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 ______________ 		10/11/2019
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)
L0538      
29559 Based on policy review, record review, and interviews the hospice interdisciplinary group (IDG) failed to ensure the plan of care specified the hospice care and services necessary to meet the patient and family-specific needs. The patient was assessed with a fall, and new interventions for safety and treatment were not addressed at the IDG meeting in one of three sampled cases (Patient/Record #2). The deficient practice has the potential to affect all patients on service with the agency. Findings included: Review of agency policy titled "IDG HOSPICE PLAN OF CARE, COORDINATION AND CONTINUITY OF CARE" Policy Number #223, revised 06/25/18 showed in part the following: -"Crossroads Hospice and Palliative Care {Crossroads} ensures continuity of patient/family care through the different settings in which care may occur, such as routine, General inpatient, respite, continuous care and in all care locations such as home, long term care facility, acute care facility, assisted living facility and other locations even in the event of the patient's declining or lack of financial resources. All individuals involved in providing services follow the hospice philosophy of care, the mission of hospice and the Interdisciplinary Plan of Care." - "The contracted facility/ staff (as applicable) Will receive a copy of the hospice plan of care to ensure coordination of care and avoidance of duplication of services; - "The Hospice will designate an IDG} who work together to meet the needs of the patient and family; - When establishing the written plan of care, the IDG consults with the primary caregiver. The plan of care (POC) 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; - The plan of pare documents are the actual, ongoing, fluid, encompassing, plan of care that will be continuously updated, based on the needs and changes of the patient and family; - Care levels will be assessed continuously and will be changed based on the patient/family needs; - The POC must include all drugs, treatments, medical supplies and appliances; - 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; - The POC Will be filed with the patient's hospice record, facility record and home record; - The Plan of care will be coordinated facilities in which the patients resides. (Long term care, ALF, hospital, etc.,) to ensure continuity of care; - Coordinating all patient/family services and prioritization of needs With the members of the IDG team. This Includes encouraging the primary caregiver/family to attend and participate in scheduled IDG care conferences, both In hospice and With facility care planning personnel to ensure all care needs are Identified and met use of case management approach and referring other services as needed; - Determining scope and frequency of services needed based on acuity and patient/family needs and preferences and clearly documenting these preferences; - Providing specialized hospice training to other staff, family members, and caregivers to ensure safe and compassionate care and the ongoing evaluation of patient/family response to care; - All orders should be incorporated into the plan of care; - When a patient resides in an LTC facility, the hospice should obtain a copy of the MDS and compare to the hospice POC, to ensure coordination of care and avoid duplication of services; - Plan of Care should be coordinated with all care providers, Including the patient/family. The care providers may be at home, In a nursing home, or In a hospital. Encourage the patient/family to attend IDG care planning meetings as appropriate; - Educate providers in other care settings on the concept of hospice care and the need to coordinate care, including the POC; - Monitor and assist care providers to make certain that the POC is followed and coordinated and that no unapproved treatments are performed; and - A plan Will be established, and the patient's needs and continuity of care must be maintained in the event of the patient's declining or lack of financial resources." Review of agency policy titled "INTERDISCIPLINARY GROUP- PURPOSE, MEMBERSHIP, ROLE & TEAM CONFERENCE MEETINGS" showed in part the following: - The Crossroads Hospice and Palliative Care Interdisciplinary Group membership includes employees who are qualified and competent to practice In the following roles of the Primary Medical Director and/or Associates Medical Director (MD or DO), Nurse Practitioner, Clinical Director or Team Leader, Registered Nurse, Social Worker, Spiritual Care Coordinator (Chaplin),Volunteer Manager, Bereavement Counselor, Hospice Aide and Homemaker, Other individuals including the direct-care volunteer, Licensed Practical Nurse, primary care physician, physical, speech, occupational, respiratory therapist, pharmacist, dietician, music therapist, massage therapist, pet therapist, and/or primary caregiver/family members are included In the Interdisciplinary Group as needed to meet patient needs; - At the IDG meeting, plans, goals and interventions for the past two weeks and upcoming two-week period will be discussed; - The IDG will discuss the active problems (physical, psychosocial, and spiritual) potential problems, goals, Interventions, progression and the resolution for each problem, for each patient; - The IDG will discuss potential problems (physical, psychosocial, and spiritual) and revise plan of care as necessary to address active problems for each patient; - Document previous changes on the Interdisciplinary Plan of Care Summary form; - The IDG ensures the coordination and integration of care; - The IDG maintains responsibility for directing, coordinating and supervising the care of the patient and family; - The IDG will ensure that care and services are based on assessments of the patient and family needs; and - Review and discuss current frequencies for each discipline. If changes are warranted, IDG will discuss and make recommendations. PATIENT/RECORD #2: Review of a "phone call patient assessment report" dated 03/19/19 showed the hospice RN documented "discussed patient pain post fall. x-ray is being ordered for the patient". During an interview with the hospice RN case manager- A on 10/09/19 at 10:46 AM, he/she stated that after the patient's fall, bolstered mattress, fall mats and low electric bed was implemented. During an interview with the hospice LPN-A (licensed practical nurse) on 10/09/19 at 10:46 AM, he/she stated that the interventions implemented after the patient's fall were low electric bed, and fall mats. Review of the 03/20/19 IDG meeting notes showed "Patient had fall with hip injury". The IDG note failed to contain discussion of interventions for the fall, consideration of increased visit frequency, the fall mats that were implemented, bolstered mattress, or the low bed that was implemented by the hospice (registered nurse) RN. The section of the meeting note for changes to the plan of care stated "Cont (continue) POC (plan of care)".
