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
261682 A. BUILDING __________
B. WING ______________ 		10/14/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
DEER VALLEY HOSPICE CARE, LLC 8600 AIRPORT ROAD, SAINT LOUIS, MO, 63134
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)
L0500      
42078 Based on policy review, record review, grievance file review, and interview, the agency failed to promote and protect the following patient rights: - To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice (L505); and - To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512). The cumulative effect of these deficient practices resulted in a finding of immediate jeopardy for one patient (Patient/Record #2) and has the potential to affect all patients served by the agency.
L0505      
42078 Based on policy review, record review, complaint log review, and interview, the agency failed to conduct/document timely grievance investigations and resolution in two (Record/Patient #1 and #2) of two applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of an agency policy revised 06/2019 and titled, "Complaint Resolution," showed that, but not limited to: - A patient complaint may be formal or informal and in writing or verbal. The complaint may be made to any hospice employee, volunteer, or individual furnishing services under arrangement. The complaint may be made by the patient or patient representative; - Patients are encouraged to make suggestions for improving care and/or register complaints to hospice without fear of coercion, discrimination, or reprisal for doing so or unreasonable interruption of care: * Hospice will investigate complaints made by patient, patient's family or guardian regarding treatment or care that is (or fails to be) furnished; * Hospice will document both the existence and the resolution (or attempts at resolution) of the complaint; and - Employees will follow the normal chain of command in pursuing resolutions to any problem. RECORD/PATIENT #1: During an interview on 10/14/21 at 10:37 AM, INT2 stated that: - During the course of care by the agency they were unable to reach staff members to ask questions; - They felt that no one would explain the role of hospice and how hospice worked, and that the agency provided terrible customer service; - They had problems with one nurse and requested that the nurse never return to the home; - Did call the after hours nursing staff multiple times; and - The agency did not provide a medication list when it was requested. Review of the faxed call logs failed to show documentation of any calls to the agency. Review of the complaint log showed that the record failed to contain documentation of the report of, or the investigation of, the patient's caregiver requesting that a particular nurse not return to his/her home. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted for hospice services in their own home with a terminal diagnosis of prostate cancer with metastasis (spreading) to the bone. The patient's primary caregiver was an unrelated person who resided in their home. Review of the faxed call logs showed that the patient's caregivers had called the answering service on: - Tuesday, 09/28/21 at 08:32 AM, and left a message stating they were, "needing to know when the nurse will be coming, he/she was there Friday but haven't heard anything yet, and has some questions;" and - Wednesday, 09/29/21 at 08:35 AM, and left a message stating that, "nurse still hasn't shown up or called, the last they spoke to him/her was 2:10 today and they are getting upset." Review of the complaint log showed that the log failed to contain documentation of the report of, or the investigation of, the patient's caregiver requesting nursing care, and becoming "upset" because the nurse hadn't shown up or called. During an interview on 10/07/21 at 12:10 PM, RN1 stated that: - He/She was the case manager for this patient; - Notified the patient and caregiver that they would visit on Wednesday and Friday of each week; and - The patient's caregiver did call the on-call nurse's cell phone because they wanted a catheter; and an order was received for catheter placement. During an interview on 10/14/21 at 11:00 AM, RN1 stated that; - Patients frequently call the nurse's cell phone to report issues and they don't always use the answering service; and - The patient's caregiver had called their cell phones asking about when the nurses would visit. During an interview on 10/12/2021 at 10:48 AM, the complainant stated that he/she had called on multiple occasions asking for the nurse to make a visit and the nurse never did, until the day he/she died (the patient). During an interview on 10/14/21 at 11:30 AM the administrator stated they were unaware of the complaints made by the patient's caregiver.
