. Review of the clinical record supervisory visit patient assessment report dated 9/18/2020 completed by RN E on the hospice aide, showed the following: - Followed established plan of care: yes; - Coordinated care with facility-family: yes; - Utilized universal precautions: N/A; - Utilized safety precautions: N/A; - Provided comfort measures: N/A; - Exhibited positive rapport with patient/family: yes; - Thorough knowledge of disease process: yes; - Accurate and timely documentation processes: yes; - Patient/family/nursing facility satisfied with care: yes; and - Followed/honored HIPAA and confidentiality: yes. Review of the hospice aide care plan visit, dated 9/24/2020, showed supply delivery only due to COVID. The RN documented inaccurate supervisory aide visits when saying the aide followed the plan of care and provided comfort measures when the facility has not been allowing aides in the facility since March 23, 2020, where the patient resides. Findings were reviewed with the Sr. Vice President of Clinical Operations and the hospice supervisory nurse on 10/01/20 at 10:00 A.M., and they said that nursing documented supervisory visits due to hospice aides making phone calls.
L0653      
29559 Based on hospice consent forms, and record review, the agency failed to ensure medications were routinely available on a 24-hour basis 7 days a week. The hospice admission form that all patients signed on admission prevented refills of medications after hours, on holidays, or on weekends in five out of five full records reviewed (Patient/Records #1, #2, #3, #4 and #5). One patient ran out of pain medications over a weekend (Patient/Record #7). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of admission documents that all patients are required to sign to be admitted to the hospice showed "Registration and Consent Forms (page 8)" showed under a section titled "NO EXCEPTIONS": - "NO refills will be authorized after-hours, on holidays or on weekends. I (the patient) will ensure that I have an adequate supply available supply available prior to any scheduled weekend or holiday period and will communicate the needs for refills with my care team prior to the depletion of the current prescription; and -" I fully understand that failure to comply with the rule will result in immediate discharge from the Crossroads Hospice Program" RECORD/PATIENTS #1, #2, #3, #4 and #5: Review of the admission consent documents showed that the patient or responsible party received and signed "Registration and Consent Forms (page 8)". RECORD/PATIENT #7: Review of the initial comprehensive assessment showed that the patient was admitted on 06/17/2020 with a primary diagnosis of bladder cancer. Review of a 06/18/2020 nurse visit note showed a narrative note as follows: "Patient very concerned about medications and wants to know exactly what will be covered by hospice". Review of a phone call by the patient's spouse/primary care giver on 06/22/2020 (untimed)showed that the patient's caregiver (PCG) "needs clarification on covered meds and does not know the names of the meds at this time" Review of a 06/22/2020 nurse visit note (untimed) showed a narrative note as follows: "(Pharmacy-A) contacted regarding remaining tablets of dexamethasone that are owed and the patient does not have any. Per pharmacist they are out of them and did not get a shipment, will not get them until July or August and will take days to get from another (Pharmacy-A) location if they have them. Requested remaining balance owed to pt transferred to (pharmacy-B)so patient can get them for his/her pain." Review of the hospice providers complaint/grievance log showed that the patient's spouse/primary caregiver called in a complaint on 06/23/2020. The complaint stated that the patient ran out of pain medication (dexamethasone used for pain) over the weekend. The above findings were reviewed with the hospice administrator on 10/01/2020 at 10:02 AM. The administrator stated that medications were available 24 hours a day, 7 days a week to the patients. No additional evidence was provided by the survey exit.
L0670      
29559 Based on policy review, clinical record review, and interview the hospice provider failed to: - Ensure each patients record included accurate advance directives (L677); and - Ensure that all clinical record documentation was documented in a timely matter (L679). The inaccurate code status in multiple records reviewed, described in L677, resulted in potential adverse outcomes for all patients on service with the provider. This deficient practice was identified at a condition level.
