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)
L0536      
29559 Based on agency policy, home visit observation, clinical record review and interview, the hospice provider's interdisciplinary group (IDG): - Failed to consult with the patient's attending physician regarding the patient's plan of care (L537); - Failed to update the plan of care orders to specify the hospice care and services necessary to meet the patient's needs with an accurate comprehensive assessment (L538); - 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); - Failed to develop an individualized written plan of care for the patient (L545); - Failed to ensure the written plan of care for each patient included interventions to manage pain and symptoms (L546); - Failed to ensure the written plan of care for each patient included the drugs and treatments necessary to meet the needs of the patient (L549); and - Failed to ensure all medical supplies and appliances necessary to meet the needs of the patient were included in the plan of care (L550). The cumulative effect of these systemic practices, 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, clinical record review, and interview, the agency failed to specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessments as such needs relate to the terminal illness and related conditions in three (Records/Patients #2, #3 and #4) of four clinical records reviewed. This deficient practice as the potential to affect the care provided to all of the agency's patients. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. Findings included: Review of agency policy dated 12/11/2018 and titled, "POLICY: COMPREHENSIVE ASSESSMENT," showed, in part, the following: - POLICY STATEMENT: Crossroads Hospice and Palliative Care maintains complete, concise, consistent records of the care provided to all hospice patients and their families. Upon admission to the hospice program, the Agency will complete an initial and comprehensive assessment. A comprehensive assessment means a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver's and family's willingness and capability to care for the patient' - The hospice interdisciplinary group in consultation with the individual's attending physician (if any) must complete the Comprehensive Assessment no later than five (5) calendar days after election (but can be completed at the time of the Initial Admission Assessment) of hospice care in accordance with §418.24 and includes identification of patient/family/caregiver needs related to the terminal illness; and - An update of the Comprehensive Assessment is conducted by the hospice IDG in collaboration with the patient's attending (if any) as frequently as the patient's condition warrants but no less frequently than every fifteen (15) days and includes identification of changes that have occurred since the initial assessment, information on the patient's progress toward desired outcomes and goals, and reassessment of the patient's response to care. Review of the agency policy dated 12/08/2018v2 and titled, "POLICY: IDG HOSPICE PLAN OF CARE-CONTENT, PLAN, GOALS, INTERVENTIONS AND OUTCOMES," showed, in part, the following: - The Initial Plan of Care (IPOC) is established at the time of admission. The comprehensive or hospice Plan of Care (POC) is an addition to the IPOC and is an ongoing, ever-changing, fluid process which is documented, to ensure that the patient (and family)'s condition and needs are assessed, identified, with appropriate interventions implemented to intervene and control problems. The progression of goals must be indicated, as well as the responsible party (such as hospice, facility, nurse, aide, caregiver, etc., as needed and appropriate); - The plan of care must reflect patient and family goals; include interventions for problems identified through the assessment process; include all services necessary for palliation and management of the terminal illness and related conditions; and - The Plan of care interventions must include measurable outcomes with data collected during the comprehensive assessment and updates. The POC must include all drugs, treatments, medical supplies and appliances, and include documentation of teaching and the patient's or representative's level of understanding, involvement and agreements with the plan of care should appear in the clinical record. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 for terminal diagnosis of congestive heart failure. The client had additional comorbidities including hypertension (an elevated pressure in the blood vessels), diabetes (a disease that results in too much sugar in the blood causing kidney, heart, and nerve disorders, and foot problems including reduced blood flow to the feet) and atrial fibrillation (a fluttering of the upper chambers of the heart). Review of the follow-up comprehensive assessment completed by the registered nurse on 11/06/2020 showed, in part, that the patient had several skin tears to bilateral lower extremities that were not bleeding and were left open to air (with no dressing). The patient was also taking Plavix (an antiplatelet agent that prevents clot formation used to treat atrial fibrillation). The plan of care updated 11/11/2020 failed to contain interventions for the care and patient/caregiver education related to the skin tears on the lower extremities and interventions for bleeding precautions associated with the antiplatelet agent. The clinical record review findings were presented on 11/17/2020 at 2:45 P.M. to the chief compliance officer, owner, director of education, and the assistant executive director. No further evidence received from the agency. RECORD/PATIENT #3: Example #1 Review of the hospice certification documents showed that the 94 year old patient was admitted to hospice on 11/10/2020 for a terminal diagnosis of heart failure. The patient had an implanted pacemaker/defibrillator, pancreatic cancer, and history of blood clots. Review of the comprehensive assessment completed on 11/10/2020 showed an incomplete comprehensive assessment. The nurse assessed that the patient had chronic back pain. The assessment failed to include: - History of pain and its treatment being treated by the routine analgesic (including non-pharmacological and pharmacological treatment); and - Characteristics of pain being treated with the routine analgesic, such as: - Intensity of pain (e.g., as