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
341585 A. BUILDING __________
B. WING ______________ 		05/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMMUNITY HOME CARE & HOSPICE 2841 DAISEY LANE SUITE , E, WILSON, NC, 27896
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0500      
34981 Based on policy review, clinical record review, staff interviews and caregiver interview the agency failed to provide effective pain management/symptom control in accordance with the condition of patient rights for 1 of 3 charts reviewed [#1]. The findings included: Cross refer 418.52 (c) Tag L512.
L0512      
34981 Based on agency policy, clinical record review, staff interviews and caregiver interview the agency failed to provide effective pain management/symptom control for 1 of 3 charts reviewed [#1]. Immediate Jeopardy began on 1/26/21. The agency was notified on 5/5/21 at 11:45 a.m. The immediate jeopardy was abated on 5/6/21 at 9 a.m. with an acceptable allegation of compliance. The policy, Pharmacy Services [November 2020], was provided on 5/5/21 at approximately 8 am by the agency director. The policy stated, "Pharmacy, biological and infusion services needed by hospice patients and families/caregivers and hospice personnel will be available 24 hours a day ..." The policy, Pain Management, Home Care [November 2020], was provided on 5/13/21 at approximately 11 a.m. The policy stated, " ...Patients also have the right to treatments and interventions to reduce pain ..." Patient # 1 had a Start of Care [SOC] date of 1/26/21 and a terminal diagnosis of Malignant Neoplasm of Lower Third of Esophagus. A review of the Plan of Care for the certification period 1/26/21 to 4/25/21 revealed orders for SN [skilled nursing] 3 times a week for 1 week. A review of the clinical record revealed RN # 4 completed the initial assessment on 1/26/21. A review of the pain section of the visit note revealed the RN documented the following information, "Type of Standardized pain tool used-Staff Observation, patient ' s pain severity-moderate, facial expression-frightened, body language-pulling or pushing away, unable to console, distract or reassure." A review of the narrative section of the initial visit revealed the following information, " ...Pain noticed when moved, unable to communicate where discomfort was ...comfort medications were put inplace [sic] upon admission ..." On 1/27/21 at 12:34 pm RN # 2 made a routine visit. A review of the visit note revealed a temperature of 99.2, pulse of 109. A review of the narrative section of the visit note revealed the following documentation, " ...Pain observed by patient moaning at rest and when repositioning ...Roxanol not picked up yet but family states they will do so. Involuntary jerking movements observed ..." A review of the corporate triage call log [used at a corporate level by corporate RN ' s and at an agency level used by agency RN ' s on call] revealed the following information: 1/27/21 at 5:37 pm Patient # 1 ' s daughter notified the triage center that "Rx [pain medication]not at pharmacy ...caller states she was able to pick up Ativan and Levsin [used for excess secretions], but Morphine script not at _____[name of pharmacy]." Corporate triage RN # 12 called and "spoke with ______ [pharmacy employee] and they do not have a prescription for Morphine." 1/27/21 at 5:44 pm RN # 10 notified RN # 1 [agency on call nurse] that "narcotic script or med authorization needed." 1/27/21 6:00 pm RN # 1 [agency on call nurse] documented the following information in Patient # 1 ' s chart," Family concerned that morphine was not at pharmacy. No scripts at pharmacy ...Qliq [secured method to send physician text messages] to _______ [name of physician] for morphine prescription to be sent to pharmacy." 1/27/21 at 7:49 pm review of the corporate triage call log reveals RN # 10 documented "________[name of pharmacy] called to advise the morphine prescription has no dose." 1/27/21 8:08 pm RN # 10 [corporate triage nurse] contacted RN # 1 [on call nurse] to advise her the prescription for morphine did not include a dose with RN # 1 replying, "will contact the physician now to notify him that his script did not include dosing." 1/27/21 9:18 pm the daughter contacted the on-call center to inform the nurse that Patient # 1 had a change in condition which included a temperature of 102.9 axillary, respirations are 32. The triage on call nurse [RN # 3] documented the following information, "patient received Ativan about an hour ago, no morphine available-states she went to pick it up, but pharmacy told her Rx was not received." 