L0677      
29559 Based on policy review, record review, and interview the hospice provider failed to ensure each patient's record included accurate advance directives in three of five full records reviewed (Record/Parent #1, #4, and #5). Patients that elected a Do-Not Resuscitate (DNR) status were incorrectly identified as Full Code. This system problem has the potential to cause patients to undergo unnecessary painful medical procedures during resuscitation efforts. This system problem is identified as condition level. Review of the agency's policy titled, "Advance Directive," dated as revised 01/23/17, showed in part the following: -An adult person has the fundamental right to control the decisions relating to the rendering of their own health care, including the decision to have life-sustaining treatment withheld or withdrawn in instances of a terminal condition or permanent unconscious condition -An adult person has the right to make a written directive instructing his/her physician to withhold or withdraw life-sustaining treatment in the event of a terminal condition or permanent unconscious condition; -An adult person has the right to control his/her health care through an authorized agent who validly holds the person's durable power of attorney for health care; -The agency's goal is to honor the treatment decisions of every patient and will advise a patient or his/her agent when the agency is unable to honor his/her advance directive; -At the time of registration all adult patients will be asked if they have an advance directive; -An advance directive stipulating "Do Not Resuscitate" (DNR) does not replace a signed physician's order. A signed physician's order for a "no code" status must be obtained prior to staff implementing a DNR advance directive. RECORD/PATIENT #1: Review of clinical record showed the patient's admittance to hospice on 08/12/20. The admitting diagnosis was Alzheimer's (progressive disorder that causes brain cells to waste away and die). The patient resided in a long-term care facility. The patient signed a Do Not Resuscitate (DNR) order on 08/11/20 and the physician signed this order on 08/27/20. During a home visit observation on 09/28/2020, the long-term care facility chart was reviewed with the long-term care staff. Review of the patient's physician's orders in the hospice binder, dated 09/28/20 provided by the hospice supervisory nurse showed the patient as a Full Code. Review of the patient's long-term care facility's physician orders, dated 09/29/20 provided by the memory care director also showed the patient as a Full Code. During an interview on 09/29/20 at 2:28 P.M., the hospice supervisory nurse stated that the facility orders are the agency orders, as the agency writes all orders in the long-term care facility chart. The state surveyor informed the hospice supervisory nurse that the facility and agency orders showed the patient as a Full Code and the patient had a DNR that he/she signed on 08/11/20. This problem was identified on 09/29/2020 and reported to the hospice supervisory nurse. The long-term care code status orders were not corrected by the survey exit. RECORD/PATIENT #4: Review of the patient's clinical record showed a "DO-NOT RESUSCITATE" form signed by the patient's power of attorney on 06/05/2020. Review of the initial comprehensive assessment dated 06/05/2020 (untimed) showed that the nurse assessed that the patient "DOES NOT" want CPR performed. The assessment also noted the patient's code status as "FULL CODE". (Full code indicates CPR would be performed). The findings were reviewed with the hospice administrator on 10/01/2020 at 10:16 AM. No additional information was provided by the survey exit. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to routine hospice care on 08/11/2020 with a diagnosis of malignant neoplasm of overlapping sites of right female breast. The comprehensive assessment completed on 08/11/2020 showed: - The patient did not want cardiopulmonary resuscitation (CPR) performed; - The patient did not have an out-of-hospital do not resuscitate (DNR) order; and - The patient had a code status of "Full Code (perform CPR)". The initial interdisciplinary comprehensive hospice care plan dated 08/11/2020 showed the patient was admitted to routine hospice care with a code status of "DNR". The interdisciplinary group (IDG) meeting notes on 08/19/2020 showed the patient was a full code at the top of the form and the MSW notes stated that the patient was a DNR. The findings were reviewed with the supervisory nurse on 10/01/2020 at 10:00 AM. No additional information was provided by the survey exit.
