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 ______________ 		08/12/2020
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)
E0006      
38507 Based on policy review and interview, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by Centers for Medicare and Medicaid Services (CMS) on 03/23/2020 "COVID-19 Focused Infection Control Survey: Acute and Continuing Care," when the agency failed to develop policies and procedures for staffing strategies during an emergency shortage of staff. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency's policy titled, "Emergency Preparedness Plan: COVID-19, " dated 03/13/2020, failed to show a policy or procedure for staffing strategies during an emergency shortage of staff due to COVID-19. During an interview on 08/11/2020 at 11:20 AM, the director of nursing was unable to verbalize what measures would be taken for a staffing shortage.
L0536      
38507 Based on policy review, record review, and interviews, the agency failed to ensure an individualized plan of care and the interdisciplinary group (IDG) maintained responsibility for the oversight of the patient's care. The agency failed to: - Develop an individualized written plan of care for each patient that reflected interventions identified in the comprehensive and updated comprehensive assessments and included all services necessary for the patient's care and was established by the IDG (L545); and - Ensure the IDG maintained responsibility for directing, coordinating, and supervising the care and services provided to the patient (L554). The cumulative effect of these deficient practices has the potential to affect the care and services provided to all the agency's patients.
L0545      
38507 Based on policy review, record review, and interview, the agency failed to develop an individualized plan of care based on the problems identified in the initial, comprehensive, and updated comprehensive assessments and include all the services necessary for the management of the terminal illness and related conditions in three (Record/Patients #1, #2, and #3) of three records reviewed. This deficient practice has the potential to affect the care and services provided to all the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care," revised 04/2019, showed in part, the following: - A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program; - The care must be in accordance with the plan of care; and - The plan of care will identify the patient's needs and services to meet those needs, including, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. Review of the agency's policy titled, "Interdisciplinary Group Meeting," revised 04/2019, showed, in part, the following: - The interdisciplinary group (IDG) will meet on a regular basis to discuss patient and family/caregiver changes, progress, and updates to the plan of care; - Each patient's plan of care (POC) will be updated utilizing the results from the ongoing comprehensive assessment; - The patient's POC will be updated if the patient's condition requires change to include social, cultural, and any special needs of the patient; - The IDG meeting POC update form will be used for updates and will note changes, response to treatment, and progress toward targeted outcomes including increase or decrease in the frequency of visits and the reason for the change, missed visits will be explained and adjustment to the POC will be made if appropriate, and psychosocial and other consultations/conferences with the patient and family/caregiver; and - Problem solving for optimal care of the patient and family/caregiver will occur and be documented. RECORD/PATIENT #1: Review of the clinical record showed the patient was readmitted on 05/27/2020 for Alzheimer's Disease/dementia (a progressive disorder that causes brain cells to waste away (degenerate) and die. Dementia is a continuous decline in thinking, behavioral and social skills that disrupts a person's ability to function independently). The patient lived in the caregiver's home with the spouse, Patient #2. Review of physician's orders and plans of care during the readmission episode of 05/27/2020 through 07/25/2020: - Showed orders for skilled nurse visits one time per week and as needed; and - Failed to show orders for use of telehealth (the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activities, and health education) to perform skilled nurse visits with the patient instead of in-person home/facility visits. Review of the documentation during the readmission episode of 05/27/2020 through 07/25/2020 failed to show any in-person or FaceTime skilled nurse visits. During an interview on 8/11/2020 at 10:02 AM the administrator stated that: -The RN calls the caregiver to set up visits through telephone calls/FaceTime (telehealth); -The RN orders medications and supplies when he/she talks with the caregiver; - It was "hit or miss" if the caregiver allowed FaceTime