L0512      
42078 Based on professional guidance, agency policy, clinical record review, and interview, the agency failed to assure that patients received effective pain management and symptom control from the hospice for conditions related to the terminal illness in one (Record/Patient #2) of three records reviewed. This deficient practice has the potential to affect the pain and symptom management of all of the agency's patients. Findings included: Review the Centers for Disease Control (CDC) Prescribing Guideline Mobile Application on 10/12/21 showed the following conversions of opioid medications to an oral morphine milligram equivalent (Morphine milligram equivalents (MME) are values that represent the potency of an opioid dose relative to morphine. MME is intended to help clinicians make safe, appropriate decisions concerning changes to opioid regimens.) : - The MME for a Fentanyl patches, 100 mcg every three days was the MME of morphine 240 mg daily; and - The MME for hydromorphone 1 mg per day was the MME of morphine 4 mg per day. Review of agency policy dated 01/2020 and titled, "Pain Assessment and Reassessment," showed: - A comprehensive assessment of the patient's pain using a standardized pain assessment tool appropriate to the patient's age, condition, ability to understand, development and cognitive status may include: * History of pain and its treatment; * Characteristics of pain including intensity, descriptor, pattern, location and radiation, frequency/timing/duration, impact of pain on quality of life, factors that precipitate or exacerbate pain, strategies/factors that reduce pain, additional symptoms associated with pain; * Physical examination; * Current medical conditions and medications; and * Patient/family's goals for pain management and their satisfactions with the current level of pain control; - Each patient will have pain reassessed on an ongoing basis using established criteria, including: * Locations * Intensity; * Duration; * Frequency; * Character; * Current pain therapy or treatment; * Effectiveness of current therapy or treatment to pain interventions; * Progress toward pain goals (including functional ability); and * Side effects and risk factors for adverse events; - When a patient's pain is not relieved, the nurse will intervene appropriately. Such interventions may include notification of the patient's physician, change in pain and symptom management medications, patient education regarding alternative pain relief measures, and referral of pain treatment; and - When pain is assessed/reassessed as a problem, a pain treatment plan will be included in the interdisciplinary group (IDG) careplan. Review of agency policy dated 06/2019 and titled, "Initial Assessment/Comprehensive Assessment," showed: - The initial assessment includes the patient's immediate physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. severity of symptoms; and - Each patient's comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments) to identify drug effectiveness, side effects, noncompliance with medications, duplicate therapy, and ineffective therapy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted for hospice services in their own home with a terminal diagnosis of prostate cancer with metastasis (spreading) to the bone. The patient's primary caregiver was an unrelated person who resided in their home. Review of the hospital discharge orders dated 09/22/21 showed: - Diagnoses of anasarca (severe and generalized edema throughout the body), prostate cancer with metastasis to the bone; - Medications including, but not limited to: * Acetaminophen (a medication used to reduce pain and fever) 500 milligram (mg) capsule, take two capsules by mouth every six hours; * Celecoxib (a non-steroidal, anti-inflammatory drug used to treat the pain and inflammation) 100 mg capsule, take one capsule by mouth two times per day; * Cyclobenzaprine (a muscle relaxer used to control muscle spasms) 10 mg tablet, take 10 mg by mouth three times a day as needed; * Diclofenac sodium (a non-steroidal, anti-inflammatory drug used to treat pain) 1% gel, apply 2 grams topically three times a day as needed for cancer pain; * Duloxetine DR (an antidepressant) 60 mg capsule, take one capsule by mouth nightly; * Fentanyl (a powerful opioid used as a pain medication) 100 microgram/hour (mcg/hr), place one patch on the skin every third day (MME 240 mg/24 hours); * Gabapentin (an anticonvulsant used to treat nerve pain) 800 mg tablet, take one tablet by mouth three times per day; * Hydromorphone (an opioid used to treat moderate to severe pain) 2 milligram/milliliter (mg/ml), infuse 0.75 milliliter (ml) (1.5 mg) into a venous catheter (vc) every two hours as needed for pain from metastatic cancer for up to seven days (MME 72 mg/24 hours); * Hydromorphone 4 mg tablet, take three tablets (12 mg total) by mouth every four hours as needed for pain up to seven days (MME 288 mg/24 hours); * Lidocaine (a local anesthetic patch used to treat pain) 5% patch, place two patches on the skin daily, remove and discard patch within 12 hours; * Naloxone (a medication used to block the effects of opioids, used to treat opioid overdose) 0.4 mg/ml injection, infuse 1 ml (0.4 mg) into a vc every 10 minutes as needed for opioid reversal or respiratory depression (call physician if thinking about giving it) for up to 3 doses; and * The patient's total MME on this schedule was 600 mg/24 hours. Review of the document signed by the patient on 09/22/21 and titled, "Hospice Patient's Bill of Rights and Responsibilities," showed that the patient had the right to receive pain management and symptom control for conditions related to terminal illness. Review of the initial comprehensive assessment dated 09/22/21 showed: - The patient had generalized, severe pain all of the time. The patient's goal for pain management was to have pain rated 0-8, on a 0-10 high scale. The patient felt the pain medications were ineffective and the patient was uncomfortable due to pain. The pain character was throbbing and aching all of the time. The pain was constant. The pain was rated a 10 on a 0-10 high scale at the beginning of the nursing visit; - The patient requested oral, liquid morphine for pain control; - The patient had a history of IV (intravenous) drug use and administered oral hydromorphone via the heplock in his/her left arm that was inserted during his/her hospital stay; - The initial comprehensive assessment failed to contain documentation of: * A medication reconciliation between the medications in the home, the medications listed on the hospital discharge instructions, and the medications provided by the agency; * The efforts of the nurse to prevent the patient from administering oral medications through his/her heplock; and * A plan for the management of the patient's pain including, but not limited to, the lack of IV hydromorphone in the home and non-pharmacological methods of pain control. Review of the hospice plan of care dated 09/23/21 showed the patient would: - Remain comfortable during care; - Receive optimal level of pain and/or symptom management on short-term basis; - Use non-pharmacological pain control measures e.g. relaxation, positioning; and - Use fentanyl patches, acetaminophen, celecoxib, and hydromorphone for pain control. The record failed to contain further documentation of assessments related to pain or symptom management for 44 hours, until the next nursing visit dated 09/24/21. Review of nursing visit note dated 09/24/21 showed: - Orders were received to modify the pain management regimen including: * Discontinue fentanyl and lidoderm patches; * Start morphine 20 mg/ml every 2 hours as needed for pain rated 6-10 on a 0-10 high scale (MME 240 mg/24 hours); * Start hydromorphone 8 mg every 8 hours as needed for pain rated 1-5 on 0-10 high scale (MME 96 mg/24 hours); * Total MME for 24 hours 336 mg/24 hours (a MME decrease of 264 MME in each 24 hour period); and - The patient rated his/her pain at the time of the medication change an 8 on a 0-10 high scale, and that the pain occurred "all of the time". (The pain rating was not within the patient's pain goal.) The record failed to contain further documentation of assessments related to pain that was not controlled within the patient's pain goal, or symptom management until the patient expired at home six days later on 09/30/21. During an interview on 10/12/2021 at 10:48 AM, the complainant stated: - He/she had called the nurse on 09/28/21 and asked that a catheter be placed (a tube inserted into the bladder to control urine) to control the patient's urine since he/she had developed a wound on his/her buttocks, and was too weak to use a urinal and he/she was told: * That the agency did not have catheter bags and that catheter insertion would have to wait until a catheter bag was delivered; * He/She stated that he/she had wondered about why a hospice would not have catheter bags in stock; * When he/she received a call that the catheter bag was available on 09/29/21, it was after 07:00 PM. The complainant stated that he/she requested the nurse come visit the next day, 09/30; and * The patient passed away 09/30 with no catheter. - The patient was in constant pain: * His/her pain worsened after the intravenous access (IVA) was removed; and the agency discontinued the fentanyl patches, started morphine and reduced the hydromorphone dosage; * He/she was giving the medications routinely; * He/she called on multiple occasions asking for the nurse to come and visit; and * He/she was so desperate to give the patient pain relief he/she reapplied a fentanyl patch, without direction from agency staff, the day the patient died.