L0679      
29559 Based on policy review, record review, and interview, the agency failed to ensure that all clinical record documentation was documented in a timely matter, in but not limited to, two of five records (Record/Patient #2 and #5) reviewed. This deficient practice has the potential to affect complete and accurate documentation of the patient's condition for all the agency's patients. Findings included: Review of the agency's policy titled, "Hospice Clinical, Human Resource and Agency Documentation and Entry Compliance Policy," dated 2018, showed the following: - The purpose of the policy was to provide processes and requirements to ensure that a thorough, exact and detailed account of the patient/family's condition, situation is available to maintain coordination and continuity of care and to avoid duplication of services; and - All documentation was to be submitted to the hospice office the following business day. RECORD/PATIENT #2: Review of the clinical record show the patient was admitted to hospice on 7/14/2019 with a terminal diagnosis of Alzheimer's (progressive brain disorder that slowly destroys memory and thinking skills). The patient resided in a long-term care facility. Review of the clinical record showed the following: - The certified nurse aide/hospice aide (CNA) visit was done on 8/13/2020 and charted by the CNA on 9/1/2020 - 19 days later; - The CNA visit was done on 8/20/2020 and charted by the CNA on 8/27/2020 - 7 days later; and - The CNA visit was done on 9/24/2020 and charted by the CNA on 9/30/2020 - 6 days later. 09/29/2020 at 11:24 AM when the hospice supervisory nurse was asked what the expectations were for timely documentation he/she replied "I don't know". The policy was then requested. Findings were reviewed with the Sr. Vice President of Clinical Operations and the hospice supervisory nurse on 10/01/20 at 10:00 A.M. The Sr. Vice President of Clinical Operations said the policy said documentation was to be completed by the next day. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to routine hospice care on 08/11/2020 with a diagnosis of malignant neoplasm of overlapping sites of right female breast. Review of the clinical record showed the following: - CNA visit was done 08/13/2020 and charted by the CNA on 08/18/2020, 5 days later; - CNA visit was done 08/14/2020 and charted by the CNA on 08/18/2020, 4 days later; - CNA visit was done 08/21/2020 and charted by the CNA on 08/25/2020, 4 days later; - CNA visit was done 09/03/2020 and charted by the CNA on 09/08/2020, 5 days later; - LPN (licensed practical nurse) visit was done on 08/18/2020 and charted on 08/24/2020, 6 days later; - RN (registered nurse) visit was done on 08/12/2020 and charted by the RN on 08/17/2020, 5 days later; - RN visit was done on 08/12/2020 and charted by the RN on 08/18/2020, 6 days later; - RN visit was done on 08/20/2020 and charted by the RN on 08/25/2020, 5 days later; - RN visit was done on 09/04/2020 and charted by the RN on 09/15/2020, 11 days later; - RN visit was done on 09/18/2020 and charted by the RN on 09/27/2020, 9 days later; - RN visit was done on 09/18/2020 and charted by the RN on 09/28/2020, 10 days later; - RN visit was done on 09/21/2020 and charted by the RN on 09/28/2020, 7 days later; and - RN visit was done on 09/24/2020 and charted by the RN on 09/28/2020, 4 days later. Clinical record findings were reviewed with the hospice supervisory nurse on 10/01/2020 at 10:00 AM. The supervisory nurse stated that they have had issues with late documentation and provided no additional information.
L0682      
29559 Based on record review and interview the hospice provider failed to ensure a discharge summary was sent to the receiving hospice provider upon transfer or discharge of hospice services in, but not limited to, one (Record/Patient #9) of one transfer/discharge focused review records. This deficient practice has the potential to affect the post-discharge care of all the agency's live patients discharged or transferred. Findings included: RECORD/PATIENT #9: Review of the clinical record showed the patient was admitted to hospice services on 11/20/2019 with a terminal diagnosis of prostate cancer with metastasis to the bone. The patient decided to use another hospice agency. The patient was transferred to another hospice. Review of the clinical record failed to show evidence that the discharge summary was sent to the receiving facility. On 10/01/2020 at 10:00 AM, the findings from the record review for Patient #9 was reviewed with the Sr. Vice President of Clinical Operations and the Supervisory Nurse. No additional information was provided by the survey exit. During an interview on 10/01/20 at 11:29 A.M., the Sr. Vice President of Clinical Operations said there was no other evidence the discharge summary had been sent to the receiving facility.
L0683      
29559 Based on record review and interview the agency failed to send a hospice discharge summary to the patient's accepting physician after discharge when the patient elected revocation of hospice services in one of one patients reviewed for revocation (Patient/Record #8). The deficient practice has the potential to affect coordination of care with all patients that revoke hospice service. Findings included: PATIENT/RECORD #8: On 09/30/20 at 3:05 P.M., the Sr. Vice President of Clinical Operations was asked for the discharge information for the patient to include revocation form, documented reason for revocation, and a discharge summary from the hospice to the accepting physician after discharge. Review of the entire clinical record provided showed no discharge summary. During an interview on 09/30/20 at 4:10 P.M., the Sr. Vice President of Clinical Operations said he could not find a discharge summary on this patient.
