| 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 ______________ |
03/12/2021 | |
| 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 |
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| 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) |
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| E0009 | |||
| 42078 Based on review of the agency's emergency preparedness (EP) binder and interview, the agency failed to include a process for cooperation and collaboration with local, regional, state or federal emergency preparedness officials. This deficient practice has the potential to adversely affect the safety of all patients during an emergency. Findings included: Review of the EP binder failed to show evidence of a process to ensure cooperation and collaboration with local, regional, state or federal emergency preparedness officials. During an interview on 03/10/2021 at 3:30 PM, the compliance officer stated that he/she will look for the missing process. The process was not presented by the end of the survey on 03/12/2021. | |||
| E0016 | |||
| 42078 Based on review of the agency's emergency preparedness (EP) binder and interview, the agency failed to include a procedure for informing state and local officials of patients and staff the agency cannot locate during an emergency. This deficient practice has the potential to adversely affect the safety of all staff and patients during an emergency. Findings included: Review of the EP binder failed to show evidence of a procedure to ensure state and local officials are contacted in the event a patient or staff member is missing during an emergency. During an interview on 03/10/2021 at 3:30 PM, the compliance officer stated that: - If a patient or staff member is not located, the agency will attempt and document trying to call them three times and then state and local officials would be contacted; and - He/she will look for the missing procedure. The procedure was not presented by the end of the survey on 03/12/2021. | |||
| E0019 | |||
| 42078 Based on review of the agency's emergency preparedness (EP) binder and interview, the agency failed to include a procedure for informing state and local officials of patients in need of evacuation during an emergency. This deficient practice has the potential to adversely affect the safety of all patients during an emergency. Findings included: Review of the EP binder failed to show evidence of a procedure to ensure state and local officials are contacted in the event a patient needs evacuation during an emergency. During an interview on 03/10/2021 at 3:30 PM, the compliance officer stated that he/she will look for the missing procedure. The procedure was not presented by the end of the survey on 03/12/2021. | |||
| E0039 | |||
| 42078 Based on review of the agency's emergency preparedness (EP) binder and interview, the agency failed to show an analysis of the agency's responses and maintain documentation of all drills, tabletop exercises and actual emergency events. This deficient practice has the potential to adversely affect the safety of all patients during an emergency. Findings included: Review of the EP binder failed to show evidence of an analysis of the agency's responses and documentation of all drills, tabletop exercises and actual emergency events. During an interview on 03/10/2021 at 3:30 PM, the compliance officer stated that he/she will look for the missing documentation. None was presented by the end of the survey, 03/12/2021. | |||
| L0502 | |||
| 42078 Based on policy review, review of the agency's admission packet, and interview, the agency failed to ensure that the patients received accurate and current written information related to his/her patient rights. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy revised June 2019 and titled, "Patient Bill of Rights," showed that the policy failed to contain information that the hospice must: - Ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator; - Immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures; - Take appropriate corrective action in accordance with state law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction, such as the State survey agency or local law enforcement agency; - Ensure that verified violations are reported to State and local bodies having jurisdiction (including to the State survey and certification agency) within 5 working days of becoming aware of the violation; - Inform the patient in writing of the extent payment may be required from patient and changes in liability within 30 days the hospice is aware of the new amount. Review of the agency's admission booklet provided to patients at the time of admission to service showed that the booklet failed to contain written information that the hospice must: - Ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the hospice administrator; - Immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance with established procedures; - Take appropriate corrective action in accordance with state law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction, such as the State survey agency or local law enforcement agency; - Ensure that verified violations are reported to State and local bodies having jurisdiction (including to the State survey and certification agency) within 5 working days of becoming aware of the violation; - Inform the patient in writing of the extent payment may be required from patient and changes in liability within 30 days the hospice is aware of the new amount. During an interview on 03/10/21 at 12:25 PM the office manager stated that he/she was unable to locate the above information in the agency policy or the admission packet. | |||
| L0509 | |||
| 42078 Based on policy review, agency complaint log, admission packet complaint procedure, record review, home visit observation, and interview, the agency failed to immediately investigate alleged violations and take action to prevent further potential violations. The agency failed to document a complete investigation when: - Example #1) A possible violation of a patient's HIPAA (Health Insurance Portability and Accountability Act) rights occurred, and - Example #2) There was an alleged misappropriation of the patient's medication. Both incidents occurred in one (Record/Patient #12) of six full record reviews conducted. This deficient practice has the potential to adversely affect the rights of all the agency's patients. Findings included: Review of the agency's policy titled, "HIPAA Breach Notification-6.3.1," dated revised June 2019, showed, in part, the following: - The purpose of the policy is to define the hospice's process for providing notice to any and all affected individuals of any breach of protected health information (PHI). PHI is individually identifiable health information that identifies the individual or for which there is a reasonable basis to believe can be used to identify the individual, including demographic data, that relates to the individual's past, present, or future physical or mental health or condition; and - The hospice will determine whether a breach of unsecured PHI has occurred as follows: * Determine first whether the use of disclosure of PHI violates the HIPAA Privacy Rule; and * In order to determine whether a breach has occurred, the hospice will conduct a risk assessment to determine whether the potential breach presents a significant risk of harm to individuals. Review of the agency's policy titled, "Patient Confidentiality-6.2.1," dated revised June 2019, showed, in part, the following: - Hospice will comply with applicable HIPAA rules and regulations; and - The staff will treat any information from patient, caregiver, physicians, and other sources in a confidential manner. Review of the agency's procedure titled, "Complaint and Grievance Process," in the admission packet given to the patients, showed on page 14, in part, the following information: - All complaints and grievances will be documented on a patient complaint/concern (form) and on the complaint log; - The complaint log will include review and evaluation of the collected information; effective action taken and outcome; communication with the client/patient/caregiver/family; and - Documentation of all activities involved with the grievance/complaint/concern, investigation, analysis and resolution. Review of the agency's form titled, "Hospice Patient's Bill of Rights/Responsibilities," dated revised January 2020 showed the patient had the right to be free from misappropriation of patient property by anyone. RECORD/PATIENT #12: Review of the clinical record showed the patient was admitted to the agency on 02/11/2021. The patient was transferred from another hospice. The terminal diagnosis was lung cancer with metastasis to the brain (spread to the brain). The patient lived in his/her adult child's home and required total personal care. EXAMPLE #1: Review of the agency's complaint log showed a complaint from the adult child of the patient dated 02/23/2021. He/she stated in the complaint that the spiritual care counselor (SCC) that came to see the patient on 02/21/2021 violated the patient's HIPAA rights by speaking to a visitor outside the home about the patient currently being on hospice. The unsigned written complaint showed that this SCC would not be back to visit the patient. Additional documentation related to the complaint