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
261660 A. BUILDING __________
B. WING ______________ 		04/11/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
THREE OAKS HOSPICE 605 EAST BOONESLICK, SUITE 2, WARRENTON, MO, 63383
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)
L0648      
29559 Based on policy review, record reviews, and interviews, the hospice provider's governing body failed to: - Manage and administer its resources for the day-to-day provision of hospice services when given two weeks notice failed to have an effective plan for onsite registered nurse (RN) availability (L649); - Ensure nursing services was made routinely available on a 24-hour basis 7 days a week (L653); - Ensure an initial hospice provider specific orientation was completed for new nurses prior to patient care (L662); and - Ensure the skills and competence of nurses furnishing care were completed by the provider prior to patient care. (L663). The cumulative effect of these deficient practices has the potential to affect nursing services for all patients on service with the hospice provider.
L0649      
29559 Based on interviews, employee file information, and electronic communication review, the hospice governing body failed to manage and administer its resources for the day-to-day provision of hospice services. The hospice provider's corporation was aware two weeks in advance, and failed to have an effective plan for onsite registered nurse (RN) availability. Findings included: During an interview on 04/05/2022 at 12:09 PM with the hospice administrator, he/she stated the following: - On 03/31/2022 was the last day of employment for all hospice nurses, the hospice had two RN's up to 03/31/2022 (these are identified as the previous administrator and previous RN-F); - The previous administrator was a RN and he/she provided 9 days notice of resignation (this contradicts electronic communication showing the previous administrator gave 14 days notice of resignation to corporate staff); - The other RN (previous RN-F), gave notice of resignation "a month ago" to the best of his/her knowledge; and - The hospice had no RN available to physically assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. The RNs taking on-call during that time were four or five hours away, if patients would have needed a onsite RN during that time, they would have been sent to the emergency room. During an interview on 04/05/2022 at 12:09 PM with the interim clinical manager on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she works remotely as the interim clinical manager; - He/she lives 4-5 hours away; - Has never been physically to the hospice, only by teleconference; and - The hospice had no RN available to assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. He/she instructed the RNs taking on-call from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM to call 911 or send the patients to the hospital if emergent registered nurse intervention or assessment was indicated. Review of electronic communications showed on 03/17/2022 that the previous administrator gave notice of resignation of employment to the corporate operations management. This notice was 14 days before his/her last day of employment. Review of the employee file for previous RN-F showed that he/she submitted a signed "two week resignation" letter on 03/14/2022. The effective resignation date was 03/31/2022. During an interview with previous administrator (no longer employed at the provider), RN-F, on 04/06/2022 at 10:26 AM, he/she stated the following: - He/she resigned from the hospice provider on 03/31/2022, he/she provided notice of resignation two weeks in advance, on 03/17/2022, by electronic communication to to the corporate operations management; - When asked why patients were still being admitted to the hospice between 03/17/2022 and 03/31/2022 after knowing the hospice would no longer have an onsite RN after 03/31/2022, she/she replied that the corporate operations manager assured him/her that there was a plan in place to care for the patients; - When asked if he/she ever withdrew his/her intent to resign after 03/17/2022, he/she stated "no"; and - When asked if he/she provided any type of hand-off or report on the existing hospice patients before her planned resignation on 03/31/2022 to any other RN, he/she stated "No". During an interview with previous RN-F (no longer employed at the provider), on 04/06/2022 at 1:52 PM, he/she stated the following: - He/she resigned form the hospice provider on on 03/31/2022, she provided a letter of resignation two weeks in advance; - He/she resigned for health reasons; - When asked if he/she ever withdrew his/her intent to resign, he/she stated "no"; and - When asked if he/she provided any type of hand-off or report on the existing hospice patients on or before 03/31/2022 to any other RN, he/she stated "No". Review of the census list showed four patients were admitted after 03/17/2022 when the hospice corporate management and administration were aware that there would be no onsite RN availability after 03/31/2022. Two patients were admitted on 3/21/2022, the other patients were admitted on 03/25/2022 and 03/29/2022.
