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
341501 A. BUILDING __________
B. WING ______________ 		07/16/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CAREPARTNERS HOSPICE & PALLIATIVE CARE SERVICES 21 BELVEDERE ROAD, ASHEVILLE, NC, 28803
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)
L0533      
34981 Based on clinical record review, agency policy review and interviews with the staff, the IDG [interdisciplinary group] failed to update the comprehensive assessment related to a safety evaluation [multiple falls] for 1 of 3 charts [#3] and failed to update the comprehensive assessment with related to pain medication for 1 of 3 charts reviewed [#3]. The findings included: A policy, IDG Review of Patient Care Plan with a revised date of 1/20/12 was provided by the clinical manager on 7/10/20 at approximately 930 am. The policy stated, " ...Interdisciplinary group members will participate in reviewing patient care plan ...The care plan will be updated on an ongoing basis based on the patient's assessment and care needs ..." 1A. Patient # 3 had a Start of Care [SOC] date of 3/6/20 and a terminal diagnosis of Non-Rheumatic Aortic Valve Stenosis [narrowing of aortic valve which reduces or blocks blood from the heart into the main artery]. A review of the physician's orders/Plan of Care [POC] for the certification period 3/6/20 to 6/3/20 revealed SN [skilled nursing] 1-3 times per week for 14 weeks and SW [social worker] orders for 1-3 times per month for 3 months. A review of the clinical record revealed Patient # 3 had documented fall[s] on the following dates 3/23/20, 3/25/20 and 3/27/20. The falls resulted in numerous skin tears and abrasions. On 4/8/20 the SW documented the following information, " .... We [SW and son] discussed the recent falls and son said that one fall had knocked father out and SW said father had talked about the time he laid 3 hours on the floor ... Son said father had mentioned needing a bathmat and perhaps a home safety eval ... SW will let him know what find out about home safety eval ..." A review of the IDG summary dated 4/21/20 did not mention the need for a safety evaluation. On 7/15/20 at approximately 125 pm a phone interview was conducted with the social worker. The social worker confirmed she failed to update the IDG plan of care with the need for a safety eval. The social worker reported, "All I can remember about that is this patient was one of my first patients when I came to work for hospice." 1 B. Patient # 3 had a Start of Care [SOC] date of 3/6/20 and a terminal diagnosis of Non-Rheumatic Aortic Valve Stenosis [narrowing of aortic valve which reduces or blocks blood from the heart into the main artery. A review of the IDG [interdisciplinary group] meeting minutes revealed Patient # 3 was discussed in IDG on 3/25/20, 4/8/20, 4/22/20, 5/6/20, 5/20/20, 6/3/20, 6/17/20 and 7/1/20. A review of the physician's orders revealed Patient # 3 had and order for Oxycodone 2.5 mg- 5 mg every 4 hours prn pain with a start date of 3/6/20 [SOC] and Hydromorphone HCL .5 mg every 3 hours prn pain with a start date of 3/6/20 [SOC]. Both medications had a stop date of 3/30/20. A review of the IDG summary dated 3/25/20 did not include the medication changes. A review of physician's orders revealed Patient # 3 had an order for Oxycodone .5 mg take every 4 hours while awake with a start date of 3/30/20 and a stop date of 5/19/20. A review of the IDG summary dated 4/8/20 did not reveal the medication change. A review of the IDG summary written on 4/22/20 revealed the following documentation by RN # 1, " ...His pain is better controlled with scheduled oxy [oxycodone] 2.5 mg 4 times per day ..." A review of the physician's orders revealed no orders for Oxycodone 2.5 mg 4 times per day, but there was an order for oxycodone 2.5mg -5 mg every 4 hours that had a stop date of 3/30/20. The IDG summary dated 5/6/20 did not include any discussion regarding medication changes. The IDG summary dated 5/20/20 revealed the following documentation by RN # 1, " ...Pt continues to complain of chest pain despite taking 2.5 mg of oxycodone 4 times per day ..." A review of the physician's orders did not reveal an order for 2.5 mg of oxycodone 4 times per day, a medication order dated 3/6/20 was noted, however, the order was Oxycodone 2.5 mg-5mg every 4 hours as needed for chest pain. This order had a stop date of 3/30/20. The IDG summary dated 6/3/20 revealed the following documentation by RN #1, " Since last IDG, oxycodone has been increased from 2.5 to 5 mg 4 times per day. Pt states that the pain is better ..." A review of the orders did not reveal that order, there was an order that had a start date of 3/6/20 and a stop date of 3/30/20 for oxycodone 2.5-5 mg every 4 hours as needed for pain. The IDG summary did not include the new order for oxycodone 10 mg every 4 hours which was written on 5/20/20. The IDG summary dated 6/17/20 revealed the following information, "Since last IDG oxycodone has been increased to 10 mg 4 times per day ..." A review of the orders did not reveal the order. The IDG summary for 7/1/20 revealed the same documentation, " ...Since last IDG, oxycodone has been increased to 10 mg 4 times per day ..." A phone interview was conducted with RN # 1 on 7/15/20 at approximately 130 pm. During the interview RN # 1 stated, "I entered the orders on the IDG summary just like I was supposed to ... I am still pretty new to hospice ..."