was requested from the compliance officer on 03/08/2021 at 12:30 PM. He/she stated that: - There was no more documentation of the incident; and - There were no detailed forms used for a complaint or grievance. During an interview on 03/09/21 at 11:00 AM, the compliance officer stated that: - The complaint documented in the complaint log did have a resolution-the SCC would not be back; - The possible HIPAA violation was not investigated or documented; and - The hospice came to the conclusion that the incident was perceived by the caregiver to be a violation and they would be sending a different spiritual care counselor. EXAMPLE #2: Review of the medication profile showed morphine sulfate ER 15 mg (a strong narcotic pain reliever) oral one tab every 12 hours started on 02/12/2021 and discontinued on 02/12/2021. Review of the skilled nurse visit notes showed the following: - On the skilled nurse visit by LPN 1 (licensed practical nurse) on 02/17/2021, documentation showed the patient had not received the morphine. The nurse spoke with the pharmacy who stated the medication would be delivered to the home ASAP (as soon as possible). LPN 1 notified the medical director and the compliance officer; - On the 02/22/2021 skilled nurse visit by LPN 1, the documentation showed the patient had still not received the morphine 15 mg. LPN 1 called the pharmacy and found out that the morphine 15 mg had been delivered by the pharmacy to the home on 02/12/2021 at 5:27 PM. The LPN received a copy of the receipt for the morphine signed by someone in the home. LPN 1 spoke with the adult child who stated the morphine was never delivered and was not in the home, though it was possible that her significant other had received the delivery. The adult child stated he/she would look for the medication. He/she requested that the morphine be discontinued because it is too strong and sedated the patient too much. If it was found, he/she wanted it destroyed; and - On the 02/24/2021 skilled nurse visit by LPN 1, the documentation showed the medication profile was up-dated to show the morphine discontinued and LPN 1 was unable to destroy the medication as it had still not been found. During a home visit observation on 03/10/2021 at 5:20 PM, the patient's adult child who is the primary caregiver stated that: - There was a miscommunication; - The morphine was supposed to come but they never received it at the home; - He/she looked all over the house and never found it; and - He/she wanted it discontinued anyway because it made the patient too sedated. During an interview on 03/11/2021 at 4:15 PM, LPN 1 stated that he/she knew the morphine was delivered to the home because the signature on the receipt matched the significant other's signature to verify visits. During a telephone call to the pharmacy on 03/09/2021 at 3:10 PM, the following conversations occurred: - Spoke with the pharmacy technician who verified that the prescription number on the delivery receipt was the morphine ER 15 mg and that the medication was delivered and signed for by someone in the home on the evening of 02/12/2021; and - Then spoke with the pharmacist who stated that on 02/12/2021 at 2:33 PM, the prescription was verified, filled, double checked, bagged and ready for delivery. He/she also checked the computer and the paper prescription and stated there was no documentation showing that the medication was reported missing. On 03/11/2021 at 12:26 PM, the hospice compliance officer stated that the pharmacy was informed that the medication was missing. The agency failed to: - Conduct complete investigations and resolutions to the incidents; - Document any follow-up; and - Inform the proper authorities. | |||
| L0517 | |||
| 42078 Based on policy and form review, record review, complaint/grievance log review, home visit observation, and interview, the hospice failed to ensure the patient's right to be free from misappropriation of the patient's property when medication delivered to the patient's home could not be found, in one (Record/Patient #12) of six full record reviews. This deficient practice has the potential to adversely affect the rights of all the agency's patients. Findings included: Review of the agency's policy titled, "Adverse Event Policy-10.3.1," dated revised June 2019, showed, in part, the following: - Hospice will investigate any incident or injury. The policy listed drug diversion of hospice provided medications; - The investigation will be initiated by the director (administrator) within 24 hours after hospice becomes aware of an adverse event; and - The investigation will be documented in an incident/variance report and include all necessary information and pertinent conclusions about what happened. Review of the agency's form titled, "Hospice Patient's Bill of Rights/Responsibilities," dated revised January 2020 showed the patient had the right to be free from misappropriation of patient property by anyone. Review of the complaint/grievance log failed to show documentation of the misappropriation of the morphine, a controlled substance. During an interview on 03/09/21 at 11:10 AM, the compliance officer stated that: - The hospice does not do a complaint/grievance report for incidents; - There is not a separate form for documentation of this type of incident; - The morphine was discontinued by the caregiver request but was not found; - The agency hot-lined the family; and - There was no documentation other than in the patient clinical record skilled visit notes regarding the incident, investigation, and resolution of the problem. RECORD/PATIENT #12: Review of the clinical record showed the patient was admitted to the agency on 02/11/2021. The patient was transferred from another hospice. The terminal diagnosis was lung cancer with metastasis to the brain (spread to the brain). The patient lived in his/her adult child's home and required total personal care. Review of the medication profile showed morphine sulfate ER 15 mg (a strong narcotic pain reliever) oral one tab every 12 hours started on 02/12/2021 and discontinued on 02/12/2021. Review of the skilled nurse visit notes showed the following: - On the skilled nurse visit note by LPN 1 (licensed practical nurse) on 02/17/2021, documentation showed the patient had not received the morphine, the nurse spoke with the pharmacy who stated the medication would be delivered to the home ASAP (as soon as possible). LPN 1 notified the medical director and the compliance officer; - On the 02/22/2021 skilled nurse visit note by LPN 1, the documentation showed the patient had still not received the morphine 15 mg. LPN 1 called the pharmacy and found out that the morphine 15 mg had been delivered by the pharmacy to the home on 02/12/2021 at 5:27 PM. The LPN received a copy of the receipt for the morphine signed by someone in the home. LPN 1 spoke with the patient's daughter who stated the morphine was never delivered and was not in the home, though it was possible that his/her significant other had received the delivery. The daughter stated she would look for the medication. She requested that the morphine be discontinued because it is too strong and sedated the patient too much. If it was found, she wanted it destroyed; and - On the 02/24/2021 skilled nurse visit by LPN 1, the documentation showed the medication profile was up-dated to show the morphine was discontinued and LPN 1 was unable to destroy the medication as it had not been found. During a home visit observation on 03/10/2021 at 5:20 PM, the patient's adult child who was the primary caregiver stated that: - There was a miscommunication; - The morphine was supposed to come but they never received it at the home; - He/she looked all over the house and never found it; and - He/she wanted it discontinued anyway because it made the patient too sedated. During an interview on 03/11/2021 at 4:15 PM, LPN 1 stated that he/she knew the morphine was delivered to the home because the signature on the receipt matched the significant other's signature which was used to verify patient visits. During a telephone call to the pharmacy on 03/09/2021 at 3:10 PM, the following conversations occurred: - The state surveyor spoke with the pharmacy technician who verified that the prescription number on the delivery receipt was the morphine ER 15 mg and that the medication was delivered and signed for by someone in the home on the evening of 02/12/2021; and - Then spoke with the pharmacist who stated that on 02/12/2021 at 2:33 PM, the prescription was verified, filled, double checked, bagged and ready for delivery. He/she also checked the computer and the paper prescription and stated there was no documentation showing that the medication was reported missing. On 03/11/2021 at 12:26 PM, the hospice compliance officer stated that the pharmacy was informed that the medication was missing. On 03/11/2021 at 3:45 PM, the administrator stated that: - They hot-lined the patient today 03/11/2021 as there is not enough help in the home and the significant other is sometimes sleeping during the day (he/she works night shift) and there is nobody to care for the patient; - He/she was not aware they could hotline a patient on hospice services; and - He/she did not report the misappropriation of narcotics to the hotline. | |||
| L0524 | |||