L0545      
29559 Based on policy review, record review, and interviews the agency failed to ensure the plan of care specified the hospice care and services necessary to meet the patient specific needs. The patient was assessed with a fall, and interventions for safety and treatment were not updated or individualized on the plan of care in one of three sampled cases (Patient/Record #2). The deficient practice has the potential to affect all patients that reside in a long-term care facility. Findings included: Review of agency policy titled "IDG HOSPICE PLAN OF CARE, COORDINATION AND CONTINUITY OF CARE" Policy Number #223, revised 06/25/18 showed in part the following: - When establishing the written plan of care, the IDG consults with the Primary caregiver. The plan of care (POC) 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; - The POC must include all drugs, treatments, medical supplies and appliances; - 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; - "The plan of care will be coordinated facilities in which the patients resides. (Long term care, ALF, hospital, etc.,) to ensure continuity of care"; and - All orders should be incorporated into the plan of care. PATIENT/RECORD #2: Review of a "phone call patient assessment report" dated 03/19/19 showed the hospice RN documented "discussed patient pain post fall. x-ray is being ordered for the patient". During an interview with the hospice RN case manager- A on 10/09/19 at 10:46 AM, he/she stated that after the patient's fall, a bolstered mattress, fall mats and a low electric bed was implemented. During an interview with the hospice LPN-A (licensed practical nurse) on 10/09/19 at 10:46 AM he/she stated that the interventions implemented after the patient's fall were low electric bed, fall mats, and additional caregiver education. Review of a durable medical equipment list from the hospice DME (durable medical equipment) company for the patient showed that the patient was utilizing the following equipment: - Bolstered Mattress - Hospital Bed; - Bed rails; - Oxygen tanks; - Oxygen concentrator; and - Nebulizer machine. Review of the patient's plan of care and all available written orders from admission to discharge showed no physician orders or plan of care orders specifically for: - Bolstered Mattress; - Hospital Bed; - Fall Mats; - Bed rails; - Oxygen tanks; - Oxygen concentrator; and - Nebulizer machine. The plan of care for 03/20/19 included under DME equipment "Provide DME and supplies needed for safety and comfort". The plan of care was not individualized for the patient's specific equipment needs for safety and fall prevention. During an interview with the hospice RN clinical manager and corporate nurse on 10/08/19 at 4:31 PM, they were unaware that DME equipment needed to be specified (individualized) on the plan of care and that plan of care verbiage "Provide DME and supplies needed for safety and comfort" was not sufficient.
