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
261680 A. BUILDING __________
B. WING ______________ 		10/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TRADITIONS HEALTH 220 NW R.D. MIZE ROAD, SUITE 101, BLUE SPRINGS, MO, 64014
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      
38507 Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the comprehensive assessment contained a complete pain assessment to promote the hospice patient's comfort in one (Record/Patient #2) of five full record reviews conducted. This deficient practice has the potential to adversely affect the pain control of all the agency's patients. Findings included: Review of the agency's policy titled, "Pain Assessment," showed, during the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain. If the patient is having pain, an in-depth pain assessment will be conducted which includes, in part, the following: - Pain intensity using a rating scale which includes current pain, worst pain, and least pain; - Pain location; - Pain quality; - Pain onset, duration, variations, and patterns; - Present pain management regimen and effectiveness; and - The patient's pain goal. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2020 with a terminal diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home with the family and a caregiver. Review of the skilled nurse visits showed conflicting pain relief assessments on the following dates: - On 09/01/2020, the pain assessment showed the patient had pain located in the back. The pain was chronic, daily and intermittent. The pain interfered with activity and movement. Relief measures were cold, heat, narcotic analgesics, and rest/relaxation. The patient is comfortable with the current treatment; and - On 09/17/2020, 10/01/2020, and 10/08/2020, the pain assessment showed the patient had pain located in the back. The pain was chronic, daily and intermittent. The pain interfered with activity and movement. Relief measures were narcotic analgesics, OTC (over-the-counter) pain relievers, and rest/relaxation. The patient is comfortable with the current treatment. Review of the plan of care dated 09/02/2020 failed to show any orders for heat or cold treatments to the back. Review of medication profile showed Norco (a combination pain reliever containing a narcotic) as the only medication ordered for pain relief. There were no OTC medications ordered. During an interview with the patient's daughter on the home visit observation on 10/13/2020 at 11:00 AM, the daughter stated the patient did not like to take pain medications and she did not think there were any in the home. Then later when the surveyor was doing the medication reconciliation, a bottle of Norco dated June 2020 was found. The family had not been giving the patient Norco. The patient did not take any over-the-counter pain relievers and there were none on the medication profile. The pain assessments on 09/01/2020, 09/17/2020, 10/01/2020, and 10/08/2020 contained inaccurate information regarding the medications the patient was taking for pain so it is unknown if pain medication would help the patient's pain. During an interview on 10/14/2020 at 9:30 AM, the corporate quality nurse stated that if the patient was having recent pain, a full, accurate pain assessment should be completed.
L0530      
38507 Based on policy review, record review, and interview, the agency failed to ensure the medication regimen review was conducted to ensure patients were taking their medications as ordered in two, Record/Patients #2 and #5, out of five full record reviews conducted. This deficient practice has the potential to affect medication safety for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Profile," dated 2003, showed a drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2020 with a terminal diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home with the family and a caregiver. Review of the medication profile showed the following: - Carbidopa-levodopa (A combination drug used to treat the symptoms of Parkinson's disease and Parkinson's-like symptoms) is a hospice covered medication which the agency is responsible for providing; - Flomax (a drug prescribed to treat benign prostatic hyperplasia (BPH) or enlarged prostate in men) is not a hospice covered medication and the patient was responsible for covering the cost; and - Simvastatin (belongs to a group of medicines called statins that is used to lower high blood cholesterol) 40 mg (milligrams) failed to appear on the medication profile but the patient is taking it. During an interview on the home visit observation on 10/13/2020 at 11:15 AM, the patient's son-in-law stated that: - Carbidopa-levodopa has not been provided or paid for by the agency, the family has been obtaining and paying for this medication; - Flomax has not been in the home since the last refill ran out around 09/01/2020 and it is not known if the patient should still be taking this; and - The patient takes simvastatin 40 mg orally daily with the last refill on 09/23/2020. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 07/23/2020 with a terminal diagnosis of senile degeneration of the brain. The patient lived at a long term care facility (LTCF). The patient passed on 09/30/2020. Review of the clinical record showed: - On the 09/24/2020 as needed skilled nurse visit notes, oxygen two liters per nasal cannula (tube with prongs to fit in the nose to deliver oxygen to the patient) continuous use was listed under respiratory treatments; - On the 09/24/2020 skilled nurse visit note narrative, the registered nurse (RN) documented that the facility nurse had put on oxygen two liters as requested after the patient had become unresponsive and the hospice RN was called; - On the 09/29/2020 skilled nurse visit notes, oxygen two liters per nasal cannula intermittent use was listed under respiratory treatments; - Review of the medication profile printed on 10/12/2020 failed to show oxygen listed as a medication; and - Review of the interdisciplinary group meeting notes dated 09/30/2020 failed to show an update for the use of oxygen during the prior 14 days. During an interview on 08/14/2020 at 9:10 AM, the corporate quality nurse stated that it was expected that medication reconciliation be completed at each comprehensive assessment.