| 42078 Based on agency policy, clinical record review, and interview, the agency failed to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process in one (Record/Patient #1) of six full records reviewed. This deficient practice has the potential to affect the well-being, comfort, and dignity of all patients served by the agency. Findings included: Review of the agency policy revised January 2020 and titled, "Pain Assessment and Reassessment," showed that: - The purpose of the policy was to define processes for pain assessment and management; - Each patient will have pain reassessed on an ongoing basis using established criteria including: * Location; * 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); - Hospice staff will reassess and respond to patient's pain, including evaluating and documenting: * Patient's response to pain interventions; * Discussing objectives that will be used to assess treatment progress; and * Provision of education regarding pain management, treatment options, and the safe use of opioid and non-opioid medications when prescribed. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Review of the nursing visit note (NVN) dated 02/23/21 showed that the patient had acetaminophen and Norco ordered for pain management, the patient was exhibiting discomfort during palpation of the wound, and the patient was unable to numerically rate his/her pain level. The nurse asked the facility staff if the patient was on pain medication for his/her dressing changes, and the facility staff member reported that the patient did have an order for Norco (hydrocodone (an opioid pain medication) and acetaminophen (a non-narcotic pain reliever) combination drug used to manage pain). The NVN failed to contain documentation of the frequency of actual administration of the Norco or an evaluation of the pain management plan. Review of the NVN dated 02/25/21 showed that the patient had acetaminophen and Norco to be given 30 minutes prior to the performance of wound care. The NVN showed that the patient yelled out in discomfort during the provision of wound care. The NVN failed to contain documentation of the frequency of actual administration of the Norco or an evaluation of the pain management plan. Review of the NVN dated 03/02/21 showed that the patient continued to have acetaminophen and Norco ordered for pain control. The NVN failed to contain documentation of the frequency of Norco administration or an evaluation of the pain management plan. During a home visit observation on 03/09/21, LPN1 asked the facility staff member if the patient was having pain or issues with wound care. The facility staff member stated that the patient was doing well and there were no changes with the current treatment plan. The nurse failed to assess the frequency of Norco administration or evaluate the pain management plan. Review of the facility treatment administration record showed that the patient had an order for Norco to be given for wound pain with an effective date of 02/22/21. The patient had received only three doses of the medication (on 02/26/21, 03/03/21, and 03/08/21). The order for the Norco was discontinued on the facility record on 03/08/21 for an unknown reason. The findings were presented to the compliance officer on 03/10/21 at 09:30 AM with no additional information provided. | |||
| L0530 | |||
| 42078 Based on agency policy, clinical record review, home visit observation, and interview the agency failed to ensure that a medication review included all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy in three (Record/Patient #1, #2, and #7) of six full records reviewed. This deficient practice has the potential to affect the medication management of all patients served by the agency. Findings included: Review of agency policy revised June 2019 and titled, "Medication Monitoring" showed: - A registered nurse will review all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy on an ongoing basis. This review is done in collaboration with other interdisciplinary group (IDG) members; and - This review includes but is not limited to: * Effectiveness of drug therapy; * Drug side effects; * Duplicate drug therapy; and * The need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient. Review of agency policy revised June 2019 and titled, "Medication Profile," showed, in part, the following: - The initial assessment performed by the RN includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and noncompliance with drug therapy; - The RN checks all medications a patient may be taking and documents on the medication profile; - All prescribed medications, over-the-counter medications and home remedies will be documented on the medication profile as well as the date the medication was prescribed, the dose, frequency and route of administration; - The nurse will add all new/changed medication(s) to the medication profile. Discontinued medications will be documented and dated. The medication profile will be reviewed every home visit, updated as change occur and reviewed by the IDG; and - The RN or LPN reviews the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effects, storage, and administration of all medications. Review of agency policy revised June 2019 and titled, "Medication Reconciliation," showed, in part, that medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Comparison of the agency medication profile (AMP) to the facility medication/treatment administration record (FMTAR) showed: - FMTAR showed Miralax powder (a laxative) give one scoop by mouth in the morning for constipation, the AMP failed to contain this medication; - The FMTAR showed olanzapine (an antipsychotic) 7.5 milligram (MG) by mouth in the evening, the AMP failed to contain this medication; - The FMTAR showed olanzapine 5 MG, one tablet by mouth every 24 hours as needed for mood, the AMP showed olanzapine 5 MG daily; - The FMTAR showed thiamine (a vitamin supplement) 50 MG tablet daily, the AMP failed to contain this medication; - The FMTAR showed metoprolol tartrate (used to treat high blood pressure) 25 MG, one tablet two times per day, the AMP showed metoprolol tartrate 25 MG with no dosing instructions; - The FMTAR showed acetaminophen (a medication used to treat pain and fever) 325 MG, give two tablets every six hours a needed for elevated temperature or pain, the AMP showed acetaminophen 325 MG, give two tablets every four hours as needed for temperature greater than 100 degrees; and - The AMP showed guaifenesin (a medication used to liquefy respiratory secretions) liquid 5 milliliters (ML) every four hours, the FMTAR did not contain this medication. The findings were reviewed with the compliance officer on 03/10/21 at 09:30 AM with no additional information provided. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 11/10/2020 with a terminal diagnosis of malignant neoplasm of the right bronchus (cancer of the right lung), and secondary diagnoses of type two diabetes (a disease characterized by elevated blood sugar leading to cardiovascular complications, changes in the ability to feel in the extremities, and slow wound healing). A review of the medications during a home visit observation on 03/10/21 at 10:00 AM showed the patient had the following medications in the home that were not on the AMP: - Loperamide (a medicine used to treat diarrhea) 2 MG, one tablet every six hours as needed for diarrhea; and - Prochlorperazine (a medicine used to treat nausea) 10 MG, one tablet every six hours as needed for nausea/vomiting. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 09/10/2020 with a terminal diagnosis of senile degeneration of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). The patient lived in the home with family for caregivers. Review of the hospice IDG (interdisciplinary group) meeting/care plan updates dated 09/11/2020 and 09/22/2020 showed under musculoskeletal status that the patient was taking Fosamax (used to prevent and treat certain types of bone loss (osteoporosis) in adults) 70 mg (milligram) by mouth weekly. Review of the hospice medication profile showing all medications current and discontinued for the time period of 09/10/2020 through 11/23/2020, failed to show Fosamax listed as a current or discontinued medication. During an interview on 03/10/2021 at 4:35 PM, the compliance officer stated that: - The patient was probably on Fosamax until they started hospice; - Then it was discontinued at the start of care: and - The plan of care did not get updated. | |||
| L0536 | |||
| 42078 Based on policy review, record review, and interviews, the agency failed to ensure the plan of care specified the hospice care and services, the frequency of services, develop an individualized plan of care and revision of the plan of care. The agency failed to: - Assure that all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (L543); and - Ensure clear evidence of a revised plan of care and evidence of the patient's progress toward outcomes and goals specified in the plan of care (L553). The cumulative effect of these deficient practices has the potential to affect the care and services provided to all the agency's patients. | |||
| L0543 | |||
