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 ______________ 		02/22/2021
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      
29559 Based on policy review, record review, grievance file review and interview, the hospice provider failed to ensure that patients received effective pain management and symptom control in two of four records reviewed (L512). The example of (L512) was identified at an immediate jeopardy level for actual harm to patients, therefore the practice is deficient at a condition level. The deficient practice has the potential to affect all patients served by the hospice provider.
L0512      
29559 Based on policy review, clinical record review, and interview the hospice provider failed to assure that patients received effective pain management and symptom control in two of four records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the pain management of all patients served by the agency. Findings included: Review of agency undated policy titled, "Hospice Patient's Bill of Rights/Responsibilities," showed the patients had the right to receive effective pain management and symptom control for conditions related to terminal illness. Review of agency policy revised January 2020 titled, "Pain Assessment and Reassessment" showed: - Each patient will receive effective pain management and symptom control for conditions related to the terminal illness; and - When a patient's pain is not relieved, the nurse will intervene appropriately. Such interventions may include: * Notification of patient's attending physician and/or medical director; * Change in pain and symptom management medications based on physician orders; * Patient education regarding alternative pain relief measures; and * Referral for pain treatment. Review of agency policy revised June 2019 and titled, "After Hours Accessibility," showed: - Purpose: To provide care to patients 24 hours/day, 7 days/week; - Nursing services, physician services and drug and biologicals are routinely available on a 24-hour basis 7 days a week; - A registered nurse (RN) is available 24-hours per day, 7 days per week; and - The director and/or manager of patient services is on-call 24-hours per day on a rotating weekly basis. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/23/2020 with a terminal diagnosis of malignant neoplasm of frontal lobe (cancer in the front lobe of the brain), and co-morbid diagnoses of epilepsy (seizure disorder), obesity, and anxiety. Review of the nursing documentation showed that: - On 09/23/2020 the RN initial comprehensive assessment showed that the patient had no pain, and had no medication or interventions ordered for pain management; - On 09/24/2020, the RN visit showed the spouse had reported that the patient had not eaten, or had anything to drink, for the last four days and was refusing medications; - On 09/26/2020 at 08:04 PM, a communication note showed that: * The spouse had reported that the patient's ribs were sore, "no pain, just sore"; and * The RN instructed the spouse to notify him/her if having pain or if soreness exacerbates; - On 09/29/2020 at 03:11 AM, the on-call log showed that the patient's spouse had called the answering service in an "attempt to get pain medication" for the patient. Further documentation showed that the nurse could not reach the doctor so the patient would have to wait until the pharmacy opened for the physician to fax in a written prescription; - On 09/29/2020 at 09:36 AM, a communication note showed that the physician was notified of the patient complaining of rib cage pain since 12:42 AM. The spouse had called the RN at 12:42 AM, 01:45 AM, and 02:45 AM, as well as calling the on-call number at 03:00 AM. The physician ordered hydrocodone/acetaminophen (a combination drug containing an opioid medication used to treat severe pain and a non-narcotic medication used to treat pain) 5/325 milligrams (MG), one tablet by mouth every hour as needed for rib cage pain (the patient was previously assessed with the inability to swallow tablets); and - On 09/29/2020 at 1:00 PM, an RN visit showed that the spouse reported that the patient had been in pain all night with no medication, and requested a transfer of care to another agency. The visit fails to contain documentation of delivery of the drug (hydrocodone/acetaminophen), administration of the drug, or education provided on use of the drug. During an interview on 02/18/2021 at 07:24 PM, the spouse/primary caregiver stated that: - The patient was not having pain when he/she was admitted to hospice, and the pain began about the second day after starting hospice care; - When he/she (the spouse) provided care the patient would "yell" out in pain; - His/Her spouse (the patient) developed pain in his/her ribs, legs, and back; - He/she had called the hospice multiple times during the night, spoke with staff members at each call, and was told each time that the physician had not "responded"; - He/she called every number on the hospice folder in the home, and finally called the answering service hoping to get help with (the patient's) pain; - The hospice staff did not visit until 1:00 PM or 2:00 PM the following day when they brought any pain medication tablets; - The patient was not eating or drinking and the agency brought a tablet to the house for his pain management; - The hospice nurse told him/her to crush the pill and put it in a drink; - He/she crushed the pill, put it in some hot water, and tried to give it to the patient, but was unsure how much the patient was actually able to swallow; - He/she stopped care (revocation) with the hospice due to poor response for the (the patient's) pain control. He/she hired a new hospice and they immediately provided the patient with stronger liquid pain medication to control (the patient's) pain. The patient was without effective pain management for 12 hours after the PCG notifed the hospice provider of the patient yelling out in pain. RECORD/PATIENT #2: The patient was admitted to hospice service with the provider on 10/10/2020 with a terminal diagnosis of lung cancer. Review of the "hospice medication profile" showed that on 10/10/2020, the patient had physician orders for Percocet tablets 10-325 mg (milligram), one tablet every eight hours for pain. Review of the initial comprehensive assessment, performed 10/10/2020, showed the nurse assessed that the patient's pain level was severe. rated at score of 10 (on a scale of 10 being most severe). The patient's pain was in the chest. The patient's acceptable level of pain goal was a "4". Review of routine nurse visit notes dated 10/11/2020, 10/13/2020, 10/15/2020, 10/17/2020, 10/18/2020, showed the patient rated his/her pain as severe at each visit, up to 10/10 pain. The patient's pain was in the chest. The patient's acceptable level of pain goal was a "4". Review of the interdisciplinary group (IDG) notes and all available physician orders showed no changes in pain management interventions from 10/10/2020 until 10/18/2020. Review of the after hours call log showed that the patient called after hours on at least one occasion, 10/16/2020, about pain management. The patient signed a revocation of hospice benefit with the provider on 10/20/2020. During interview with the patient/primary caregiver on 02/19/2020 at 5:22 PM showed that the patient stopped hospice with the provider (revocation) because "they (the hospice) would not control (the patient's) pain". The patient was without effective pain management for seven days without any new intervention from the hospice provider.