L0774      
29559 Based on policy review, record review, home visit observation, and interview, the hospice agency failed to ensure the written coordination of care between the long-term care facility and the hospice agency identified the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon in two of two cases sampled where home visits were completed in long-term care facilities. (Record/Patient #1 and #2). The deficient practice has the potential to affect all patients residing in long term care facilities and on service with the hospice provider. Findings included: Review of the agency's policy titled, "Nursing Facility Coordination of Care, Hospice Services, and MDS 3.0/Care plan Coordination," dated as revised 07/09/15, showed the following: -The hospice will coordinate care with all contracted nursing facilities to ensure proper care and utilization of hospice protocols, procedures, philosophy and palliative care principles. To ensure the coordination of patient care, the agency personnel, especially the case manager, shall attend nursing facility care plan meetings being held to discuss/review hospice patients. Upon admission, the hospice will review the facility plan of care to ensure the implementation and coordination of problems within the hospice plan of care as related to the terminal condition; -Hospice will provide to the facility the most recent plan of care specific to each patient. The names and contact information for hospice personnel involved in hospice care of each patient; -The hospice will develop and maintain a mechanism whereby care is coordinated between Interdisciplinary Group members (IDG/IDT) and persons providing routine care, respite care, or continuous care within the nursing facility; -The hospice staff will ensure that all patient care is coordinated with the facility staff to maintain coordination of care and to avoid duplication of services; -The hospice will maintain medical management of all hospice patients residing inside the facility while ensuring that the facility staff and hospice staff work as a team to provide coordinated, additional care, not replace nursing facility care to the patient. RECORD/PATIENT #1: Review of the hospice plan of care showed that the nurse was to visit twice a week on Mondays and Fridays, the social worker was to visit once a month, and the chaplain was to visit twice a month. During a home visit observation on 09/29/20 at 10:41 A.M., the hospice nurse (RN D) was observed completing a visit with the patient. RN D stated that the coordination documents were kept in a three ring binder at the facility nurse's station. Review of the three ring binder with the documents hospice provided the long-term care facility showed the following a "written coordinated task plan of care" (the document used by the hospice to coordinate services between the facility and the hospice agency). The document had no phone numbers listed, the nurse listed was no longer seeing the patient, the document had no hospice chaplain listed and no frequency of visits for the hospice chaplain, and the document had no hospice social worker listed and no frequency for the hospice social worker. The "written coordinated task plan of care" was reviewed by the hospice nurse (RN D) during the 09/29/20 visit and he/she agree that the document was incomplete. Findings were reviewed with the Sr. Vice President of Clinical Operations and the Supervisory Nurse on 10/01/20 at 10:00 A.M. No additional information was provided by the survey exit. RECORD/PATIENT #2: Review of the patient's face sheet showed that the patient was admitted to hospice service on 07/14/19, and that the patient resided in a long term care facility. Example #1 During a home visit observation on 09/29/2020, the current long term care facility physician orders were reviewed. The long term care facility orders showed that the physician ordered on 03/18/2020 that the patient was to receive barrier cream to his/her buttocks twice daily as needed for redden areas. During the home visit observation on 09/29/2020, the current written coordination of care (task plan) between the hospice and long term care facility located in a hospice binder at the long term care facility nurse's station was reviewed. Review of the "Coordinated Care Plan" showed that the hospice failed to document that the patient was to receive barrier cream to his/her buttocks twice daily as needed for redden areas. Example #2 During a home visit observation on 09/29/2020, the current written coordination of care (task plan) was reviewed at the long-term care facility where the patient lived. The hospice agency registered nurse (RN) E went behind the nurses station and got the white hospice binder that was used for hospice coordination of care. Review of the binder showed the coordinated care plan was incomplete. The Coordinated Care Plan failed to show the following: - The correct name of the RN case manager; - The correct name of the hospice chaplain; - The correct name of the hospice social worker; - The hospice social worker frequency visits; and - The chaplain frequency visits. Findings were reviewed with the Sr. Vice President of Clinical Operations and the Supervisory Nurse on 10/01/20 at 10:00 A.M. No additional information was provided by the survey exit.