measured on a standardized pain scale); - Descriptors of pain (e.g., burning, stabbing, tingling, aching); - Pattern of pain (e.g., constant or intermittent); - Location and radiation of pain; - Frequency, timing and duration of pain; - Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood); - Factors such as activities, care, or treatment that precipitate or exacerbate pain; - Strategies and factors that reduce pain; - Additional symptoms associated with pain (e.g., nausea, anxiety). The plan of care had no interventions related to the patient's chronic back pain. Example #2 Review of patient #3's initial comprehensive assessment showed the nurse identified a problem regarding the patient's management of CHF (congestive heart failure - the patient's primary problem). " The patient has been refusing to take diuretics due to frequent urination at night. The patient had severe edema in the lower extremities and crackles (crackles - an abnormal lung sound made by air moving through a congested airway) auscultated in both lungs. The nurse documented that the patient appeared to be "fluid overloaded". Review of the plan of care showed no updated interventions regarding the patient refusing his/her diuretics for CHF. The IDG notes show discussion on changing the type of diuretic, dose of diuretic, the time of when the diuretic should be taken, or intervention regarding specific education to the patient. It should be noted that the severe edema, alteration in lung sounds, and the patient being fluid overloaded, and the patient refusing diuretics was not reported to the physician in any documents provided. The clinical record review findings were presented on 11/17/2020 at 2:55 PM to the chief compliance officer, owner, director of education, and the assistant executive director. No further evidence was received from the hospice provider. RECORD/PATIENT #4: Review of the admission physician certification showed the patient was a 76 year old that was admitted to hospice on 11/10/2020 for terminal chronic obstructive pulmonary disease (COPD). Review of the patient's admission medication profile showed Tylenol (an analgesic) for pain used routinely three times a day. The patient was on oxygen at three liters per minute (LPM) per nasal cannula continuously. Review of the comprehensive assessment completed by RN-A on 11/10/2020 showed an incomplete comprehensive assessment. The assessment failed to include: - History of pain and its treatment being treated by the routine analgesic (including non-pharmacological and pharmacological treatment); and - Characteristics of pain being treated with the routine analgesic, such as: - Intensity of pain (e.g., as measured on a standardized pain scale); - Descriptors of pain (e.g., burning, stabbing, tingling, aching); - Pattern of pain (e.g., constant or intermittent); - Location and radiation of pain; - Frequency, timing and duration of pain; - Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood); - Factors such as activities, care, or treatment that precipitate or exacerbate pain; - Strategies and factors that reduce pain; - Additional symptoms associated with pain (e.g., nausea, anxiety). - The clinician documented that oxygen was not present in the home in the safety portion of the assessment. The clinical record review findings were presented on 11/17/2020 at 3:05 P.M. to the chief compliance officer, owner, director of education, and the assistant executive director. No further evidence received from the agency.
L0543      
29559 Based on policy review, clinical record review, and interview, the agency failed to ensure hospice care followed the written plan of care in two (Record/Patients #3 and#4) out of four full records reviewed. 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. PATIENT/RECORD #3: Review of the hospice certification documents showed that the 94 year old patient was admitted to hospice on 11/10/2020 for a terminal diagnosis of heart failure. The patient had an implanted pacemaker/defibrillator, and history of blood clots. Example #1 Review of the written plan of care showed a problem with cardiovascular was identified on 11/12/2020. The intervention for this problem was to use medication, and monitor edema. The plan of care failed to include specific interventions to include oxygen oximetry and weight monitoring. Example #2 Review of the patient's plan of care medication profile showed the patient was taking Coumadin (an anticoagulant) seven days a week. Review of the written plan of care showed a problem with cardiovascular was identified on 11/12/2020. The intervention for this problem was to use medication, and monitor edema. The plan of care failed to include specific problems related to the implanted pacemaker/defibrillator, or interventions such as a protocol regarding lab monitoring of the Coumadin therapy. It should be noted that on a 11/10/2020 emergent visit note the nurse documented that the patient would be going to his/her primary care physician for "PT INR" (INR-International Normalized Ratio, a standard of measurement for the effects of Coumadin) and urine culture. The nurse visit notes and all communication notes showed no coordination/collaboration regarding any results of the tests. PATIENT/RECORD #4: Review of the plan of care medication profile, showed that the patient was started on oxygen at 3 LPM (liters per minute) continuously for shortness of breath starting 11/10/2020. Review of a document titled "interdisciplinary comprehensive hospice plan of care" showed that equipment to be ordered as an "oxygen concentrator 4 liters". The plan of care provided showed no intervention was ordered for oxygen oximetry. Review of the initial comprehensive assessment on 11/10/2020 showed the nurse assessed in the respiratory section of the document that the patient using oxygen at 4 LPM continuously with an oxygen saturation of 96%. Review of the nurse visit notes, dated 11/10/2020 and 11/12/2020 showed that the nurse documented that the patient was on 3 LPM of oxygen at times, and 4 LPM of oxygen at times. The nurse assessed the patients oxygen saturation with every visit. The findings were reviewed with the hospice administrator on 11/17/2020 at 3:02 PM. At the survey exit, the administrator provided additional documents. No relevant documents were provided regarding following the plan of care in regards to the oxygen flow rate.