| 42078 Based on agency policy, clinical record review, and interview, the agency failed to ensure that all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician in two (Records/Patients #1 and #3) of six full records reviewed. This deficient practice has the potential to affect the hospice care and services furnished to all patients served by the agency. Findings included: Review of agency policy revised January 2020 and titled, "IDG Care Planning Process," showed, in part, the following: - The "care of plan" specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions; and - All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any). Review of agency policy revised June 2019 and titled, "Nursing Services," showed that nursing care will be provided in accordance with the patient's IDG plan of care, under the supervision of a registered nurse. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Review of the IDG/Careplan Update notes for the period of 12/27/2020 to 01/11/21 showed that an order was received on 12/31/2020 to treat the wound on the left heel using triple antibiotic ointment (TAO). Review of nursing visit documentation for 01/12/21, 01/14/21, and 01/19/21 showed that the RN did not apply TAO to the wound during the provision of wound care. The visit notes failed to contain documentation that the physician or nursing facility staff were notified of the change in the wound care. Review of hospice physician orders dated 02/21/21 showed: - A wound care order to include medihoney topically to the left heel on Monday, Wednesday, and Friday, and as needed for dislodging, wrap with kerlix and secure with coban; and - "Hydrocodone 5/325", one tablet by mouth 30 minutes before dressing change to left foot MWF and PRN dislodging. Review of nursing visit on Tuesday, 02/23/21 showed that: - The nurse performed wound care during the visit; - The visit note failed to contain documentation of premedicating the patient with Norco prior to wound care performance, - The nurse documented wound care of wound wrapped with non-adherent gauze, ABD, and Kerlix, secured with coban; and - The nurse performed wound care on a day it wasn't ordered, and did the wrong wound care. Review of nursing visit on Thursday, 02/25/21 showed that: - The nurse unraveled the dressing and noted a strong foul odor coming from the wound; - The visit failed to contain documentation of premedicating the patient with Norco prior to wound care performance: * The patient reported pain during the dressing change procedure; * The patient pulled his/her foot back while dressing the wound; and - The nurse performed wound care on a day it wasn't ordered and did not premedicate for painful wound care. Review of nursing visit documentation for Tuesday, 03/02/21 showed: - "Wound redressed using current orders;" - The visit failed to contain documentation of premedicating the patient with Norco prior to wound care performance; and - The nurse performed wound care on a day it wasn't ordered, and didn't premedicate for painful wound care. The findings were reviewed with the compliance officer on 03/10/21 at 09:30 AM with no additional information provided. RECORD/PATIENT #3: Review of the clinical record showed that the patient was admitted to hospice services with a terminal diagnosis of chronic kidney disease ( a type of kidney disease characterized by gradual loss of kidney function over a period of months to years), and secondary diagnoses of congestive heart failure (a condition where the heart is unable to pump sufficiently to meet the body's needs frequently characterized by swelling and respiratory congestion) and type two diabetes (a disease characterized by a high blood sugar level over a prolonged period of time which may result in cardiac, circulatory, visual, and kidney problems, as well as, delayed wound healing). Review of the comprehensive assessment performed on 02/11/21 showed secondary diagnoses of type two diabetes and failed to contain an endocrine assessment (an assessment of blood sugars testing and levels.) The assessment identified congestive heart failure as a secondary diagnosis and failed to contain documentation of a baseline weight. Review of the plan of care dated 02/11/21 failed to include: - The secondary diagnoses of type two diabetes (or interventions for the assessment and management of the disease) identified during the comprehensive assessment; and - Orders to measure the patient's weight. Review of the nursing visit note on 02/23/21 showed that the patient had a visit with the nephrologist (kidney doctor) and a weight gain of 22.6 pounds was noted over a one month period. Interventions within the nursing visit note stated that the nurse would continue to monitor the patient's weight. Review of a physician's order dated 02/23/21 showed the nurse would obtain a weekly weight, if weight gain greater that five pounds notify physician to readjust the bumex (a diuretic used to reduce fluid retention). Review of nursing visit notes for 02/25/21, 03/02/21, 03/04/21, and 03/09/21 failed to contain documentation of the patient's weight. During an interview on 03/10/21 at 11:16 AM, the compliance officer stated that: - They would not expect the nurse to assess for symptoms of secondary diagnoses if the patient is not receiving treatment for those diagnoses; - The nurse did identify that the patient would need to monitor his/her weight and that the family agreed to get a scale. When asked if the nurses carried scales to weigh patients, the compliance officer stated, "No, but I guess they could, we will get scales for the nurses."; and - No further information or documentation provided. | |||
| L0553 | |||
| 42078 Based on agency policy, clinical record review, and interview, the agency failed to maintain a revised plan of care that included information from the patient's updated comprehensive assessment and included the patient's progress toward outcomes and goals as specified on the plan of care for two (Records/Patients #1 and #2) of six full records reviewed. This deficient practice has the potential to affect the careplanning for all of the patient's served by the agency. Findings included: Review of the agency policy revised June 2019 and titled, "Reassessments/Update to the Comprehensive Assessment," showed: - The update of the comprehensive assessment must be accomplished by the hospice interdisciplinary group (IDG) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. The update to the comprehensive assessment will include assessments of changes in physical, psychosocial, emotional, and spiritual needs; and - Staff will analyze the data from assessments and reassessments. Such analysis of data will assist staff in identifying and prioritizing patient needs and problems to direct care and services and update the IDG care plan. Review of the agency policy revised January 2020 and titled, "IDG Care Planning Process," showed, in part: - The hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; - The plan of care specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions; - The IDG works together to meet the physical, medical, psychosocial, emotional and spiritual needs of hospice patients and families facing terminal illness and bereavement. IDG members provide the care and services offered by hospice. IDG supervises the care and services; - An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions including: * Interventions to manage pain/other symptoms; * A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs; * Measurable outcomes anticipated from implementing and coordinating the plan of care; * Drugs and treatments necessary to meet the needs of the patient; * Medical supplies and appliances necessary to meet the needs of the patient; * Documentation of the patient's/representative's level of understanding, involvement and agreement with the plan of care in the patient record; - The IDG reviews, revises, and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days; * The revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress toward outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Review of the 02/23/21 nursing visit showed the patient's wound had developed an odor, the patient had received new wound care orders effective 02/21/21. Review of physician orders for IDG date range of 02/23/21 to 03/08/21 showed: - On 02/21/21 wound dressings (Medihoney Wound/burn dressing (a wound treatment containing medical grade honey in a suspension)) topically to left heel M-W-F and PRN dislodging, wrap with kerlix and secure with coban; - On 02/24/21 the patient to receive doxycycline (a broad spectrum antibiotic used to treat infections) 100 milligram (MG) daily for seven days and a probiotic (live microorganisms used to restore normal flora in the gut) 250 MG daily for 14 days with both medications beginning 02/20/21 in response to foul smelling wound drainage; and - On 03/02/21 wound care orders received: Dressing to be changed on Monday, Wednesday, and Fridays using silver alginate (a moisture absorbing dressing containing a topical antibiotic used to control bacterial infections) in place of medi-honey, 4x4 gauze, ABD and kerlix. Secure with tape or coban. Review of the hospice IDG/Careplan Update on 03/09/21 failed to contain documentation of the worsening of the patient's wound, orders for antibiotics and probiotics, and the changes in the wound care orders. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 11/10/2020 with a terminal diagnosis of malignant neoplasm of the right bronchus (cancer of the right lung), and secondary diagnoses of type two diabetes (a disease characterized by elevated blood sugar leading to cardiovascular complications, changes in the ability to feel in the extremities, and slow wound healing). Review of the nursing visit note on 02/23/21 showed that the patient had a visit with the nephrologist (kidney doctor) and a weight gain of 22.6 pounds was noted over a one month period. Interventions within the nursing visit note stated that the nurse would continue to monitor the patient's weight. Review of a physician's order dated 02/23/21 showed the nurse would obtain a weekly weight, if weight gain greater that five pounds notify physician to readjust the bumex (a diuretic used to reduce fluid retention). Review of hospice IDG/Careplan update 03/09/21 failed to contain documentation of a discussion of the new order for weekly weights, assessment of the cardiovascular status, or the weight gain that occurred over the past month. During an interview on 03/10/21 at 11:12 AM the compliance officer stated that all changes in the patient's plan of care are discussed during the IDG meetings; the discussions are not documented in the patient's clinical record. | |||