L0545      
34981 Based on clinical record review, agency policy review and staff interview, the plan of care [POC] failed to include wound care orders for 2 of 3 patients with wounds [#2 and 3] and failed to include orders for skilled nursing to prefill med planner [pill box]for 1 of 1 patient using a med planner [#3]. The findings included: The policy, IDG [interdisciplinary group] Review of Patient Care Plan with a revised date of 1/20/12 was provided by the clinical manager on 7/9/20 at approximately 4 pm. The policy stated, " ...IDG members will participate in reviewing patient care plan ...The Case Manager will notify the primary physician of any care plan revisions and obtain physician orders as needed ..." 1. Patient # 2 had a Start of Care [SOC] date of 5/8/20 and a terminal diagnosis of Other Ulcerative Colitis. A review of the physician's orders/Plan of Care [POC] for the certification period 5/8/20 to 8/5/20 revealed orders for SN [skilled nursing] 1-3 times per week for 14 weeks; 1-5 PRN [as needed] visits x 14 weeks. A review of the SOC documentation by RN # 6 revealed the following information, " ...LLE [left lower extremity] has 3 + edema, no palpable pulse. Foot is black, blistered and areas of broken blisters draining serosanguinous fluid. Dressing changed. Current regimen from ______[name of hospital] is Vaseline gauze covered with abd pads secured with kerlex." Patient # 2 received SN visits for wound care on 5/9/20 then daily dressing changes beginning 5/12/20 through 6/3/20. At each visit the type of dressing documented was " Vaseline gauze covered with abd pads and secure with kerlex." A review of the POC did not reveal any orders for a dressing change. A phone interview was conducted with the clinical manager on 7/15/20 at approximately 1 pm. During the interview the clinical manager confirmed a physician's order should have been obtained. The POC did not include treatment orders for the Left lower extremity. 2A. Patient # 3 had a Start of Care [SOC] date of 3/6/20 and a terminal diagnosis of Non-Rheumatic Aortic Valve Stenosis [narrowing of aortic valve which reduces or blocks blood from the heart into the main artery]. A review of the physician's orders/Plan of Care [POC] for the certification period 3/6/20 to 6/3/20 revealed orders for SN [skilled nursing] 1-3 times per week for 14 weeks . A review of the SN visit notes revealed on 3/28/20 RN # 4 made a PRN visit post fall. RN # 4 documented the following information, "Assessed pt's skin: pt. has multiple bruises on back and extremities. Several small dressings on back are intact but dressing on skin tear @ L upper arm/shoulder is saturated: changed dressing and applied gauze wrap to hold in place." On 3/30/20 RN # 1 made a routine visit and identified numerous skin tears. RN # 1 documented skin tears on the right forearm, 3 skin tears on the left knee, skin tear on the left elbow and 3 skin tears on the left upper back. RN #1 documented the following wound care, "Wounds cleaned with wound cleaner. Drsgs [dressings] changed." A review of the clinical documentation for 4/6/20 by RN # 1 revealed the following information, "Drsg changes to L knee, L elbow, L upper back, RFA [right forearm]. Skin tears healing as expected." A review of the plan of care does not reveal any treatment orders. On 7/15/20 at approximately 115 pm a phone interview was conducted with RN # 1. During the interview RN # 1 confirmed the POC did not include treatment orders for the multiple skin tears. 2B. Patient # 3 had a Start of Care [SOC] date of 3/6/20 and a terminal diagnosis of Non-Rheumatic Aortic Valve Stenosis [narrowing of aortic valve which reduces or blocks blood from the heart into the main artery]. A review of the physician's orders/Plan of Care [POC] for the certification period 3/6/20 to 6/3/20 revealed orders for SN [skilled nursing] 1-3 times per week for 14 weeks. A review of the SN visit notes dated 3/30/20 and 4/6/20 by RN # 1 revealed the RN prefilled a med box for the patient for Patient #3. On 4/28/20 RN # documented the following information, "RN was asked to fill pill box ...RN followed all instructions on pill bottles recently filled ..." On 5/4/20 RN # 1 made a routine visit to see Patient # 3. A review of the clinical note revealed the following information, " ...discussed his son filling his pill box rather than me. Both agreeable to that." The plan of care did not contain orders related to the nurse prefilling the med planner. A phone interview was conducted with RN # 1 on 7/15/20 at approximately 115 pm. During the interview RN # 1 confirmed the plan of care did not contain orders for the SN to prefill the med planner. RN #1 stated, "I didn't realize I had to have an order for me [sic] to prefill the pill box."