visits from staff; - No staff had been to the patient's residence since the start of care (05/27/2020); - The patient's caregiver was doing the assessments and relaying the information to the nurse; and - The administrator was unaware the caregiver was only allowing text message visits. During an interview on 8/11/2020 at 10:48 AM the nursing supervisor stated that: - The patient's caregiver refused visits since Covid-19; and - He/she would expect the care plan and IDG notes to address the patient's caregiver refusing visits and only communicating via telephone or text messaging. During an interview on 08/11/2020 at 2:38 PM, RN B stated that: - He/she needed to "lay eyes" on the patient but the caregiver would come up with excuses; - The caregiver never allowed FaceTime visits; - He/she would call and leave a voicemail that a visit needed to be done and the caregiver would not call back but would only text message back and forth; - He/she discussed with IDG each meeting the inability to see the patient; - The plan of care and the IDG notes failed to show the patient's caregiver refused all the visits; and - The caregiver only allowed text messages for communication. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 03/10/2020 for Alzheimer's Disease/dementia. The patient lived in the caregiver's home with the spouse, Patient #1. The comprehensive assessment dated 03/10/2020 showed the patient also had the following conditions/problems: - Needed assistance with activities of daily living (ADLs) such as bathing and dressing, meals and housekeeping, and medications; - Unable to do most activity; - Safety issues related to ambulation precautions, fall precautions, and transfer precautions; - Incontinence of bowel and bladder; - High blood pressure; and - COPD (chronic obstructive pulmonary disease) with use of inhalers and nebulizer. Review of the plan of care included on the IDG meeting notes dated 04/08/2020 showed only the following problems indicated: - Coping: Family/Caregiver; Discipline: MSW- Interventions included only: teach primary caregiver/family coping strategies and assess caregiver/family coping behaviors; and - End Stage Dementia; Discipline; LPN/LVN- Interventions included only: assess pain level and discomfort using PAINAD scale (Pain Assessment In Advanced Dementia-a tool commonly used to assess pain in older adults with cognitive impairment), assess for behavioral disturbances, and assess cognitive limitations. Review of the plan of care included on the IDG meeting notes dated 04/08/2020 failed to show: - Interventions related to any of the above problems identified on the comprehensive assessment dated 03/10/2020 which included: assistance with ADLs, safety issues, incontinence, and chronic diseases of the heart and lungs; - Interventions or changes in the plan of care related to only telehealth visits allowed by caregiver after 03/21/2020; and - Discussion and new interventions due to the caregiver refusing visits. Visits refused included weekly visit attempts documented on: 03/25/2020, 04/01/2020, 04/08/2020, 04/15/2020, 04/22/2020, and 04/29/2020. During an interview on 08/11/2020 at 10:50 AM, the nursing supervisor stated that the change to telephone visits should be on a physician order and on the plan of care. The care plans were incomplete. RECORD/PATIENT #3: Review of the clinical record showed the patient was recertified to hospice services on 03/22/2020 for Alzheimer's Disease/dementia. The patient lived in a skilled nursing facility. Review of the physician's orders and POCs showed orders for weekly skilled nurse visits and failed to show orders for the use of telehealth to perform skilled nurse visits with the patient instead of in-person home/facility visits during the recertification episode of 03/22/2020 through 05/20/2020. Review of the Interdisciplinary/Patient Communication (IPC) notes dated 03/24/2020 and 03/25/2020 showed staff performed telehealth visits/assessments with the skilled nursing facility nurse and patient's family member. During an interview on 08/11/2020 at 10:50 AM, the nursing supervisor stated: - Telehealth began for the patient on 03/30/2020; - Typically there is no written order for telehealth; - A telehealth visit was made every week via the telephone and the facility nurse obtained vital signs and information needed about the patient; - The person spoken with was entered into the nurse's note; - Telehealth was not included in the plan of care; - He/she would expect to see documentation of the use of telehealth visits recorded in the care plan and physician's orders; - FaceTime visits were performed by the nurse practitioner only. The skilled nursing facility would not allow for the other hospice staff to do FaceTime (face to face) visits; and - The administrator (who is an RN) performed face to face visits with the patient prior to 03/30/2020 then there were no other" eyes on the patient" visits.