| L0579 | |||
| 42078 Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions in one (Patient/Record #1) of three home visit observations. This deficient practice has the potential to affect the prevention of infection and communicable diseases for all of the patients served by the agency. Findings included: Review of agency undated policy titled, "Nursing Bag Technique," showed, in part: - Close the bag and give the patient care; - If additional items are needed after care has started, wash hands before re-entering bag; * Clean any visibly soiled items which will be returned to the bag; and * Wash hands and return equipment to the bag, close bag. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). During the home visit observation on 03/09/21 at 11:30 AM, LPN1 removed his/her soiled gloves, failed to perform hand washing, and reached into their nursing bag to retrieve his/her computer. LPN1 then completed the patient care portion of the visit, cleaned his/her equipment, and return the cleaned items to the nursing bag. LPN1 then failed to close the nursing bag. As LPN1 was preparing to exit the building, a can of antibacterial spray fell from the open bag to the floor, LPN1 then picked up the spray can, failed to clean the exterior of the can, and placed the can into his/her open nursing bag. During an interview on 03/09/21 at 12:00 PM, home visit findings were reviewed with LPN1. LPN1 stated that he/she did reenter the nursing bag and pick up a soiled item off of the floor without washing his/her hands. The results of the home visit finding were reviewed with the compliance officer on 03/10/21 at 3:30 PM with no additional information provided. | |||
| L0582 | |||
| 42078 Based on review of agency admission packet, home visit observation, and interview, the agency failed to perform/document infection control education to patients and caregivers regarding measures to prevent the spread of COVID-19 in, but not limited to, one (Patient/Record #1) of six full records reviewed. This deficient practice has the potential to result in unsafe infection control practices or increased infection transmission between staff/patients/caregivers for all the agency's patients. Findings included: Review of the agency admission packet showed the agency failed to provide written literature to the patient/family/caregiver in regard to the prevention of COVID-19. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). The patient resided in a nursing facility. During a home visit observation on 03/10/21 at 11:30 AM the patient admission folder in the home failed to contain educational materials on the prevention and spread of COVID-19. During an interview on 03/10/21 at 9:30 AM, the compliance officer stated that there was not COVID-19 specific educational materials in the admission packets left at the client's home. | |||
| L0587 | |||
| 42078 Based on policy review, clinical record review, home visit observation, and interview, the hospice failed to meet the requirements for the Condition of Participation: Core Services when the hospice failed to ensure medical social services were available and the needs of the patient were met (L594). The cumulative effect of these systemic practices resulted in the inability of the hospice to provide effective core services to meet the needs of all hospice patients. | |||
| L0594 | |||
| 42078 Based on policy review, review of the social worker job description, record review, home visit observation, and interviews, the agency failed to provide all core services when the social worker resigned without notice and there were no back-up social workers to see patients. Due to the lack of a social worker, substandard care was provided in but not limited to one (Record/Patient #12) of eleven patients on the current census. This deficient practice has the potential to adversely affect the psychosocial care of all the agency's patients. Findings included: Review of the agency's undated policy titled, "Core Services," showed, in part, the following: - The hospice will routinely provide substantially all core services directly by hospice employees; and - Core services include medical social services. Review of the social worker/social work assistant job description showed, in part, the following. The hospice social worker: - Is to provide the initial emotional, spiritual, psychosocial assessments, ongoing counseling, and bereavement services; - Conducts ongoing reassessments of patient/family needs and counseling as required; - Is an integral part of the hospice IDG (interdisciplinary group); and - Assists in the development and implementation of a goal-directed IDG care plan. RECORD/PATIENT #12: Review of the clinical record showed the patient was admitted to the agency on 02/11/2021. The patient was transferred from another hospice. The terminal diagnosis was lung cancer with metastasis to the brain (spread to the brain). The patient lived in his/her adult child's home and required total personal care. Review of the clinical record failed to show a social worker visit during the episode of care. During an interview on 03/11/2021 at 12:03 PM, the compliance officer stated that: - There were no social worker visits or initial assessment done by a social worker; - The social worker could not do the initial assessment within the required time period; - He/she (compliance officer) did the psychosocial assessment with the family over the phone; - The social worker had not been doing initial assessments in a timely manner for some time; - The social worker resigned without notice on 03/09/2021; and - There was no back up social worker employed by the agency. During a home visit observation visit on 03/10/2021 at 5:30 PM, an interview was conducted with the primary caregiver. He/she stated that the family needed more help in caring for the patient. He/she was asking for assistance. When asked by the surveyor if the social worker had been there to assess the situation, the caregiver stated that he/she had not seen a social worker at the home since the start of care with this agency. The patient was at home during the day while the caregiver worked with the caregiver's significant other who worked night shift and slept during the day. The patient was mainly confined to the bed. During an interview on 03/11/2021 at 3:30 PM, the human resources coordinator stated that the hospice: - Is already working to correct the social worker problem; - Has a new social worker (SW) ready to start in two weeks on 03/24/2021; - Will hire a BSW (bachelor's prepared social worker) from one of their in-home agencies to do social worker visits for the next two weeks; and - Will see if the resigned SW or the pending hire SW will supervise him/her. | |||
| L0615 | |||
| 42078 Based on review of agency policy, Missouri Home Health Aide/Hospice Aide Competency Evaluation form, personnel file review, and interview, the agency failed to ensure completion of the required Missouri competency evaluations prior to providing aide services to patients, in one (Aide A) of one aide employee file reviewed. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of the agency policy, revised January 2020 and titled, "Hospice Aide Services and Training Program," failed to contain procedural guidance on the Missouri Home Health Aide/Hospice Aide Competency Evaluations. Review of the current Missouri approved Home Health Aide/Hospice Aide competency skills portion of the exam instructs the agency to have the qualified registered nurse (RN) observe the aide performing all tasks listed while providing care to a patient. The RN must document specific comments regarding the tasks and the aide's performance, identifying the patient by initials, enter the date the aide satisfactorily completed the task, and sign each task observed. The aide must complete all of the tasks to pass the basic skills test. An aide is not qualified and cannot provide care independently unless all tasks have been satisfactorily completed. Aide A: Review of Aide A's personnel file showed the following: - Aide was hired 02/01/21; - The agency used their own competency evaluation in addition to the Missouri state approved aide basic skills written exam; and - The agency failed to document competencies on the Missouri state approved basic skills test. During interview on 03/10/21 at 9:30 AM, the compliance officer stated that he/she was not aware of the requirement to complete every task on the state of Missouri aide competency exam. | |||