L0653      
29559 Based on policy review, record review, home visit observation, and interviews the hospice governing body failed to ensure nursing services, were available on a 24-hour basis 7 days a week in, but not limited to, three of four sampled patients (Patient/Records #1, #2, and #4.) The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency policy titled "Plan of Care Process", revised 05/01/2020, showed in part that all hospice care and services furnished to patients and their families will follow an individualized written plan of care established by the interdisciplinary group (IDG), in collaboration with the attending physician, the patient, and primary caregiver in accordance with the patient's needs. Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were currently employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on-call schedule showed three RNs were on call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs for new hire orientation, competency, and background checks. During an interview on 04/05/2022 at 12:09 PM with the hospice administrator, he/she stated the following: - On 03/31/2022 was the last day of employment for all hospice nurses, the hospice had two RN's up to 03/31/2022 (these are identified as the previous administrator and previous RN-F); and - The hospice had no RN available to physically assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. The RNs taking on-call during that time were four or five hours away, if patients would have needed a onsite RN during that time, they would have been sent to the emergency room. On 04/05/2022 at 3:14 PM the administrator stated that there was no employee file information on RN-A, RN-B, RN-C, RN-D, or RN-E for new hire orientation, competency, or background checks. Any information rearguing orientation and competency would come from another hospice provider in Texas or Kansas City. He/she stated that background checks were in process. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM.; - When asked if he/she received any type of verbal report, hand-off from the nurses that resigned on 03/31/2022, he/she stated "no", had to review what was in the EMR; and - When asked if he/she had any specific orientation to duties, he/she responded "no", was provided a binder by the office manager with patient names, face sheets, and a visit schedule, and started immediately visiting patients. During an interview with (registered nurse) RN-B on 04/05/2022 at 4:22 PM, he/she stated the following: - He/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022; - He/she worked for a hospice in Texas that is owned by the same corporation that "recently bought this hospice"; - When asked if he/she received orientation to the hospice provider, he/she stated she was provided a binder by the office manager and visited patients with RN-A that morning; and - She is unaware of the medical directors name or the location of the GIP (general inpatient acute) facility, has met the chaplain. Review of the informational binder provided to RN-A and RN-B in lieu of orientation showed the provider provided the nurses a list of patients including a face sheet, and a visit schedule of the hospice patients. Review of the visit schedule provided to RN-A and RN-B showed that 13 patients are scheduled to receive visits on Tuesday and Fridays. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated the following: - Works for a hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No", but he/she worked for the corporation at another location in Kansas City, MO and was familiar with the clinical software; - He/she lived approximately four hours away from Three Oaks hospice in Warrenton; and - He/she was informed by the director of clinical services to send hospice patients to the hospital emergency room if they need any RN intervention or physical assessment. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated the following: - Works for another hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received new hire orientation to the Three Oaks hospice in Warrenton, he she responded "No"; - He/she lived approximately four hours away from the Three Oaks hospice Warrenton location; - When asked if he/she was provided access to the electronic medical record, he/she responded "I think so"; and - He/she was informed by the director of clinical services to send hospice patients to the hospital emergency room if they need any RN intervention or physical assessment. During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated the following: - Works for a different hospice provider in Kansas City Missouri, was asked to take call on 04/03/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No". He/she stated that she asked for a list of IDG (interdisciplinary group), the GIP (general inpatient acute) location, and hospice pharmacy from the director of clinical services and it was not provided; and - He/she lived approximately five hours away from Three Oaks hospice in Warrenton. Patient/Record #1: The hospice recently adopted new clinical software when the hospice provider was purchased. The records that were requested were unable to be clearly printed for timeline of visit dates and times. The medical record was reviewed in the electronic Medical record (EMR) with the office manager. Review of the RN recertification assessment on 03/08/2022 showed that the RN educated the patient to a visit frequency change to twice weekly. Review of nurse visit notes showed a RN visited the patient: - On 03/09/2022 for (PRN) as needed visit because the patient "passed out" twice; and - On 03/11/2022 (Friday), 03/15/2022 Tuesday), 03/18/2022 (Friday), 03/21/2022 (Monday), 03/25/2022 (Friday), and 03/29/2022 (Wednesday) for a routine visits. Review of the visit schedule posted in the hospice conference room showed the patient was to receive visits on Tuesdays and Fridays. Review of the visit schedule provided to RN-A and RN-B showed the patient was to be visited on