L0544      
29559 Based on policy review, clinical record review, and interview, the agency failed to ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care in two (Record/Patients #3 and #4) of four clinical records reviewed. This deficient practice has the potential to affect the care provided to all of the agency's patients. Findings Included: Review of the agency policy dated 12/08/2018v2 and titled, "POLICY: IDG HOSPICE PLAN OF CARE-CONTENT, PLAN, GOALS, INTERVENTIONS AND OUTCOMES," showed, in part, the following: - The Initial Plan of Care (IPOC) is established at the time of admission. The comprehensive or hospice Plan of Care (POC) is an addition to the IPOC and is an ongoing, ever-changing, fluid process which is documented, to ensure that the patient (and family)'s condition and needs are assessed, identified, with appropriate interventions implemented to intervene and control problems. The progression of goals must be indicated, as well as the responsible patty (such as hospice, facility, nurse, aide, caregiver, etc., as needed and appropriate); - The plan of care must reflect patient and family goals; include interventions for problems identified through the assessment process; include all services necessary for palliation and management of the terminal illness and related conditions; and - The plan of care interventions must include measurable outcomes with data collected during the comprehensive assessment and updates. The POC must include all drugs, treatments, medical supplies and appliances, and include documentation of teaching and the patient's or representative's level of understanding, involvement and agreements with the plan of care should appear in the clinical record; and - The plan of care will contain the interdisciplinary group's documentation of the patient or representative level of understanding, involvement, and agreement with the plan of care. Review of agency policy dated 3/04/2013 and titled, "POLICY: EMERGENCY HOSPICE SYMPTOM RELIEF KIT," showed, in part, the following: - Crossroads Hospice follows all state and federal regulations, including the control of pain and symptoms. To ensure that a patient's symptoms are adequately and quickly controlled, we provide an Emergency Hospice Symptom Relief Kit to all home patients and nursing facility patients if allowed per facility procedures and regulations. This kit will only be utilized in the event of a pain or symptom crisis. Crossroads Hospice will follow all state and federal regulations regarding the delivery, administration and monitoring of all medications including narcotics. Upon admission, during the initial nursing assessment if the patient exhibits symptoms that may warrant emergent medications, or the case manager will immediately following admission to hospice (during the comprehensive assessment), the hospice nurse will obtain a signed physician's order for administration and delivery of an Emergency Hospice Symptom Control Kit. - After delivery of the Emergency Hospice Symptom Control Kit, the hospice RN will instruct the patient, family and/or caregiver regarding the use, administration, dosage, and side effects of the medications. The nurse will document such teaching on a visit sheet. RECORD/PATIENT #3: Review of "Emergency Symptom Relief Kit Physician Order Form" completed on 11/10/2020 showed that Morphine Sulfate (an opioid) oral solution (20 mg/milliliter) would be available in the patient's home for emergency use. The form showed, in part that the physician would be notified of any medication used from the emergency symptom relief kit. Review of the 11/10/2020 "emergent" nurse visit note showed that the nurse documented that opioids were initiated due to the patient's shortness of breath. Review of all provided nurse visit notes showed no education to the patient's caregiver or patient regarding the use of the opioid (Morphine). The above findings were reviewed on 11/17/2020 at 2:45 PM with the chief compliance officer, owner, director of education, and the assistant executive director. No additional documentation specific to patient education regarding Morphine was provided. PATIENT/RECORD #4: Review of the medication profile, showed that the patient was started on oxygen at 3 LPM continuously for shortness of breath starting 11/10/2020. Review of a document titled "interdisciplinary comprehensive hospice plan of care" showed that equipment to be ordered as an "oxygen concentrator 4 liters". Review of the initial comprehensive assessment on 11/10/2020 showed the nurse assessed in the respiratory section of the document that the patient was using oxygen at 4 LPM continuously with an oxygen saturation of 96%. Review of the nurse visit notes, dated 11/10/2020 and 11/12/2020 showed the family was educated on safe medication administration. The nurse failed to document if oxygen was specifically taught, or the flow rate taught. The nurse failed to document/educate specifically on the oxygen flow rate. (The oxygen flow rate is conflicting from the medication profile and medical equipment ordered) The findings were reviewed with the hospice administrator on 11/17/2020 at 3:02 PM. At the survey exit, the administrator provided additional documents. One document provided was a "fax order", dated 11/10/2020 at 1:00 PM, signed by the physician on 11/11/2020 for "DME: 10 Oxygen Concentrator".
