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
331548 A. BUILDING __________
B. WING ______________ 		10/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE AND PALLIATIVE CARE OF CHENANGO COUNTY 33 COURT STREET, NORWICH, NY, 13815
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)
L0530      
42422 Based on clinical record review, interviews with the Director of Patient and Family Services (DPFS) and the hospice nurse (HN), it was determined in 1 of 3 records (Patient # 1), the hospice nurse failed to conduct a comprehensive assessment including a complete review of the patient's medications. Evidence as follows: 1. Patient # 1 was admitted to the Hospice on 09/10/21 with a terminal diagnosis of malignant neoplasm of the colon. The hospice nurse (HN) failed to perform a complete medication assessment to determine if medications were available to alleviate symptoms should they occur. On 09/10/21, the HN documented in the initial comprehensive assessment "all medications reviewed from discharge summary." The HN failed to assess and document: - names of the medications the patient was currently taking - the medications available in the home - the current drug therapy ordered and it's effectiveness - the presence of any side effects - actual or potential drug interactions - duplicate drug therapy On 10/22/21, the above findings were reviewed with the DPFS, who acknowledged the findings and provided no additional information. Failure to ensure that a comprehensive assessment of the patient's medication was completed has the potential for unmet patient needs.
L0591      
42422 Based on clinical record reviews and interviews with the hospice nurse and Director of Patient and Family Services (DPFS), it was determined in 1 of 3 clinical records (patient # 1), the hospice nurse failed to provide adequate nursing assessments to meet the changing needs of the patient. Evidence as follows: 1. Patient # 1 was admitted to the Hospice on 09/10/21 with a terminal diagnosis of malignant neoplasm of the colon. The hospice nurse failed to assess and document the patient's non-terminal diagnoses, which may impact the caregiver's ability to provide safe and effective care to the patient. When changes in the patient's condition were reported to the agency, the hospice staff failed to provide adequate assessments and symptom management. - On 09/10/21 at 11:30 am, the case manager (CM) visited the patient and documented in the initial comprehensive assessment the patient had severe cognitive deficits, was alert, confused all of the time, and was unable to follow commands. The patient was disoriented and had changes in memory, both short and long-term. Required total care for ambulating, maximum assistance with taking medications, bathing, grooming, and transferring. The case manager was at the home when the patient arrived from the hospital and documented Medivan employee and nurse transferred the patient to a wheelchair at admission. - The CM failed to assess the patient's medication regimen or identify the medications available in the home. The visit summary included a notation that Tramadol was in use as needed for pain and "wishes no morphine at this time." (it was unclear if the patient or the caregiver declined morphine use.) - On 09/11/21 at 12:06 am, the patient's caregiver (PCG) called the agency to report that the patient was hallucinating. This was recorded in the on-call log from the answering service. - The on-call nurse documented in the patient record a return call to the PCG regarding the report of the patient hallucinating. The nurse began to ask questions about the patient's condition and, "right away the daughter became very agitated and screaming over the phone." The HN documented the PCG did not want to answer questions and the nurse couldn't give recommendations without asking questions because the patient was just admitted yesterday; it was the middle of the night, and there was no comfort kit (medications for symptom management) available at the home yet. The PCG continued to yell, remained upset, and hung up the phone. On 10/21/21 at 10:46 am, the surveyor interviewed the on-call nurse who stated the PCG "was frantic, didn't know what to do, her father was agitated, they had no comfort pack yet. She got upset, then hung up the phone." The on-call nurse stated, she did not offer a visit because there were no medications there yet, and she feared for her safety. She stated she reported the call to her supervisor, the DPFS, immediately after the call. - On 09/11/21 at 03:43 pm, the PCG called the agency again to discuss the patient's personality change and had questions regarding medication, as documented in the on-call log. - The on-call nurse for Saturday 09/11/21 was the hospice nurse who admitted the patient and would be the case manager for the patient. The CM returned the call and documented "PCG reports last evening the patient was agitated, chanting and had personality changes, she gave Tramadol, and the patient became calm and restful, seems more confused." The CM reviewed medication. The CM failed to document what medications were reviewed, offer an in-home visit to assess the patient's current condition, notify the physician regarding the previous night's agitation and failed to obtain medication necessary to alleviate symptoms should they recur. On 10/21/21, at 11:31 am the CM was interviewed and stated the call from the PCG was very civil, like the admission visit, and the conversation was discussed afterward with the DPFS. The CM did not indicate why a visit wasn't conducted. - On 09/12/21 at 02:47 am, the PCG called the agency again and the on-call log included the patient fell. - The CM, who was on-call, returned the call to the PCG and offered to visit. The PCG declined the visit and stated she already called the ambulance. The CM could not determine any further details regarding the fall. - During the interview on 10/21/21 at 11:31 am, the surveyor asked the CM why she had not obtained an order from the primary physician for medications typically in the comfort pack to have on hand over the weekend if the patient became agitated. The CM reported the patient "had no history of agitation", and the patient didn't want morphine. When asked if they had discussed any other medications in the comfort pack, such as Ativan, she stated, "we didn't discuss Ativan." The CM failed to visit the patient on 09/11/21 in the afternoon when the PCG called to report the events from the early morning hours, including agitation, personality changes, and chanting, and failed to recognize that the caregiver needed education regarding interventions to manage the new onset of symptoms which resulted in a patient fall with injury. On 10/22/21, the record was reviewed with the DPFS. She acknowledged the findings, and no additional information was provided. Failure to ensure that the nursing needs of the patient are adequately assessed, and symptoms managed, has the potential for unmet patient needs.
L0653      
42422 Based on a review of the hospice's current contracts and interview with the Director of Patient and Family Services (DPFS), the Governing Authority failed to ensure drugs and biologicals are routinely available to patients on 24-hour a day basis. Findings: During an interview on 10/22/21, the DPFS stated the hospice holds one current pharmaceutical contract. The contract does not include a provision to ensure medication are available on a 24 hour a day basis. The DPFS stated there were no 24-hour pharmacies available to obtain medications within a reasonable proximity. Failure to ensure patients routinely have access to drugs and biologicals 24 hours a day has the potential to result in the hospice's inability to provide pain and symptom management in a timely fashion resulting in negative patient outcomes.