Survey Report for 261646

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	261646	A. BUILDING __________ B. WING ______________	11/05/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
INTEGRITY HOME CARE + HOSPICE	2960 N EASTGATE AVE, SPRINGFIELD, MO, 65803
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)
L0520
L0520	29559 Based on clinical record review, policy review, and staff interviews, the hospice provider failed to ensure that the ongoing comprehensive assessments had an effective clinical review and education of all of a patient's prescription medications. This deficiency example was identified at an immediate jeopardy level (L530). The administrator was verbally informed of the preliminary survey findings identified at an immediate jeopardy (IJ) level and also informed in writing on 11/04/2020 with an IJ template. The effect of this deficient practice has the potential to affect nursing services for all patients on service with the agency.
L0530
L0530	29559 Based on policy review, record review, and interview, the hospice provider failed to ensure the ongoing comprehensive assessments had an effective clinical review and education of all of a patient's prescription medications. A hospice patient was delivered medication without instruction from the hospice staff, the patient self administered an undetermined amount of liquid benzodiazapine that caused the patient to become unresponsive and be transported to the hospital (Patient/Record #2). The deficient practice was identified in one of three clinical records reviewed. The deficiency example was identified at an immediate jeopardy (IJ) level. The deficiency has the potential to affect all patients on service with the agency. Findings included: Review of the agency drug regimen review policies showed in part the following: - Hospice patients will have a current and accurate medication profile in the medical record - Medication profile will be used as a teaching guide to caregivers; - A medication review will include effectiveness of drug therapy, drug side effects, drug interactions, noncompliance with drug therapy regimen, and duplicate drug therapy. - Based on review of the medication profile as well as the written material, changes in the plan of care may be required. - Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians. - Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized independent practitioner) will be notified upon the hospice staff becoming aware of such deviation. Review of the agency policy titled "ONGOING COMPREHENSIVE ASSESSMENTS" Policy showed in part the following: - The policy purpose is to "provide guidelines for assessments of patients during ongoing care" - The scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. - The hospice nurse to assess pain, secondary symptoms, current treatment related to the identified symptoms, the patient's response to treatment, vital signs, breath sounds, skin integrity, functional status, safety/home environment, patient and family/caregiver support, compliance with treatments and medication regimen, and the need for an alternative setting or level of care. - Based on the assessments, the plan of care including problems, needs, goals, and outcomes will be reviewed and updated by the interdisciplinary group members responsible for the case. - The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions. Review of the agency policy titled "INTERDISCIPLINARY GROUP COORDINATION OF CARE" showed in part the following: - The purpose is to "ensure the coordination of services for each patient"; - The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner. - The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. - It will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician; - Personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings, and home visits. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. - When the patient requires services from the interdisciplinary group, the Case Manager will be responsible for cooperative care planning to assure goals, interventions, and outcomes are palliative in nature. - Written evidence of care coordination will be found in the plan of care and/or inter-disciplinary team meeting forms in the patient's clinical record, and will involve the hospice patient's attending physician. - Continuity of care will be maintained throughout the patient's course with hospice. Exchange of information between hospice staff and contracted providers will be documented in the clinical record. - The interdisciplinary group will provide ongoing support for patient and family/caregivers. - Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week, as will be drugs, biologicals, and medical supplies. PATIENT/RECORD #2: Review of the admission certification notes showed that the patient was admitted to hospice on 05/07/2020 with colon cancer with metastasis to the lungs. Review of the patient's hospice plan of care, medication profile, Interdisciplinary care team notes, and all interim physician orders show no documentation