L0545      
29559 Based on policy review, clinical record review, and interview, the agency failed to develop an individualized written plan of care for each patient. The plan of care did not reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in, but not limited to, two (Records/Patients #1 and #2) of four clinical records reviewed. This deficient practice as the potential to affect the care provided to all of the agency's patients. Findings Included: Review of the agency policy titled, "IDG Hospice Plan of Care: Content, Plan, Goals, Interventions, and Outcomes," dated 12/08/2018 v2 showed, in part, the following: - The initial plan of care is established at the time of admission. The comprehensive or hospice plan of care is an addition to the initial plan of care and is an ongoing, ever-changing, fluid process which is documented, to ensure that the patient (and family)'s condition and needs are assessed, identified, with appropriate interventions implemented to intervene and control problems. The progression of goals must be indicated, as well as the responsible party (such as hospice, facility, nurse, aide, caregiver, etc., as needed and appropriate); - The plan of care must reflect patient and family goals; include interventions for problems identified through the assessment process; include all services necessary for palliation and management of the terminal illness and related conditions; and - The plan of care interventions must include measurable outcomes with data collected during the comprehensive assessment and updates. The plan of care must include all drugs, treatments, medical supplies and appliances, and include documentation of teaching and the patient's or representative's level of understanding, involvement and agreements with the plan of care should appear in the clinical record Review of the agency policy titled, "Comprehensive Assessment," dated 12/11/2018 showed, in part, the following: - Policy statement: agency maintains complete, concise, consistent records of the care provided to all hospice patients and their families. Upon admission to the hospice program, the agency will complete an initial and comprehensive assessment. A comprehensive assessment means a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver's and family's willingness and capability to care for the patient: - The hospice interdisciplinary group in consultation with the individual's attending physician (if any) must complete the comprehensive assessment no later than five (5) calendar days after election (but can be completed at the time of the initial admission assessment) of hospice care and includes identification of patient/family/caregiver needs related to the terminal illness; and - An update of the comprehensive assessment is conducted by the hospice interdisciplinary group in collaboration with the patient's attending (if any) as frequently as the patient's condition warrants but no less frequently than every fifteen (15) days and includes identification of changes that have occurred since the initial assessment, information on the patient's progress toward desired outcomes and goals, and reassessment of the patient's response to care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of brain (mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age including decreased ability to perform activities of daily living and verbalize needs/wants). The patient has secondary diagnosis of chronic obstructive pulmonary disease, diabetes (failure of the body to make insulin causing the level of sugar in the blood to rise and is a leading cause of cardiovascular disease, blindness, kidney failure, and lower limb amputation). The patient was in the second hospice certification period which began 10/16/2020. Review of the follow-up comprehensive assessment dated 11/10/2020 showed, in part, the following: - The patient stated he/she would like to return to his/her home but stated that the hospital would not let him/her; - The patient wears adult briefs for the inability to control his/her urine; - Requires the assistance of two persons to transfer. The patient cannot remember to call for help; - Facility staff assists with the activities of daily living; and - The comprehensive assessment failed to show documentation that reflected the patient and/or family goals of care. The hospice plan of care updated 11/10/2020 failed to show documentation that reflected the patient and/or family goals of care. The findings were presented to the hospice chief compliance officer, owner, director of education, and the assistant executive director on 11/17/2020 at 2:45 PM. No further evidence was received from the agency. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 11/02/2020 for terminal diagnosis of congestive heart failure. The client had additional comorbidities including hypertension (an elevated pressure in the blood vessels), diabetes (a disease that results in too much sugar in the blood causing kidney, heart, and nerve disorders, and foot problems including reduced blood flow to the feet) and atrial fibrillation (a fluttering of the upper chambers of the heart). Review of the follow-up comprehensive assessment dated 11/06/2020 failed to show documentation that reflected the patient and/or family goals of care including, but not limited to, desired goal for pain control. The hospice plan of care updated 11/11/2020 failed to show documentation that reflected the patient and/or family goals of care including, but not limited to, desired goal for pain control. The findings were presented to the chief compliance officer, owner, director of education, and the assistant executive director on 11/17/2020 at 2:45 PM. No further evidence received from the agency.