Tuesdays and Fridays. During interview with RN-A on 04/05/2022 at 3:59 PM, he/she stated the following: - When asked if any routine visits or needed visits were missed on 04/01/2022, he/she stated that Patient #1 and Patient #2 should of had skilled nurse visits; and - Patient #1 had a worsening wound that was from a cat scratch. Review of all available documentation showed that the patient was only assessed once (on 03/30/2022) by a hospice nurse the week of 03/20/2022 through 03/26/2022 when the patient required two visits. Patient/Record #2: The hospice recently adopted new clinical software when the hospice provider was purchased. The records that were requested were unable to be clearly printed for timeline of visit dates and times. The medical record was reviewed in the electronic Medical record (EMR) with the office manager. Review of the plan of care showed that the patient was to be visited twice weekly. Review of the visit schedule posted in the conference room, nurse orientation binders, showed the patient was to receive visits on Tuesdays and Fridays. Review of all available nurse visit notes showed the patient had routine visits on 03/16/2022, 03/28/2022, 03/30/2022, 03/31/2022, and 04/04/2022. During interview with RN-A on 04/05/2022 at 3:59 PM, he/she stated the following: - When asked if any routine visits or needed visits were missed on 04/01/2022, he/she stated that Patient #2 "definitely" should of had skilled nurse visits; - Patient #2 had a worsening wound with dressing from a spider bite; - The caregivers work, have disabilities, and are a limited help to care for the patient; and - The patient has an approximately one inch deep wound that requires it to be packed with antibiotic ointment and gauze. This dressing needs changed daily. Review of the nurse visit note, dated 03/31/2022 showed the nurse provided wound care to the patient's left foot with Betadine and calcium alginate. The medication list showed orders Santyl dressing was ordered on 01/27/2022. Review of the 04/04/2022 nurse visit showed the nurse measure the patient's wound as 2.0 CM(centimeters) by 3.0 CM, with a depth of "1.5-2CM". The left foot wound was coated with Santyl and covered with gauze and Kerlix. Review of all available interim orders showed no changes in wound care between 01/27/2022 and 04/04/2022. Patient/Record #4: Review of the electronic medical record (EMR) with the office manager showed: - Effective 02/05/2022 that the patient was to receive three visits a week by the hospice nurse; - A care plan identified problem that the patient has at risk for alteration in skin integrity; - A care plan identified problem that the patient had a skin deficit related to wounds; - A plan of care intervention that the patient's wounds would be assessed and measured at least every two weeks by the hospice nurse; and - The visit "general details" dated 03/18/2022, 03/21/2022, 03/25/2022, and 03/30/2022 show that the patient is ordered to be visited by a hospice nurse three times a week. Review of the nurse visits from 08/18/2022 through 04/03/2022 showed no assessment or measurements of the patients wounds. Review of the nurse visit note, dated 03/25/2022 showed in the narrative section that the "Facility nurse changes wound dressings". (This indicates the hospice plan of care was not followed regarding the patient's wound management). Review of the visit schedule provided to RN-A and RN-B, and posted in the hospice conference room showed the patient is scheduled to receive visits twice weekly on Mondays and Fridays (this contradicts the EMR order for visits three times a week by a hospice nurse). Further review of the electronic medical record with the office manager showed: - During the week of 03/13/2022 through 03/19/2022 that the patient had a two visits by a hospice nurse on Monday and Friday. (This indicates the hospice plan of care was not followed regarding the nurse visit frequency); - During the week of 03/20/2022 through 03/26/2022 that the patient had a two visits by a hospice nurse on Monday and Friday. (This indicates the hospice plan of care was not followed regarding the nurse visit frequency); and - During the week of 03/27/2022 through 04/02/2022 that the patient had only one visit by a hospice nurse on Wednesday (03/30/2022). This shows the plan of care was not followed on this patient. Review of the EMR showed no missed visit notifications to the physician or (interdisciplinary care group) IDG regarding the two missed hospice nurse visits. During a home visit to the skilled nursing facility (SNF) where the patient resided on 04/06/2022, the written coordinated plan of care could not be located by the charge nurse, director of nursing, the SNF administrator or the hospice office manager. During a joint interview with the SNF charge nurse and SNF director of nursing, on 04/06/2022 at 10:40 AM, the following was stated: - When asked if the hospice coordinated what days the SNF staff would be responsible for the patient's wound care and what days the hospice would be responsible, they said "No"; and - The charge nurse and director of nursing were unaware the name of the hospice nurse that is responsible for care of the patient, were unaware what days the hospice nurse visits, the nurse visit frequency, or when the hospice would need to assess or change the patient's dressings. It should be noted that two of the hospice provider's patients resided in this facility (SNF). There was no written coordination, no hospice plan of care, no advance directive from the hospice, no physician certification of terminal illness, no hospice medication profile, or contact information of hospice personnel involved in care of the patient available to SNF staff. During interview with RN-A on 04/05/2022 at 3:59 PM, when asked if any routine visits or needed visits were missed on Friday 04/01/2022, he/she stated that Patient #4 had dressing changes, lives in a long-term care facility so the facility staff should change it.