L0531      
38507 Based on policy review, clinical record review, and interview, the agency failed to ensure a bereavement assessment was conducted on the start of care comprehensive assessment on one (Record/Patient #5) out of five full record reviews completed. This deficient practice has the potential to adversely affect the family and friends that are grieving after the death of the patient for all the agency's patients. Findings included: Review of the agency's policy titled, "Comprehensive Assessment," dated 2003, showed during the comprehensive assessment, the patient assessment information will be documented in the patient's clinical record and include at least the following information: - The nature of the relationship to the patient; - Circumstances surrounding the illness/prognosis; - Behaviors prior to and after the illness; - Survivor needs (social, spiritual and cultural) that may impact coping skills; and - Potential for pathological grief reactions. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 07/23/2020 with a terminal diagnosis of senile degeneration of the brain. The patient lived at a long term care facility (LTCF). Review of the start of care comprehensive assessment showed: - The registered nurse (RN) assessment was completed on 07/23/2020 and was in-person; - The social worker assessment was completed on 07/25/2020 by a telephone call to the patient's daughter; - The chaplain assessment was completed on 07/24/2020 by a telephone call to the patient's daughter; and - The visit note documentation failed to show a bereavement assessment completed by the skilled nurse, social worker, or chaplain. During an interview on 10/12/2020 at 10:30 AM, the administrator stated that the social worker and chaplain evaluation visits were over the phone and they probably forgot to do the bereavement assessment.
L0587      
38507 Based on policy review, standards of practice review, clinical record review, review of the long term care facility records, and interviews, the agency failed to ensure nursing needs of the patient were met as identified in the patient's comprehensive assessments, in a manner consistent with acceptable standards of practice. The findings in one clinical record (Patient/Record #5) were so grievous that the one deficient practice caused the standard to rise to a condition level finding when the agency failed to: - Ensure the registered nurse performed/documented a complete assessment and measurement of the patient's wound to ensure that the nursing needs of the patient were met. (L591) The cumulative effect of this deficient practice has the potential to affect nursing services and wound management for all patients on service with the agency.
L0591      
38507 Based on policy review, standards of practice review, record review, review of the long term care facility clinical record, and interview, the agency failed to ensure the nursing needs of the patient were met as identified in the patient's comprehensive assessment in one (Patient/Record #5) of five full record reviews conducted. This deficient practice has the potential to adversely affect the nursing care provided to all the agency's patients. Findings included: Review of the agency's policy titled, "Ongoing Comprehensive Assessment," dated 2003, showed, in part, the nurse will assess each patient on each visit for skin integrity and compliance with treatments. Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses by Karen S. Clay, RN, BSN, CWCN Copyright 2008 Chapter 9-Wound Healing-Page 95: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes." http://www.hcpro.com/content/76944.pdf RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted on 07/23/2020 with a terminal diagnosis of senile degeneration of the brain. The patient lived at a long term care facility (LTCF). Review of the clinical record showed the following: - On 08/25/2020, a telephone call was received by the hospice licensed practical nurse (LPN) from the long term care facility (LTCF) where the patient resided. The facility nurse reported the patient had a raised area on the lower back and an ultrasound was requested. The ultrasound was negative with no abnormal findings. The facility nurse requested the hospice order Calmoseptine (topically applied moisture barrier cream that protects and helps heal skin irritations) to be used on the area; - On the 08/28/2020 registered nurse A (RN A) visit, the lower back area failed to be assessed. Review of systems-integumentary area showed "not assessed this visit" and "no problem this visit"; - On the 09/01/2020 and 09/08/2020 RN A visits, the lower back area failed to be assessed; - On the 09/09/2020 aide visit note, the hospice aide documented that Calmoseptine cream was applied to the patient's buttock where there was an open wound. The patient also had a wound on the right shin. The "nurse" was aware and bandaged it. RNCL (hospice RN case leader) RN A and facility nurse notified; - On 09/15/2020, RN A documented on the nurse's note, a stage 2 pressure ulcer on the posterior buttocks/coccyx (tailbone). A wound assessment and measurement was done and orders received for Medihoney (a medical grade honey gel) to wound and cover with Mepilex (foam dressing); - On 09/22/2020, RN A assessed the wound but failed to document measurements. Documentation showed wound care was completed by cleansing with soap and water and covering with a Band-Aid (not the ordered dressing change of Medihoney and Mepilex); - On 09/29/2020, RN A documented that the wound was not assessed due to the patient was up in the chair. The