L0554      
38507 Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) maintained communication and responsibility for coordinating the care and services provided to the hospice patient in two (Records/Patients #1 and #2) of three records reviewed. This deficient practice has the potential to affect the individualized care received by all the agency's patients. Findings included: Review of the agency's policy titled, "Interdisciplinary Group Meeting," revised 04/2019, showed, in part, the following: - The interdisciplinary group (IDG) will meet on a regular basis to discuss patient and family/caregiver changes, progress, and updates to the plan of care; - Each patient's plan of care (POC) will be updated utilizing the results from the ongoing comprehensive assessment; - The patient's POC will be updated if the patient's condition requires change to include social, cultural, and any special needs of the patient; - The IDG meeting POC update form will be used for updates and will note changes, response to treatment, and progress toward targeted outcomes including increase or decrease in the frequency of visits and the reason for the change, missed visits will be explained and adjustment to the POC will be made if appropriate, and psychosocial and other consultations/conferences with the patient and family/caregiver; and - Problem solving for optimal care of the patient and family/caregiver will occur and be documented. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 03/10/2020 and was discharged on 05/21/2020 due to caregiver noncompliance. The patient lived at home with the spouse, Patient #2, and had the same family caregiver. Review of the clinical record (admission date 03/10/2020), showed visits were refused on: 03/25/2020, 04/01/2020, 04/08/2020, 04/15/2020, 04/22/2020, 04/29/2020, and 05/04/2020. All visits were recorded on a skilled nursing visit note and showed under description: RN (registered nurse) Patient refused Non reportable (non-billable). Review of the interdisciplinary communications showed: - RN IDT (interdisciplinary team) 04/22/20- Created by RN A-RN frequency 1x (once) per week and as needed, (caregiver) refuses any staff to go into home due to COVID-19. (RN A) continues to order medications and supplies for patient and the caregiver is to call with issues/questions. Interventions since last IDT: Continue plan of care; - MSW (medical social worker) IDT 04/22/20- Created by social worker C (SW C)-MSW frequency: Discontinued due to family request for no MSW visits during COVID 19 pandemic. Changes since last IDT: DC MSW visit schedule. Plan of care effective; and - These notes showed that the plan of care is to continue and is effective, but the IDT notes fail to show discussions, changes, or updates related to the caregiver refusing visits. Review of the skilled nursing visit note dated 05/21/2020 by RN E (no longer an employee) showed the patient was discharged from the agency due to the caregiver: - Making multiple text messages and phone calls to numerous staff members; - Being belligerent and inappropriate to staff; - Refusing, since admission (03/10/2020), to allow hospice staff into the home due to COVID-19 restrictions; - Demanding extra supplies and medication throughout the certification period; - Calling the equipment company and pharmacy to discuss matters without conversing with the hospice first; and - Calling the pharmacy on 05/20/2020 and impersonated RN A to try to order medications. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 03/10/2020, discharged on 05/21/2020 due to caregiver noncompliance. The patient lived at home with the spouse, Patient #1, and had the same family caregiver. Review of the clinical record (admission date 03/10/2020), showed visits were refused on: 03/25/2020, 04/01/2020, 04/08/2020, 04/15/2020, 04/22/2020, and 04/29/2020. All visits were recorded on a skilled nursing visit note and showed under description: RN (registered nurse) Patient refused Non reportable (non-billable). Review of the IDG meeting notes dated 04/08/2020 showed: - RN frequency 1x (once) per week, refusing staff but wants medications and supplies; - MSW frequency: discontinued due to family request for no MSW visits during COVID 19 pandemic; and - Failed to show any discussion and new interventions due to the caregiver refusing visits. Review of the interdisciplinary communications showed: - RN IDT (interdisciplinary team) 04/22/20- Created by RN A-RN frequency 1x (once) per week and as needed, (caregiver) refuses any staff to go into home due to COVID-19. (RN A) continues to order medications and supplies for patient and the caregiver is to call with issues/questions. Interventions since last IDT: Continue plan of care; - MSW (medical social worker) IDT 04/22/20- Created by social worker C (SW C)-MSW frequency: DC'd due to family request for no MSW visits during COVID 19 pandemic. Changes since last IDT: DC MSW visit schedule. Plan of care effective; - These notes show that the plan of care is to continue and is effective, but the IDT notes failed to show discussions, changes, or updates related to the caregiver refusing visits. Review of the skilled nursing visit note dated 05/21/2020 by RN E (no longer an employee) showed the patient was discharged from the agency due to the caregiver: - Making multiple text messages and phone calls to numerous staff members; - Being belligerent and inappropriate to staff; - Refusing, since admission (03/10/2020), to allow hospice staff into the home due to COVID-19 restrictions; - Demanding extra supplies and medication throughout the certification period; - Calling the equipment company and pharmacy to discuss matters without conversing with the hospice first; and - Calling the pharmacy on 05/20/2020 and impersonated RN A to try to order medications. During an interview on 08/10/2020 at 11:30 AM, the director of operations stated that the problems with the caregiver for Patients #1 and #2 had been going on since the beginning of care. During an interview on 08/11/2020 at 2:00 PM, registered nurse, RN A, regarding Patients #1 and #2, stated that; - He/she took over in the middle of the episode (admission 03/10/2020) and was given report by the other RN that the caregiver was texting and calling a lot and would call the equipment company and the pharmacy; - He/she did not know if the telehealth visits were discussed early in the episode at IDT meeting as he/she was not the case manager then; - When asked if the caregiver had been causing problems during his/her care of the patient, he/she stated, "absolutely"; and - RN A did not document this but did report the problems to his/her supervisor, RN E. The agency's IDT failed to ensure oversight of the patient's care when: - The refused visits and caregiver problems were not discussed; and - New or changed interventions and goals failed to be added to the plan of care.