| L0625 | |||
| 42078 Based on record review, and interview, the agency failed to ensure the registered nurse (RN) prepared complete written care instructions for the hospice aide in one (Record/Patient #1) of three records with aide services. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of the agency's policy titled, "Hospice Aide Supervision," revised June 2019, showed the hospice aide must follow the patient's plan of care for completion of tasks assigned to the aide by the registered nurse. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Review of the Hospice Aide Assignment sheet (HAAS) dated 06/03/2020, and electronically signed by the RN on 02/06/21, failed to show guidance and tasks associated with the open wound on the left heel, use of heel floaters/ protectors, methods to assure the integrity of the left heel dressing during personal care and bathing, or the actions needed to coordinate the patient's wound care after the personal care and bathing process was competed. During an interview on 03/10/21 at 12:08 PM, the compliance officer stated that: - The patient does have orders on the plan of care for heel floaters/heel protectors; - The aide visits are on the same day as the dressing changes; and - The aide performs a shower, notifies the facility staff that the shower has been completed, and then the facility nurse removes the dressing and performs wound care. | |||
| L0628 | |||
| 42078 Based on review of clinical records and review of clinical findings with administrative staff, the hospice failed to ensure the hospice aide documented the reporting of changes in the patient's condition or problems with patient reaction to care provided as part of the clinical documentation in, but not limited to, two (Records/Patients #1 and #7) of three records with aide services. This deficient practice has the potential to affect the quality of care provided to the patient and effectiveness of the hospice aide plan of care. Findings included: Review of agency policy revised June 2019 and titled, "Hospice Aide Documentation," showed that: - The hospice aide will be responsible for reporting any changes in the patient's condition and/or other pertinent observations to the supervising registered nurse (RN), and - The manager of patient services or designated RN is responsible for reviewing the hospice aide's charting. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. Review of the Hospice Aide Assignment sheet (HAAS) dated 06/03/2020, and updated by the RN on 02/06/21, failed to show guidance and tasks associated with the open wound on the left heel, use of heel floaters/ protectors, methods to assure the integrity of the left heel dressing during personal care and bathing, vital sign parameters, or the actions needed to coordinate the patient's wound care after the personal care and bathing process was competed. Review of aide visit documentation for 12 visits performed during February and March of 2021 failed to contain documentation of RN notification of the wound on the left heel or the use of heel floaters/protectors. Review of aide visit documentation on 03/09/21 showed the patient's blood pressure reading of 161/93, and failed to contain documentation of notification of the RN of the findings out of agency parameters. The findings were reviewed with the compliance officer on 03/10/21 at 12:08 PM with no additional documentation/information provided by the agency. During an interview on 03/11/21 at 10:40 AM the compliance officer stated that unless otherwise specified the aides are directed to report any blood pressures outside of the agency parameters (systolic greater than 160 or less than 100, diastolic greater than 90 or less than 50). RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 09/10/2020 with a terminal diagnosis of senile degeneration of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). The patient lived in the home with family for caregivers. Review of the aide assignment sheet dated 09/11/2020 showed the hospice aide was to report the following to the supervisor/case manager: - Temperature over 100.4 degrees; - Temperature under 96.5 degrees; - Systolic blood pressure (top number) over 160 and under 90; - Diastolic blood pressure (bottom number) over 100 and under 50; and - Pulse over 100 beats per minute (bpm) and less than 60 bpm. Review of the aide assignment sheet dated 09/11/2020 showed the hospice aide was to document the date of the last bowel movement. Review of the hospice aide visit notes showed: - The aide failed to report temperatures, blood pressures, or pulses out of parameters on the following dates: 09/16/2020, 09/18/2020, and 09/21/2020; and - The hospice aide failed to document the date of the last bowel movement on the following dates: 09/14/2020, 09/16/2020, 09/18/2020, 09/21/2020, and 09/23/2020. On 03/10/2021 at 4:35 PM the findings were reported to the compliance officer. No further documentation was received prior to the exit date of 03/12/2021. | |||
| L0648 | |||
| 42078 Based on review of the administrator job description, employee files, governing body minutes review, observation, and interview the agency failed to meet the requirements for the Condition of Participation: Organization and Administration of Services, when the agency failed to ensure that the administrator was responsible for the day-to-day operations of the hospice (L651). The cumulative effect of this deficient practice has the potential to affect the ability of the agency to ensure all patients would receive services with the appropriate administrative and clinical oversight to provide quality hospice care. | |||
| L0651 | |||
| 42078 Based on agency policy, employee file review, observation, review of CMS (Centers for Medicare/Medicaid Services) letter dated 02/25/2021, current survey findings, and interview, the agency failed to ensure that the administrator effectively assumed responsibility for the overall administration, supervisory functions, and overall operations of the home health agency. This deficient practice has the potential to affect the care, treatment, and services for all patients served by the agency and led to the failure of the agency to comply with five Federal Conditions of Participation. Findings included: Review of agency policy, revised June 2019 and titled, "Administrator: Defined," showed: - The administrator is responsible for the hospice's functions and day-to-day operations; - The administrator has a job description that identifies his/her respective duties and responsibilities; - The governing body has appointed the administrator to run the hospice's day-to-day operations and reports to the governing body; - The administrator is a person who is an employee of hospice and who has the education and experience required by the governing body and has training and experience in health services administration and at least one year of supervisory or administrative experience in hospice care or related health programs; - The administrator is responsible for directing and monitoring organizational Quality Assessment/Performance Improvement (QAPI) activities; and - The administrator of hospice has the following responsibilities: * Planning, organizing, directing, and evaluating operations to ensure the provision of adequate and appropriate care and services to patients, families, and caregivers necessary for the palliations and management of the terminal illness and related conditions; * Complying with applicable laws and regulations; * Establishing and maintaining effective channels of communication; and * Assuring appropriate staff supervision during all operating hours. Review of the administrator job description signed by the administrator on 09/27/2019 showed that the administrator is responsible for: - Negotiation of required contracts and ultimately oversees contract provisions; - Assists employees to support policies and achieve necessary changes; - Uniformly enforces policies and procedures; - Directs hospice's ongoing functions; - Evaluates effectiveness and efficiency of hospice; - Maintains compliance with applicable federal, state and local rules and regulations; - Plans and directs operations to ensure the provision of adequate and appropriate care and services; - Ensures staff development including orientation, in-service education, and continuing education; - Ensures that appropriate service policies are developed and implemented; and - Directs staff in performance of their duties including admission, discharge, and provision of service to patients. Direct observation of the office staff, clinical supervisory staff, and the administrator, showed the administrator failed to be involved in the agency's day to day activities and be qualified to administer a hospice agency when the following was observed: - The administrator was unaware that a full survey was to be completed under the direction of CMS and that the agency had lost deemed status because the email from CMS was not read (found); - He/she was unaware that the hospice could hotline a family for neglect or mistreatment of a patient (mandatory reporting); - He/she failed to comply with applicable laws and