L0591      
34981 Based on clinical record review, agency policy review and interviews with staff, nursing failed to provide updated assessments related to wound measurements for 2 of 2 patients with a wound [#2 and 3]. The findings included: A policy titled, Palliative Wound Treatment and Dressing Selection, with a revision date of 1/31/20, was provided by the clinical manager on 7/14/20 at approximately 11 am. The policy stated, " ...Measure wound [length x width x depth] in centimeters ...The wound will be measured during comprehensive assessment then weekly or anytime there is a change ..." 1. Patient # 2 had a Start of Care [SOC] date of 5/8/20 and a terminal diagnosis of Other Ulcerative Colitis. A review of the physician's orders/Plan of Care [POC] for the certification period 5/8/20 to 8/5/20 revealed orders for SN [skilled nursing] 1-3 times per week for 14 weeks; 1-5 PRN [as needed] visits x 14 weeks. A review of the SOC visit on 5/8/20 by RN # 6 revealed the following information, " ...Foot is black, blistered and areas of broken blisters draining serosanguinous fluid ..." No wound measurements were obtained at the time of admission. Patient # 2 received daily visits for wound care from 5/12/20 - 6/3/20. A review of the SN visit notes revealed no wound measurements were obtained during any of the visits. A phone interview was conducted on 7/15/20 at approximately 1 pm with the clinical manager [RN # 6 was unavailable for interview]. During the interview the clinical manager confirmed the nursing staff failed to obtain wound measurements in accordance with agency policy. 2. Patient # 3 had a Start of Care [SOC] date of 3/6/20 and a terminal diagnosis of Non-Rheumatic Aortic Valve Stenosis [narrowing of aortic valve which reduces or blocks blood from the heart into the main artery]. A review of the physician's orders/Plan of Care [POC] for the certification period 3/6/20 to 6/3/20 revealed orders for SN [skilled nursing] 1-3 times per week for 14 weeks. A review of RN #6 visit note dated 3/27/20 revealed the following information," ... Facility RN had already cleaned multiple skin tear [sic] with NS [normal saline] and covered with bandages. These include 2 areas to the left lateral back, left shoulder and bilateral elbows ..." There is no evidence RN # 6 removed the dressings to assess or measure the wounds. A phone interview was conducted with the clinical director on 7/15/20 at approximately 1 pm. During the interview the clinical manager confirmed the wounds should have been assessed and measured. RN # 4 made a PRN visit on 3/28/20 [post fall] and documented the following information, " ...Assessed pt's skin: pt. has multiple bruises on back and extremities. Several small dressings on back are intact but dressing on skin tear @ L upper arm/shoulder is saturated: changed dressing and applied gauze wrap to hold in place. Pt. has scabs on both knees and an abrasion below L knee, which was covered with non-adhesive dressing held in place with Telfa." A phone interview was conducted on 7/15/20 with RN # 4 at approximately 145 pm. During the interview, RN # 4 confirmed she did not remove the dressings to assess or measure the wounds. She reported, "I didn't see the need to do that." During a follow up phone interview with the clinical manager on 7/15/20 at approximately 130 pm the clinical manager confirmed the wounds [skin tears] should have been measured. RN # 1 made a routine visit on 3/30/20 and documented the following findings in the integumentary section, " ...Location r fa [right forearm], Location l knee x 3, Location l elbow Type Skin Tear, Location l upper back x 2, Location l upper back, Type Skin Tear Location r inner wrist ..." [sic] On 4/6/20 RN # 1 saw the patient for a routine visit and documented the following findings, " Drsg [dressing] changes to L knee, L elbow, L upper back, RFA. Skin tears healing as expected." A review of the documentation completed by RN # 1 on 4/13/20 revealed the following information, "Multiple skin tears in healing process. No dressings needed at this time." On 7/15/20 at approximately 230 pm a phone interview was conducted with RN # 1. During the interview, RN # 1 confirmed she failed to measure any of the wounds in accordance with the policy.