L0577      
38507 Based on agency observation, policy review, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by Centers for Medicare and Medicaid Services (CMS) on 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to: - Maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel from COVID-19 (L578); - Maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of COVID-19 that includes a method for identifying infectious disease problems and a plan for implementing appropriate actions (L581); - Provide infection control education related to COVID-19 to patients and family members (L582): and - Include strategies for addressing emergency events identified by the risk assessment, including staffing shortages (E0006) The cumulative effect of these deficient practices has the potential to affect the health and safety of all the agency's patients.
L0578      
38507 Based on agency observation, policy review, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by Centers for Medicare and Medicaid Services (CMS) on 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care." The hospice failed to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: On 08/10/2020 at 11:10 AM, the surveyor approached the outer doors of the agency's office. Observation failed to show any signage to visitors or staff to show visitation restrictions and screening procedures for COVID-19. There failed to be signs addressing the need for individuals with symptoms of a respiratory infection to put on a mask, cover their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after contact with respiratory secretions. After entering the agency, there failed to be any type of screening of visitors for COVID-19 signs and symptoms. The staff were not wearing masks or complying with social distancing requirements. Review of the agency's policy titled, "Emergency Preparedness Plan: COVID-19, " dated 03/13/2020, failed to show procedures for identification and mitigation of COVID-19 in the office for visitors or staff. During an interview on 08/11/2020 at 11:20 AM, the director of nursing stated that: - The agency did not have a process for evaluating office visitors; - The agency office building had been mainly closed until just a few weeks ago; - Agency office staff were working from home; and - Starting 08/11/2020, they have implemented signs on the door and screening for people entering the office.
L0581      
38507 Based on policy review and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by Centers for Medicare and Medicaid Services (CMS) on 03/23/2020, "COVID-19 Focused Infection Control Survey: Acute and Continuing Care" when the hospice failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of COVID-19 that included a method for identifying the infectious disease and a plan for implementing appropriate actions. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency's policy titled, "Emergency Preparedness Plan: COVID-19, " dated 03/13/2020, failed to show the following: - Procedures for an established surveillance plan; - A plan that includes early detection and management of a potential infectious, symptomatic patient; - A process for communicating the diagnosis, treatment, and laboratory test results when transferring patients to a facility or healthcare provider; and - Staff able to identify/describe the communication protocol with local/state public health officials. During an interview on 08/11/2020 at 11:20 AM, the director of nursing was unable to show a specific surveillance plan for COVID-19.
L0582      
38507 Based on policy review, review of agency admission packet, and interviews, the agency failed to ensure an effective COVID-19 infection control program using guidance provided by Centers for Medicare and Medicaid Services (CMS) on 03/23/2020 "COVID-19 Focused Infection Control Survey: Acute and Continuing Care," when the agency failed to provide infection control education to patients and family members. This deficient practice has the potential to affect the health and safety of all the agency's patients. Findings included: Review of the agency's policy titled, "Emergency Preparedness Plan: COVID-19," dated 03/13/2020, showed: - All patients and families will receive education regarding COVID-19 regarding symptoms, handwashing guidelines, and other educational items as provided by the CDC and State and local health departments; and - Updates to this education will be provided as they become available. Review of the admission packet that contained patient education materials failed to show any specific COVID-19 or pandemic disease written instructions to be given to the patient and family at the time of admission. During an interview on 08/11/2020 at 11:20 AM, the director of nursing stated that: - There was no written material given to the patients for COVID-19 education; and - The field staff have been instructed to educate the patients/caregivers on hand hygiene, limiting visitor, etc. During an interview on 08/11/2020 at 2:00 PM, when asked how the patients were educated on COVID-19, RN A stated that there was no formal education or written material to use.