LTC facility nurse reported to hospice RN A, the wound was unchanged; - On 09/30/2020, the patient passed away. RN A delayed assessing the patient's coccyx and buttock area 21 days after the facility reported a raised area on the lower back and failed to document the wound assessment and measurements weekly after 09/15/2020. Review of the long term care facility record showed: - On 08/23/2020, an ultrasound was ordered to the lower back/buttock hardened lump area "related to pain, discomfort, and continue to grow in size"; - On 08/25/2020, the facility nurse noted that the ultrasound showed there were no new findings for the lump to lower back/buttock; - On 09/16/2020, an order was received to cleanse coccyx with wound cleanser, apply Medihoney to coccyx, cover with Mepilex, and change every three days and PRN; - The facility did not send records to show the Medihoney dressing changes were completed; and - The facility did not send records to show facility wound measurements and assessments. During a telephone interview on 10/27/2020 at 11:15 AM, the LTC facility director of nursing stated that: - She would normally email the documentation of the medihoney and mepilex dressing changes done by the facility staff; - There was no documentation of wound assessments or measurements because it was not done; - He/she was on vacation during the time of this wound and the assistant director of nursing was ill; - Normally the floor staff lets him/her know if there is a wound and he/she or the assistant director of nursing assesses and measures the wound weekly; - This is normally documented on an observation report when the assessment is completed; - If the patient has hospice involved, the hospice nurse usually assesses the wounds; - The facility had received orders on 09/29/20 to get the wound specialist involved in the wound care but then the patient expired on 09/30/2020; - He/she was not aware of this wound until this was brought to his/her attention to look for documentation for the surveyor; and -This facility is an ICF (intermediate care facility) and private pay. During an interview on 10/14/2020 at 9:45 AM, the hospice administrator stated that wounds should be assessed weekly and the physician ordered wound care should be followed.
L0598      
38507 Based on record review and interview, the agency failed to ensure that spiritual counseling was provided to meet the spiritual needs of the patient and family in one (Record/Patient #2) of five full record reviews conducted. This deficient practice has the potential to adversely affect the spiritual well-being of all the agency's patients requesting spiritual counseling. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2020 with a terminal diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home with the family and a caregiver. Review of the clinical record failed to show spiritual counseling visit notes from 08/20/2020 through 09/30/2020. Review of the interdisciplinary group (IDG) notes showed the following: - On 09/02/2020, an order for chaplain one time per month starting 08/31/2020 and ending 08/31/2020. The chaplain note on the IDG note showed that the plan of care remains effective and collaboration with the IDG occurred; - On 09/16/2020, the IDG note failed to show an order for the chaplain for 09/01/2020 through 09/30/2020 but the chaplain note still showed the frequency of one time per month and the plan of care remains effective and collaboration with the IDG occurred; and - The chaplain failed to meet the spiritual needs of the patient and family during this period of time. During an interview on 10/14/2020 at 9:20 AM, the administrator stated he/she would attempt to find the visit notes for 08/20/2020 through 09/30/2020. On 10/14/2020 at 3:00 PM, the administrator stated that he/she was unable to locate the chaplain visit notes.
L0625      
38507 Based on record review and interview, the agency failed to ensure the hospice aide assignments prepared by the registered nurse (RN) were precise and individualized to the patient's specific conditions when the RN assigned interventions that had the potential to cause harm in one (Record/patients #2) out of five records with hospice aide services. This deficient practice has the potential to adversely affect the safety of all the agency's patients that receive hospice aide care. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2020 with a terminal diagnosis of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). The patient lived at home with the family and a caregiver. Review of the aide care plan dated 06/16/2020 showed the following: - Activity-Transfer to bed/chair with assistance of 1-2 person every visit. The directions failed to show when one or two persons would be indicated; - Safety-bleeding precautions every visit; - Hygiene-May trim or file any long or uneven nails on Tuesday; and - Hygiene-Shave every Thursday. The directions failed to indicate what type of razor to use. Review of the aide visit notes dated 08/20/2020 through 10/08/2020 showed, the hospice aide marked done on all these tasks. The documentation did not show how many people it took to transfer the patient or what method was used to shave the patient. During an interview on 0/14/2020 at 2:00 PM, the administrator stated that: - The patient was on aspirin 325 mg (milligram) by mouth daily for a blood thinner; - He/she would expect the aide care plan to show the method for shaving and no nail trimming or cutting; and - The aide care plan should show parameters for when one or two people should be used to transfer the patient.
