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
331530 A. BUILDING __________
B. WING ______________ 		01/31/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
NIAGARA HOSPICE INC 4675 SUNSET DRIVE, LOCKPORT, NY, 14094
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)
L0505      
38037 Based on review of clinical records, the hospice's complaint log, policy and procedure, and interviews with staff, the hospice failed to ensure that in one (1) out of four (4) clinical records (Patient #2) that verbal complaints are formally documented, investigated, and resolved and that the hospice's complaint policy was implemented. Failure to implement the hospice policy and formally document, investigate, and attempt to resolve complaints places all patients at risk for poor quality of care. Findings are: Review of the hospice's undated policy and procedure entitled "Patient/Family Complaint Policy" reveals the following: 2. Hospice provides a toll-free phone number for patients and families to register a complaint. The staff receiving the complaint shall ask the following questions to the individual they are speaking with, "Is this a complaint?", "Do you wish to file a formal complaint? Complaints can be received either orally or in writing on the official complaint form. The form must be completed in totality and forwarded to the department supervisor ASAP (as soon as possible). Patient #2 - This 59-year-old patient with the terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD) was admitted to the hospice on 03/15/2019. Review of the Charts/Clinical Notes dated 11/14/2019 revealed: patient still very (SOB) short of breath at times, expressed concern with his oxygen bottle not being kept filled with distilled water and call bell not working most of the time. Review of the Charts/Clinical Notes dated 11/15/2019 revealed: writer listed as patient relayed his complaints but also stated that he was doing okay just having a lot of pain in his shoulder and lung. Review of the Charts/Clinical Notes dated 11/20/2019 revealed: patient feels lack of compassion for others around him and frustration with bell system in the facility. Review of the Charts/Clinical Notes dated 11/28/2019 revealed: patient was friendly and conversational with this writer but had complaints about staff on previous shifts. Review of the Charts/Clinical Notes dated 12/03/2019 revealed: writer spent considerable amount of time listening to patient talk about his grievances with a staff member. Patient expressed he needs help and feels that he doesn't receive prompt care at times as well as not feeling like he is wanted here. Review of the hospice complaint log from January 2019 to January 2020 lacked documented evidence that the issues raised by the patient were identified as a complaint by the hospice, was recorded in the complaint log, and a formal investigation into the issues was initiated. During an interview on 01/10/2020 at 11:35 AM, the Director of Clinical Services stated that the hospice's documentation does not but should reflect that she had gone in several times to address concerns and issues that the patient has. She continued to say that the patient would say everything is okay when she would go in to address the concerns and issues raised by this patient.
L0578      
27487 Based on review of the Hospice's Infection Control Program, policy and procedure, and interview with staff, the Hospice failed to maintain and document an effective Infection Control Program. Failure to maintain and document an effective Infection Control Program has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative patient outcomes and adversely affect Hospice operations. Findings are: Review of the Hospice's undated Infection Control Manual revealed the Hospice control program lacked protocols for prevention of infection for infusion therapy and urinary tract care. During interview on 01/10/2020 at 11:35 AM, the Vice President of Hospice Clinical Operations stated that she reviewed the infection control manual and did not find any protocols for the prevention of infection for infusion therapy and urinary tract care.
L0579      
27487 Based on review of agency policy and procedure, observational home visits, and interview with agency staff, the agency staff failed to follow accepted professional standards and agency policies and procedure for infection prevention. Specifically, agency staff failed to ensure infection control practices were implemented during medication administration. Failure to ensure compliance with acceptable professional standards and agency policies has the potential to place patients and staff at risk for exposure to infectious and/or communicable diseases which may result in negative staff and patient outcomes. Findings are: Review of the undated hospice policy entitled "Contamination & Biohazard Waste" revealed "Principles of asepsis shall be followed in all patient care environments...Shall designate and maintain clean and contaminated areas within each facility unit and further shall not commingle items in such a fashion as to risk the transmission of pathogens from one location to another." The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 states "Sources of infectious agents. Infectious agents transmitted during healthcare derive primarily from human sources but inanimate environmental sources also are implicated in transmission." On 01/09/2020 at 09:26 AM the surveyor observed a medication pass involving two patients (Patient # 1 and Patient #2). During the medication pass, the Licensed Practical Nurse (LPN) entered Patient #1's room carrying the Medication Administration Book (MAB) containing the medication Administration Records for all ten (10) patients residing in the Hospice Residence. Upon entry into the patient's room, the LPN entered the patient's bathroom, and placed the MAB directly onto the sink top without disinfecting the sink top with an approved disinfectant, or placing a barrier under the MAB. The LPN then unlocked the medication storage cabinet located in the bathroom closet adjacent to the sink, and removed multiple unit dose medication cassettes. She then placed the cassettes directly on the sink top next to the MAB. The LPN then dispensed the medication into a souffle cup, brought the medications to the patient's bedside, and assisted the patient while the patient took her medications. After the medications were administered, the nurse returned to the bathroom, washed her hands, and left the room with the MAB in her arms. Without disinfecting the MAB, the nurse entered Patient #2's room, entered the bathroom, which contained two infectious waste receptacles against the wall located between the toilet and bathroom sink, and placed the MAB directly on the sink top without first disinfecting the sink top, or placing a barrier under the MAB. She washed her hands, then opened the medication lock box and removed a single dose vial of nebulizer medication. She exited the bathroom, went to the patient's bedside, and placed the medication in the nebulizer. She then returned to the bathroom, washed her hands, grabbed the MAB and left the room with the MAB in her arms. On 01/10/2020 at 09:00AM the surveyor observed a second medication pass involving Patient's # 4 and Patient # 1. During the medication pass the Registered Nurse was observed to carry the MAB into Patient #4's room, entered the bathroom, and without disinfecting the bathroom sink top, or placing a barrier on the sink top, placed the MAB directly on the sink top. She removed the medications from the medication lock box, placed the medication unit-dose cassettes directly on the sink, then dispensed the medication into the medication souffle cup. Once the medications were administered to the patient, who was in bed, the nurse returned to the bathroom, washed her hands, then picked the MAB up and left the room with the MAB in hand. Without disinfecting the MAB, the RN entered Patient #1's room, and placed the MAB directly onto the sink top with disinfecting the sink or placing a barrier under the book. She removed the medication cassettes from the medication cabinet, and dispensed the medications into a souffle cup for administration. Once the medications were administered at the patient's bedside, the RN returned to the bathroom, washed her hands, then picked up the MAB and left the patient's room. The RN did not disinfect the MAB after leaving a bathroom containing two infectious waste receptacles. During interview on 01/10/2020 at 01:30 PM , the findings were presented to the Vice President of Hospice Clinical Operations and Director of Clinical Services. No information to refute the findings was presented.