L0584      
38507 Based on policy review, clinical record review, and interview, the agency failed to ensure that the licensed professional services delivered by their health care professionals was practiced under the hospice's policies and procedures when the agency discharged patients without proper notice in two (Record/Patient #1 and #2) of three records reviewed. This deficient practice has the potential to affect the quality of care provided to all the agency's patients. Findings included: Review of the agency's policy titled "Discharge from Hospice Program," revised October 2019, showed, in part, the following: - The hospice interdisciplinary group (IDG) will develop a discharge plan; - The case manager will ensure that necessary paperwork is completed at the time of discharge; - Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours; - If the patient is discharged to the community, the organization will inform the family both verbally and in writing, including a timeline for discontinuation of services; and - If the hospice determines the patient should be discharged for the cause of disruptive abuse or uncooperative behavior, the following steps will be taken: *Advise the patient and/or caregiver that a discharge for cause is being considered; *Make a serious effort to resolve the problem(s) caused by the behavior or situation of a patient or other persons in the patient's home and document problems and efforts made to resolve it in the clinical record; * Determine that the patient's proposed discharge is not due to the patient's use of necessary hospice services; * Prior to discharging a patient for cause, the hospice IDG must obtain a written discharge order from the hospice medical director. If the patient has an attending physician involved in the care, this physician should be consulted before discharge and his/her review and decision should be included in the discharge note; * The hospice should also consider referrals to other appropriate and/or relevant state/community agencies or health care facilities prior to discharge; and * The hospice notifies its Medicare Administrative Contractor and the state licensure agency of the circumstances surrounding the impending discharge for cause. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 03/10/2020. Patient #2 is the spouse and they live at a family member's home with the same caregiver. Review of the skilled nursing visit note, dated 05/21/2020 at 3:00 PM, RN E documented the following: - This administrator contacted the patient's caregiver regarding issues between the agency and him/her; - The caregiver has been making multiple text messages and phone calls to numerous staff numbers being belligerent and inappropriate to staff; - Since admission, the caregiver has refused to allow hospice staff into the home due to Covid-19 restrictions; - The caregiver has been demanding extra supplies and medications throughout the certification period; - The caregiver will often call the durable medical equipment or pharmacy to discuss matters without conversing with hospice first and has been redirected multiple times to contact hospice main number for things he/she may need and has not complied; - On 05/20/2020, hospice was notified by the pharmacy that the caregiver had attempted to disguise his/herself as RN A, the patients RN case leader, however, the pharmacy was able to identify the caregiver's phone number on caller ID; - The caregiver called in a brand new script for the patient's Buspar and claimed he/she was RN A when RN E asked the caregiver about this issue he/she adamantly denied it; raised his/her voice and was accusatory towards hospice company and RN E; - RN E attempted to give parameters on future conduct, including not contacting the pharmacy, durable medical equipment company, hospice staff members via their personal numbers all hours of the day and night; - The caregiver refused and went silent; - RN E instructed they would discharge the patient for cause for lack of cooperation and unwillingness to comply; - The agency would provide supplies, medications and durable medical equipment until 06/04/2020; - The primary care physician and medical director notified of discharge circumstances and were in agreement; - RN E notified IDG who were supportive of decision; and - RN E entered the skilled visit nursing note on 5/26/2020 at 3:34 PM (five days after the patient's discharge). Review of the clinical records showed the agency failed to follow their policy and procedure titled "Discharge from Hospice Program," when the agency failed to do the following: - Develop a discharge plan and discharge/transfer form; - Notify the patient/caregiver in writing of the discharge, including a timeline for discontinuation of services; - Document in the clinical records regarding problems with the caregiver until the day of discharge; - Advise the patient and/or caregiver that a discharge for cause is being considered; - Make a serious effort to resolve the problem or efforts made to resolve the problems documented in the clinical record; - Obtain a written order for discharge or provide the patient's physician review/decision in the discharge note; - Provide referrals to other appropriate and/or relevant state/community agencies or health care facilities prior to discharge; and - Notify its Medicare Administrative Contractor (MAC) and the state licensure agency of the circumstances surrounding the impending discharge for cause. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the agency on 03/10/2020. Patient #1 is the spouse and they live at a family member's home with the same caregiver. Review of the skilled nursing visit note, dated 05/21/2020 at 14:30 PM, RN E (who is no longer employed by the agency) documented the following: - This administrator contacted the patient's caregiver regarding issues between the agency and him/her; - The caregiver has been making multiple text messages and phone calls to numerous staff numbers being belligerent and inappropriate to staff; - Since admission, the caregiver has refused to allow hospice staff into the home due to Covid-19 restrictions; - The caregiver has been demanding extra supplies and medications throughout the certification period; - The caregiver will often call the durable medical equipment or pharmacy to discuss matters without conversing with hospice first and has been redirected multiple times to contact hospice main number for things he/she may need and has not complied; - On 05/20/2020, hospice was notified by the pharmacy that the caregiver had attempted to disguise his/herself as RN A, the patients RN case leader, however, the pharmacy was able to identify the caregiver's phone number on caller ID; - The caregiver called in a brand new script for the patient's (Patient #1) Buspar and claimed he/she was RN A when RN E asked the caregiver about this issue he/she adamantly denied it; raised his/her voice and was accusatory towards hospice company and RN E; - RN E attempted to give parameters on future conduct, including not contacting the pharmacy, durable medical equipment company, hospice staff members via their personal numbers all hours of the day and night; - The caregiver refused and went silent; - RN E instructed they would discharge the patient for cause for lack of cooperation and unwillingness to comply; - The agency would provide supplies, medications and durable medical equipment until 06/04/2020; - The primary care physician and medical director notified of discharge circumstances and were in agreement; - RN E notified IDG who were supportive of decision; and - RN E entered the skilled visit nursing note on 5/26/2020 at 3:33 PM (five days after the patient's discharge). During an interview on 08/10/2020 at 11:30 AM, the director of operations stated that: - The problems with Patient #1 and #2's caregiver were going on since the beginning of care (03/10/2020); - The caregiver requested a Hoyer lift (assistive medical device which apply specially-designed slings and pads to safely lift a patient from a bed). The hospice was willing to provide it and train the caregiver but he/she refused to allow training: - He/she was "sure" the caregiver tried to call in a medication to the pharmacy; and - The medication situation was the "tipping point" on the decision to discharge the patients. During an interview on 08/11/2020 at 2:00 PM, regarding Patient #1 and #2, registered nurse A (RN A) stated that: - The problems with the caregiver was from the start of care (03/10/2020); - He/she took over for another RN in the middle of the episode and report was received from the other RN that the caregiver was texting and calling the nurse frequently. If he/she did not get what was requested, the caregiver would then call the medical equipment company or pharmacy; - This continued when RN A took over the cases; - The problems were discussed with the caregiver numerous times and reported to the supervisor, RN E; - RN E spoke with the caregiver "multiple times" regarding boundaries and inappropriate behavior; and - RN A did not document the discussions with the caregiver in the clinical records regarding the inappropriate behavior. Patient #1 and #2's caregiver was interviewed on 08/12/2020 at 3:24 PM by telephone. The caregiver stated that: - During the episode of care starting 03/10/2020, the hospice never called or discussed any issues related to using texts or calling the pharmacy until the last day (05/21/2020); - On 05/21/2020, the hospice called and RN E told him/her that hospice services would be discontinued for Patient #1 and #2 related to the caregiver impersonating a nurse and calling in medications; - RN E stated that the equipment would be removed from the home that day; - The equipment company called the home two times that day wanting to come and get the equipment; - He/she never called the pharmacy trying to call in a prescription. He/she is not a doctor; - After the telephone call from RN E, he/she called the State of Missouri and received a call back from the home care assistant administrator; - The home care assistant administrator contacted the hospice agency on the caregiver's behalf and he/she requested that the patients be allowed to keep the equipment and supplies for two weeks until a decision was made about the patient's care; and - Another hospice was not contacted and RN E was contacted and the caregiver requested to resume hospice care if another nurse would be assigned to the patients. Review of the clinical records showed the agency failed to follow their policy and procedure titled "Discharge from Hospice Program," when the agency failed to do the following: - Develop a discharge plan and discharge/transfer form; - Notify the patient/caregiver in writing of the discharge, including a timeline for discontinuation of services; - Document in the clinical records regarding problems with the caregiver until the day of discharge; - Advise the patient and/or caregiver that a discharge for cause is being considered; - Make a serious effort to resolve the problem or efforts made to resolve the problems documented in the clinical record; - Obtain a written order for discharge or provide the patient's physician review/decision in the discharge note; - Provide referrals to other appropriate and/or relevant state/community agencies or health care facilities prior to discharge; and - Notify its Medicare Administrative Contractor (MAC) and the state licensure agency of the circumstances surrounding the impending discharge for cause.