that Ativan (benzodiazapine) was prescribed for the patient. Review of all nurses notes from admission to discharge showed no education was specifically provided to the patient or caregivers regarding the use of Ativan. Review of an 08/11/2020 nurse visit note by RN-A showed the nurse documented that the patient "fears going to the hospital", and that the patient was forgetful and confused at times. It should be noted that the nurse documented that the patient had 150 mcg/hr Fentanyl patch (the physician order was for 50 mcg/hr). The nurse documented "sent in new script for Ativan intensol but specific orders not given to RN at this time". Review of an after hours on-call nurse coordination note on 08/12/2020 (untimed) showed RN-B documented the following: - Message received from (caregiver) at 0115, called (caregiver) back at 0116. (caregiver) states he/she just arrived to the patient's home and morphine and Ativan (lorazepam) was delivered today. Morphine is spilled on the floor, lorazepam is empty and patient is unresponsive. Review of an 08/12/2020 on-call after hours nurse visit that occurred between 1:47 - 3:42 AM showed that the nurse documented the following: - " Pt's caregiver thinks patient has taken a whole bottle of Ativan". - The nurse documented that the patient had 25 mcg/hr Fentanyl patch (the physician order was for 50 mcg/hr). - The patient was disorientated, confused, forgetful and drowsy. - The nurse failed to document that the patient was transported to the hospital. Review of an after hours on-call nurse coordination note on 08/12/2020 at 1:46 PM showed RN-B documented the following: - The (caregiver) talked to the patient around 10 PM on 08/11/2020, the patient's words were slurred and the patient was not making any sense; - When the caregiver arrived to the patient's home after getting off work at 1:00 AM, a lorazepam intensol (liquid Ativan) bottle was on the kitchen counter empty with the lid off; - When EMS (emergency medical services) questioned the patient, the patient stated he/she took multiple doses of Ativan without measuring; and - The patient was taken to the hospital by EMS (emergency medical services). Review of a social worker coordination note on 08/12/2020 (untimed) showed MSW-A documented that the patient was sent to the hospital on 08/12/2020 for a possible medication overdose. It was discovered that (the patient) admitted that he/she had taken more of the medication than prescribed. The MSW contacted the patient's family on 08/12/2020 to have a family member or caregiver stay with the patient 24/7 after returning home from the hospital. During interview with RN-A on 11/04/2020 at 11:45 AM, he/she stated the following: - The patient lived alone: - On 08/11/2020, he/she reached out to the physician's office to suggest an order for Ativan, since the patient was having increasing episodes of shortness of breath; - The physician never responded to what dose of Ativan that he/she may have ordered; - When asked if he/she had provided education to the patient regarding Ativan use, the nurse stated that he/she typically educates on new medications, but was unsure what dose the physician may order; and - He/she "takes full responsibility for not teaching the patient on the medication, I didn't know what he (the physician) called in". During interview with RN-B on 11/04/2020 at 2:25 PM, he/she stated the following: - He/she is an after hours on-call nurse; - The patient lived alone; - He/she received an after hours call from a friend of a patient that the patient was unresponsive and the friend found an empty bottle of Ativan intensol in the home; - When he/she arrived to the home, the patient had his/her eyes open, very lethargic, slurred and mumbling speech; - The liquid morphine bottle was knocked over with spilled liquid near the bottle; - A empty upright bottle of Ativan intensol was observed in a different area of the house than the Morphine bottle; - The patient was sent to the hospital for potential medication overdose; - He/she did not see Ativan on the patient's medication profile or plan of care; and - After talking with RN-A, he/she determined RN-A sent a request to the physician for Ativan on 08/11/2020, but RN-A was unsure of the order since RN-A did not speak with the physician directly. Findings were reviewed with the provider's administrator on 11/04/2020 at 11:01 AM, verbally and in writing with an Immediate Jeopardy template. The administrator acknowledged the findings. The administrator stated that the provider had already identified this instance with Patient/Record #2 as a sentinel event, and that steps were taken immediately to correct the issue internally. The administrator provided training on drug regimen review, and medication education to all the hospice nurses in October 2020. The in-service information was reviewed. After consult with the SA (state agency) and CMS (Centers for Medicare and Medicaid Services) regional office, the IJ was removed on-site based on the training the provider provided to the hospice nursing staff.