L0628      
38507 Based on record review and interview, the agency failed to ensure the hospice aides reported changes in the patient's medical, nursing, and social needs as related to the changes to the plan of care, to a registered nurse (RN) in one (Record/Patient #1) of five records reviewed with aide services. This deficient practice has the potential to adversely affect the personal care services and safety of all the agency's patients that are provided hospice aides. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/14/2020 with a terminal diagnosis of end-stage COPD (chronic obstructive pulmonary disease). The patient lived in her own home. Review of the clinical record showed: - On the plan of care dated 09/14/2020, the hospice aide visit frequency was seven times per week beginning the week of 9/15/2020 through 11/11/2020; and - On the interdisciplinary group (IDG) meeting notes dated 10/07/2020, the hospice aide visit frequency was changed to one time per week starting 10/09/2020. Review of the record's hospice aide visit notes showed the following: - On 09/25/2020, the care plan checklist showed the patient refused all personal care and bed linen change. There failed to be documentation that the RN case leader (RNCL) was notified; - On 09/28/2020, the care plan checklist showed the patient refused all personal care and weight check. The hospice aide narrative showed "companionship and personal care day" and there failed to be documentation that the RN case leader was notified; - On 10/03/2020, the care plan checklist showed the patient refused to have the bed linen changed. Elimination and weight were documented "not applicable this visit." There failed to be documentation that the RN case leader was notified. During an interview on 10/14/2020 at 9:00 AM, the corporate quality nurse stated that the hospice aide would be expected to contact the RNCL if the patient refused care and the aide assignment could not be followed.
L0684      
38507 Based on record review and interview the agency failed to document a complete discharge summary when the patient was discharged from the agency in one, (Record/Patient #8) of three live discharge records reviewed. This deficient practice has the potential to adversely affect the post-hospice medical care of all the agency's live discharged patients. Findings included: RECORD/PATIENT #8: Review of the clinical record showed the patient was admitted to hospice services on 08/13/2020 and revoked hospice on 09/03/2020 to enter the hospital for further care. Review of the discharge summary sent to the physician on 10/14/2020 (date of the survey) showed the following missing items: - A summary of the patient's hospice stay including treatments, symptoms and pain management; - The patient's current plan of care; and - The patient's latest physician orders. During an interview on 10/14/2020 at 3:05 PM, the administrator stated that he/she was not aware that the discharge summary was supposed to contain specific information.
L0694      
38507 Based on policy review, review of the admission packet, and interview, the agency failed to provide copies of their written policies and procedures for the management and disposal of controlled drugs in the patient's home at the time when controlled drugs are first ordered. This deficient practice has the potential to adversely affect medication safety in the home for all the agency's home patients. Findings included: Review of the agency's policy titled, "Home Use and Disposal of Controlled Substances," dated 2003, showed the admitting nurse/case manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family and will verbally discuss the policy to ensure the safe use and disposal of controlled drugs. Review of the admission packet presented for review on 10/12/2020 failed to show copies of the written policies and procedures. During an interview on 10/12/2020 at 4:00 PM, the administrator stated that: - "I don't think the policy is in the admission packet"; and - The agency provided the policy at the time of the patient's death when the medications need to be destroyed.
L0798      
38507 Based on review of Section 192.2490.12 RSMo, employee file review, and interview, the agency failed to obtain the employee disqualification list (EDL) prior to hire on six (Employees E1, E2, E3, E4 and Volunteers V1 and V2) out of eight employee files reviewed. This deficient practice has the potential to adversely affect the safety of all the agency's patients. Findings include: Review of Section 192.2490.12 RSMo showed: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." EMPLOYEE E1: - E1 was hired on 12/17/2019 for the position of registered nurse (RN); and - The EDL date was 12/29/2019, 12 days after hire. EMPLOYEE E2: - E2 was hired on 07/15/2019 for the position of social worker; and - The EDL date was 08/19/19/2019, 33 days after hire. EMPLOYEE E3: - E3 was hired on 08/08/2020 for the position of chaplain: and - The EDL date was 08/28/2020, 20 days after hire. EMPLOYEE E4: - E4 was hired on 12/17/2019 for the position of hospice aide; and - The EDL date was 12/19/2019, 2 days after hire. VOLUNTEER V1 and V2: - V1 was hired on 09/09/19; - V2 was hired on 10/03/19; and - The EDL was not checked on either volunteer. During an interview on 10/14/20 at 11:30 AM, the human resources director stated that: - The EDL checks were late; - The hiring process was not complete; - The agency needed a better hiring process; and - The agency was not aware that an EDL check was needed for the volunteer staff.