L0662      
29559 Based on employee records review and interviews, the hospice provider failed to ensure a specific initial orientation for nurses was completed prior to the nurses being assigned care to patients. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on call schedule showed three RNs were on call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs for new hire orientation, competency, and background checks. On 04/05/2022 at 3:14 PM the administrator stated that there was currently no employee file information on RN-A, RN-B, RN-C, RN-D, or RN-E for new hire orientation to Three Oaks hospice in Warrenton. Employee files have been started, but any information regarding orientation would be from the hospice provider in Texas and the Hospice provider in Kansas City, MO where the nurses worked. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM.; - When asked if he/she received orientation to the hospice provider, he/she stated that he was familiar with the corporations procedures since he/she worked for another corporate provider in Texas; and - When asked if he/she had any specific orientation to duties, he/she responded "no", was provided a binder by the office manager with patient names and visit schedule, and started immediately visiting patients. During an interview with (registered nurse) RN-B on 04/05/2022 at 4:22 PM, he/she stated the following: - He/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022; - He/she worked for a hospice in Texas that is owned by the same corporation that "recently bought this hospice"; - When asked if he/she received orientation to the hospice provider, he/she stated she was provided a binder by the office manager and visited patients with RN-A that morning; and - She is unaware of the medical directors name or the location of the GIP (general inpatient acute) facility, has met the chaplain. Review of the informational binder provided to RN-A and RN-B in lieu of orientation showed the provider provided the nurses a list of patients including a face sheet, and a visit schedule of the hospice patients. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated the following: - Works for a hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No", but he/she worked for the corporation at another location in Kansas City, MO and was familiar with the clinical software. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated the following: - Works for another hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received new hire orientation to the Three Oaks hospice in Warrenton, he she responded "No". During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated the following: - Works for a different hospice provider in Kansas City Missouri, was asked to take call on 04/03/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No". He/she stated that she asked for a list of IDG (interdisciplinary group), the GIP (general inpatient acute) location, and hospice pharmacy from the director of clinical services and it was not provided. It should be noted that RN-C, RN-D, and RN-E were not identified as hospice employees on the hospice employee list.
L0663      
29559 Based on employee records review and interviews, the hospice provider failed to ensure the skills and competence of all individuals furnishing care, were assessed by the provider prior to being assigned care to patients. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on-call schedule showed three RNs were on-call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs regarding the assessment of nursing skills and competence. On 04/05/2022 at 3:14 PM the administrator stated that there was currently no employee file information from this specific hospice provider on RN-A, RN-B, RN-C, RN-D, or RN-E for assessment of skills and competence. Employee files have been started, but any information regarding skills and competence would be from the hospice provider in Texas and the Hospice provider in Kansas City, MO. RN-A and RN-B were brought in from the corporation in an emergency manner since the hospice had no RN's left after 03/31/2022 at 5:00 PM. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated that he/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM. During an interview with RN-B on 04/05/2022 at 4:22 PM, he/she stated that he/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated that he/she works for a hospice provider in Kansas City Missouri (another provider number), was asked to take primary call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated that he/she works for hospice provider in Kansas City Missouri (another provider number), took secondary call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton. During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated that he/she works for a different hospice provider in Kansas City Missouri (another provider number), took call on 04/03/2022 for the Three Oaks hospice in Warrenton.