L0558      
29559 Based on policy review, record review, and interview, the hospice failed to ensure an effective written system of communication in accordance with the hospice's own policies and procedures, to provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. A hospice patient resided in an assisted living facility. The hospice agency utilized a written coordinated task plan of care when a patient resided in any long-term care facility . The agency failed to keep the coordinated task plan of care updated when a patient need and plan of care changed in one of three sampled cases (Patient/Record #2). The deficient practice has the potential to affect all patients that reside in a long-term care facility. Findings included: Review of agency policy titled "IDG HOSPICE PLAN OF CARE, COORDINATION AND CONTINUITY OF CARE" Policy Number #223, revised 06/25/18 showed in part the following: -"Crossroads Hospice and Palliative Care {Crossroads} ensures continuity of patient/family care through the different settings in which care may occur, such as routine, General inpatient, respite, continuous care and in all care locations such as home, long term care facility, acute care facility, assisted living facility and other locations even in the event of the patient's declining or lack of financial resources. All individuals involved in providing services follow the hospice philosophy of care, the mission of hospice and the Interdisciplinary Plan of Care"; - "The contracted facility/staff (as applicable) will receive a copy of the hospice plan of care to ensure coordination of care and avoidance of duplication of services;" - "The Hospice will designate an IDG} who work together to meet the needs of the patient and family; - Establish the written plan of care, the IDG consults with the Primary caregiver. - The POC must include all drugs, treatments, medical supplies and appliances. - 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; - The POC Will be filed with the patient's hospice record, facility record and home record; - The Plan of care will be coordinated facilities in which the patients resides. (Long term care, ALF, hospital, etc.,) to ensure continuity of care; - Coordinating all patient/family services and prioritization of needs With the members of the IDG team. This Includes encouraging the primary caregiver/family to attend and participate in scheduled IDG care conferences, both In hospice and With facility care planning personnel to ensure all care needs are Identified and met use of case management approach and referring other services as needed; - Providing specialized hospice training to other staff, family members, and caregivers to ensure safe and compassionate care and the ongoing evaluation of patient/family response to care; - When a patient resides in an LTC facility, the hospice should obtain a copy of the MDS and compare to the hospice POC, to ensure coordination of care and avoid duplication of services; - Plan of Care should be coordinated with all care providers, Including the patient/family. The care providers may be at home, In a nursing home, or In a hospital. Encourage the patient/family to attend IDG care planning meetings as appropriate; and - Educate providers in other care settings on the concept of hospice care and the need to coordinate care, including the POC." Review of agency policy titled "PROVIDING AND COORDINATION OF HOSPICE CARE TO RESIDENTS OF A SNF/NF, LONG TERM CARE (LTC) OR ICF/MR/DD FACILITY AND CONTRACTUAL AGREEMENT" showed in part the following: - Crossroads Hospice and Palliative Care {Crossroads} provides hospice care to patients in many settings, including Skilled Nursing - Facilities include Long Term Care Nursing Facilities, ICF, and MR Facilities. The hospice will ensure all guidelines are met and care is provided, regardless of the place of the patient's residence; - All hospice care provided is in accordance with the hospice plan of care; - Care will be established and maintained for each patient m accordance with all state and federal guidelines; - Any changes in the hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/MR/DD representatives, and must be approved by the hospice before implementation; - Crossroads along with the facility, is responsible for ensuring coordination of services. All care will be coordinated with the SNF/NF (LTC) or ICF/MR/DD. This will be met in a variety of methods including documentation, checking in/out with facility, verbal reports, telephone calls and the sharing of information including medication and treatment changes/orders; Crossroads designates a member of each interdisciplinary group that is responsible for a patient who is a resident of a SNF/NF or ICF/MR/DD and assigns that member to be responsible for coordination; - Provide overall coordination of the hospice care of the SNF/NF or ICF/MR/DD resident with SNF/NF or ICF/MR/DD representatives; - Communicating (long-term care) LTC representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family; - Crossroads ensures that the hospice IDG team communicates with the SNF/NF or ICF/MR/DD medical director, the patient's attending physician, and other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the hospice patient with the medical care provided by other physicians; and - The hospice provides the (long-term care) LTC facility with hospice election form, any advance directives specific to each patient, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved In hospice care of each patient, instructions on how to access the hospice's 24-hour on-call system, hospice medication information specific to each patient, and the hospice physician and attending physician (if any) orders specific to each patient. PATIENT/RECORD #2: During an interview with the hospice RN clinical manager on 10/08/19 at 4:31 PM, he/she stated that coordination of care with long-term care (LTC) facilities occurs verbally, in written binder materials, and with the written coordinated task plan of care. The written coordinated task plan of care is utilized in the hospice agency regardless of the level of care of LTC facility (skilled, assisted living, and residential care). During an interview with the hospice RN case manager- A on 10/09/19 at 10:46 AM, he/she stated that coordination of care with long-term care facilities occurs by speaking with the facility staff, and with the written coordinated task plan of care. The patient was a high fall risk. After the patient's fall, a bolstered mattress, fall mats and a low electric bed was implemented. During an interview with the hospice LPN-A (licensed practical nurse) on 10/09/19 at 10:46 AM he/she stated that the patient was a high fall risk. Coordination of care with long-term care facilities occurs verbally, and with the coordinated task plan of care. Review of the "Hospice/LTC Coordinated Task Plan of Care" for Patient #2 showed the written communication failed to coordinate: - The contact name for the hospice case manager; - The nurse visit frequency or days; - The nurse aide visit frequency or days; - Failed to indicate that the patient was a fall risk; and - Failed to have the fall safety DME (durable medical equipment) required by the patient such as the fall mats, bolstered mattress, or low electric bed.