regulations; - He/she failed to maintain core services when the agency failed to have a social worker; - He/she failed to be aware of and report the QAPI activities of the agency; and - The compliance officer appeared to fulfill the administrator's duties of running the office day to day. The administrator's oversight was not apparent and he/she failed to be involved in any of the operational programs like Emergency Preparedness and QAPI. Ancillary office staff and the compliance officer answered surveyor's questions and found documentation needed for the surveyors. The administrator's involvement in the survey process was minimal. Further findings regarding the survey process included the following information: - A letter was emailed from the CMS regional office on 02/25/2021. The header on the letter read as follows: Loss of deemed status and authorization for full survey; and - The agency was deemed by an accrediting organization and since 02/25/2021 their deemed status was removed and they were now under the jurisdiction of CMS. The administrator was not aware of this since the emailed letter had not been read. During the entrance to the agency on 03/08/2021 at 11:20 AM, after being greeted by the administrator and the compliance officer, the administrator: - Questioned why the surveyors were there; - Denied being notified by CMS of the pending full survey and the loss of deemed status; - Stated that he/she was unaware that the surveyors would be back and had not heard from CMS since the last survey; and - Then checked his/her junk email and found the emailed letter. During an interview on 03/11/2021 at 3:00 PM, the administrator stated that he/she was unaware that he/she could hotline someone on hospice services. | |||
| L0694 | |||
| 42078 Based on policy review, clinical record review, and interview, the agency failed to ensure the safe disposal of all controlled drugs in the patient's home in two (Record/Patient #7 and #11) of two applicable records reviewed. This deficient practice has the potential to affect the safe disposal of all controlled drugs used by the agency. Findings included: Review of the agency's undated policy titled, "Medication Disposal," showed that hospice employees may safely dispose of unused controlled substances on site after the death of a patient, or when the controlled substances are expired, or no longer needed because the hospice patient's plan of care has been modified. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 09/10/2020 with a terminal diagnosis of senile degeneration of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). The patient lived in the home with family for caregivers. Review of the skilled nurse visit dated 09/22/2020 showed the physician discontinued Ativan 0.5 milligram (mg) tablets and morphine solution 20mg/ml (milligrams per milliliter). The RN (registered nurse) documented discarding the Ativan tablets and failed to show the disposal of the morphine solution. The record was reviewed with the compliance officer on 03/10/2021 at 4:35 PM. No further documentation was offered by the exit date, 03/12/2021. RECORD/PATIENT #11: Review of the clinical record showed that the patient was admitted to hospice services on 07/13/2020 with a terminal diagnosis of senile degeneration of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly). The patient died at home on 02/07/21. Review of the hospice nurse's clinical note dated 02/07/21 showed, "the patient has no narcotics in the home". Review of the medication profile showed the controlled substance of diazepam in the home. The clinical record failed to contain documentation for the destruction of the controlled substance (diazepam) by the patient's family or the hospice employee. During an interview on 03/10/21 the chief compliance officer stated that they had not been completing controlled substance destruction on all controlled substances, that they had been destroying only narcotics. | |||
| L0713 | |||
| 42078 Based on policy review, clinical record review, and interview, the agency failed to assure that a copy of the discharge summary be provided to the hospice at the time of discharge from an inpatient respite stay in one (Record/Patient #5) of one applicable record reviewed. This deficient practice has the potential to affect the respite services of all patient served by the agency. Findings included: Review of the agency's policy, updated June 2019 and titled, "Inpatient Care and Respite,: showed, in part, the written agreement with the facility specifies that the hospice patient's clinical record would include a copy of the discharge summary from the inpatient facility. Review of the agency's policy, updated June 2019 and titled, "Coordination of Care during General Inpatient or Respite," showed, in part, that following the discharge from the facility, the discharge summary will be copied and forwarded to hospice. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted to hospice services on 11/20/2020 with a terminal diagnosis of dementia with behavioral disturbances (Symptoms that occur when the brain is damaged by injury or disease and includes behavioral abnormalities that may include depression, anxiety, agitation, and aggression). An inpatient stay for respite was planned in advance for the dates 02/04/2020 to 02/09/2020 to provide care to the patient while the primary caregiver moved to a different residence. The clinical record failed to contain a discharge summary from the facility. During an interview on 03/10/21 at 3:30 PM, the compliance officer confirmed that the agency did not have a copy of the discharge summary from the patient's respite stay in the clinical record. | |||
| L0714 | |||
| 42078 Based on review of the agency contract for general inpatient (GIP)/ respite services and interview, the agency failed to ensure the contract contained the requirement that the inpatient facility has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement, in one (Contract A) of one contract reviewed. This deficient practice has the potential to affect the inpatient and respite services for all of the agency's patients. Findings included: Contract A: Review of the agency's contract titled, "Skilled Nursing Facility Services Agreement," dated 03/05/2020, with a contracted nursing facility showed the contract did not contain the requirement for the inpatient facility to identify an individual within the facility who is responsible for the implementation of the provisions of the agreement. During an interview on 03/10/21 at 11:25 AM, the compliance officer and office manager stated that: - The contract provided for review was the general inpatient contract with an addendum for respite services; - The contract failed to contain the regulatory requirement that the inpatient facility identify an individual within the facility who is responsible for the implementation of the provisions of the agreement. | |||
| L0723 | |||
| 42078 Based on review of the agency contract for general inpatient (GIP) services, and interview, the agency failed to ensure the contract included the regulatory requirement statement that each shift must include a registered nurse (RN) who provides direct patient care, in one (Contract A) of one contract reviewed for GIP services. This deficient practice has the potential to affect GIP services for all patients served by the agency. Findings included: Contract A: Review of the agency's contract titled, "Skilled Nursing Facility Services Agreement," dated 03/05/2020 with a contracted nursing facility showed the contract did not state the facility must have a registered nurse who provides direct patient care each shift. During an interview on 03/10/21 at 11:25 AM, the compliance officer and office manager stated that: - The contract provided for review was the general inpatient contract; and - The contract failed to contain the regulatory requirement statement that each shift must have a RN on duty who provides direct patient care. | |||
| L0729 | |||
| 42078 Based on review of the agency contract for general inpatient (GIP)/respite services, and interview, the agency failed to ensure the contract included the requirement that the hospice must provide a home-like atmosphere, in one (Contract A) of one contract reviewed for GIP services. This deficient practice has the potential to affect GIP/respite services for all patients served by the agency. Findings included: Contract A: Review of the agency's contract with a contracted nursing facility titled, "Skilled Nursing Facility Services Agreement," dated 03/05/2020, showed the contract failed to include that the hospice must provide a home-like atmosphere for hospice patients. During an interview on 03/10/21 at 11:25 AM, the compliance officer and office manager stated that the contract failed to contain the regulatory statement that the hospice must provide a home-like atmosphere for GIP/respite patients. | |||
| L0759 | |||
| 42078 Based on policy review, clinical record review, and interview, the hospice provider failed to ensure responsibility for professional management of a patient that resided in a long-term care facility (L762). The cumulative effect of this deficient systemic practice has the potential to affect the care of all patients who reside in a long-term care facility. | |||
| L0762 | |||
| 42078 Based on agency policy, clinical record review, and interview, the agency failed to assume responsibility for professional management of the resident's hospice services in one (Record/Patient #1) of one applicable record reviewed when the agency failed to: - Ensure the patient received delivery of pain medications in a timely manner (Example 1); - Ensure that the facility staff administered the patient's pain medication in accordance with the hospice plan of care (Example 2); and - Provide consistent oversight and coordination in the management of the patient's wound (Example 3). This deficient practice has the potential to affect the care of all hospice patients who reside in a facility. Findings included: Review of agency policy reviewed January 2020 and titled, "Care to Residents of a SNF/NF or ICF/MR," showed: - The hospice assumes responsibility for professional management of the resident's hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation; - The term professional management for a hospice patient who resides in a SNF/NF or ICF/MR has the same meaning that it has if the hospice patient were living in his/her own home. Professional management involves assessing, planning, monitoring, directing, and evaluating the patient's/resident's hospice care across all setting; - The professional services provided by hospice to the patient in his/her home will continue to be provided by hospice to the patient in a facility, or other place of residence. Hospice core services will be routinely provided by the hospice, and will not be delegated to the facility; and - Hospice will specify that facility staff should immediately notify hospice of unplanned interventions. In the contract between hospice and the facility, potential crisis situations and temporary emergency measures will be addressed and determined how they will be handled by facility staff. Hospice is responsible for providing all hospice services including: - Ongoing assessment, care planning, monitoring, coordination, and provision of care by the Hospice interdisciplinary group; - Assessment, coordination, and provision of any needed general inpatient or continuous care; - Consultation about the patient's care with facility staff; - Coordination by the hospice registered nurse for the implementation of the plan of care for the patient; and - Provision in a timely manner, of all supplies, medications, and home medical equipment an needed for the palliation and management of the terminal illness and related conditions. A written hospice plan of care will be established and maintained in consultation with SNF/NF or ICF/MR representatives. All hospice care provided will be in accordance with this hospice plan of care; - The hospice plan of care will identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care; and - Any changes in the hospice plan of care must be discussed with the patient or representative, and SNF/NF or ICF/MF representatives, and must be approved by hospice before implementation. RECORD/PATIENT #1: Review of clinical record showed that the patient was admitted to hospice services on 01/29/2020 with a terminal diagnosis of senile dementia of the brain (widespread loss of nerve cells and the shrinkage of brain tissue associated with the elderly), and an open wound on the left heel. The patient resided in a nursing facility. Example #1: Review of the nursing visit documentation on 02/17/2021 showed that the patient was experiencing pain with dressing changes and the facility staff requested an order for hydrocodone (an opioid pain medication)/acetaminophen (a non-narcotic pain medication) from the patient's primary physician to be administered prior to the provision of wound care. Review of the facility treatment administration record showed that the facility performed wound care on 02/19/2021 and hospice clinical documentation showed the hospice nurse performed wound care on 02/20/2021. The record failed to contain documentation of the administration of any medications to alleviate pain during the provision of wound care on these two dates. Review of the hospice physician order dated 02/21/2021 (four days and two dressing changes later) showed an order for hydrocodone/acetaminophen 5/325 milligrams (MG), take one tablet by mouth 30 minutes before dressing change. Example #2: Review of hospice nursing visits showed documentation that the patient was receiving hydrocodone/acetaminophen from the facility staff prior to the performance of wound care on hospice visits dated 02/23/2021, 02/25/2021, and 03/02/2021. Review of facility documentation showed that the facility failed to administer hydrocodone/acetaminophen 5/325 MG during dressing changes on 02/22/2021, 02/24/2021, 02/25/2021, 03/05/2021, and 03/07/2021. The hospice nursing visits dated 02/23/2021, 02/25/2021, and 03/02/2021 showed: - Inconsistencies regarding pain management by the facility; and - Failed to contain documentation of the hospice oversight and management of the patient's plan of care as evidenced by the patient not receiving hydrocodone/acetaminophen prior to the performance of wound care. Example #3: Review of the hospice coordinated task plan dated 01/09/2021 showed that the facility staff were to provide wound care to the patient three times weekly (on Monday, Wednesday, and Friday) using Medihoney (a medical grade honey suspension) wound/Burn dressing, secured with kerlix (rolled gauze), and coban. The hospice nurse was to visit on Tuesday and Thursday and would change the wound dressing as needed for wound observation and measurement. Review of the facility treatment administration record showed that the patient was to receive wound care every two days and as needed. The hospice failed to maintain responsibility of the patient's plan of care when the coordinated task plan and the facility orders did not correspond. The nurse should have assessed all orders for accuracy and reconciled discrepancies with the facility. During an interview on 03/10/2021 at 09:30 AM, when asked about the delay in obtaining the hydrocodone/acetaminophen order for pain management during wound care, the compliance officer stated that the facility staff were getting the order for the medication and the hospice staff did not take measures to assure the medication arrived at the facility prior to the facility staff performing the next wound care on 02/19/2021. No other information was provided. | |||
| L0798 | |||
| 42078 Based on agency policy review, review of the State of Missouri 19 Code of State Regulations (CSR) 30-35.010 (2)(G)5. B and C, record review, and interview, the agency failed to operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients in one (Record/Patient #4) of one bereavement record reviewed. This deficient practice has the potential to affect the compliance with all Federal, State, and local laws for all patients served by the agency. Findings included: Review of agency policy revised July 2020 and titled, "Bereavement Services," showed: - The purpose of these services is to facilitate a normal grieving process and to identify and appropriately refer those persons who may be experiencing pathological grief reactions which may interfere with the eventual resolution and integration of their losses. Bereavement services will be coordinated with the individual's spiritual counselor or hospice chaplain as well as with other community resources judged to be useful and beneficial to the family/caregiver; - An initial bereavement risk assessment (IBRA) will be performed as part of the comprehensive assessment. Depending on the initial assessment, a plan of care will be developed to include specific counseling to patient and family members to be provided by the social worker, chaplain, or bereavement counselor. The plan of care (POC) will reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery; - Within two weeks of the patient death, a condolence card will be mailed to the family. - Within a month of the death, a twelve-month bereavement mailing program will be initiated for designated family members; - At least one bereavement visit (other than funeral attendance/visitation) shall occur within six months after the death of the patient. Staff will attend an in-service to educate them of the requirement. Review of the State of Missouri 19 CSR 30-35.010(2)(G)5. B) showed within two months following the patient's death, there shall be an assessment of risk of the bereaved individual and a plan of care that extends for one year appropriate to the level of risk assessed, and C) In addition to the assessment, at least one bereavement visit (other than the funeral attendance/visitation) shall occur within six months after the death of the patient. RECORD/PATIENT #4: Review of the bereavement record showed the hospice patient expired on 10/05/2020, in the home. The bereavement record failed to show a bereavement assessment within two months of the patient's death and failed to show a bereavement visit or an offered visit within six months of the death of the patient. During on interview on 03/10/2021 at 4:00 PM, the bereavement coordinator stated that: - He/she only does the bereavement assessment at the start of care for the patient; - He/she does not do another bereavement assessment after the death of the patient; - There was not a home visit made, just telephone calls; and - He/she was not aware of these State of Missouri requirements. | |||