1/27/21 9:28 pm the corporate on call log indicates RN # 1 [agency on call nurse] was notified by RN # 3 of the change in the patient ' s condition. 1/27/21 9:57 pm RN # 1 documented the following in the on-call log, "Spoke at length with family, sounds like patient is transitioning. No morphine in the home ...Family request RN visit. ______ [name of agency RN who started her on call shift at 10:00 pm] on call at 10 pm with go to patient home [sic]" 1/27/21 10:12 pm RN # 2 documented, "On my way." 1/27/21 10:54 pm RN # 2 documented in the visit note, "Patient expired." On 5/3/21 at approximately 5:30 pm a phone interview was conducted with Patient # 1 ' s caregiver. She stated "When I called them the first time it was about 15 til 6 [5:45 pm]. I told them the pharmacy didn ' t have any pain medicine for daddy. I asked _______ [RN # 1] to call the medicine into a backup pharmacy and we would go pick it up. I told her it didn ' t matter how far I had to drive. She told me that Hospice didn ' t do that. She said Hospice only used ______ [name of pharmacy]. When I talked to her the last time, she told me if my daddy was in so much pain to carry him to the hospital. I told her that was not what hospice was about. ______ [RN # 2] called me back about 10 or 10:15 pm and my daddy died while I was on the phone with her." On 5/4/21 at approximately 2 pm a phone interview was conducted with RN # 4 [admitting RN]. RN # 4 advised, "The family said the patient was using Tylenol for pain. I knew this man was going to need some pain medicine. That ' s why I called _____[physician] and asked for a prescription to be send to the pharmacy for morphine. I guess I should have followed up with the pharmacy to make sure the prescription was sent." On 5/4/21 at approximately 2:20 pm a phone interview was conducted with RN # 2 [RN who made the visit on 1/27/21] and pronounced the patient expired on 1/27/21 at 10:54 pm. The RN advised, "I went on call at 10 pm on 1/27/21. I am not the nurse who spoke with the caregiver during any of the calls made to the call center. I split the shift with ______ [RN # 1]. When I called the family back to let them know I was on the way to see the patient the daughter told me in the middle of the conversation he had passed away." A telephone interview was conducted with RN # 1[agency on call nurse from 1/27/21 at time of the 1st call from the family until 10 pm] on 5/4/21 at approximately 3 pm. During the interview RN # stated, "I sent Dr. _______ a click [used to send secure text messages to staff]. I asked him to send a prescription to the pharmacy. When I was notified by _____ [RN # 10] the pharmacy didn ' t get a complete order for the morphine I sent him another click. I didn ' t call the pharmacy to see if Dr.________ [name of physician] replied or not. I guess I should have called him to make sure he saw the message and from now on that is what I will do." On 5/5/21 at approximately 3:45 p.m. a phone interview was conducted with RN # 5. RN # 5 had spoke with the physician on 5/5/21 at approximately 3:30 p.m. RN # 5 stated she was advised by the physician when he woke up 3:19 am on 1/28/21 he sent another electronic prescription to the pharmacy. RN # 5 stated, "There is no way to tell what time the nurse [RN # 1] sent me the last message about the morphine. The doctor and I went back on his phone and cant find the exact time." On 5/5/21 at approximately 4 p.m. a phone interview was conducted with RN # 7. RN # 7 stated, " ________ [RN # 1] knows if the doctor doesn't respond there are other ways to get an order for pain medicine. She could have notified the medical director for the order. We also have administrators on call to help with any issues that might come up while our nurses are on call. I went back and looked and there is no record _____ [RN # 1] called the administrator on call. " The Area Director of Education, Corporate Director of Survey and Resource Development and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on 5/5/21 at 11:45 a.m. The Immediate Jeopardy was abated on 5/6/21 at 9:00 a.m. with an acceptable Credible Allegation of Compliance. The deficient practice continues at a lower level. Credible Allegation of Compliance Community Home Care and Hospice, Wilson, NC The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. Upon reviewing the charts and speaking with the nurses and triage nurse, the surveyor found credible allegation which led to notification of an Immediate Jeopardy at 11:45am 5/5/21 related to hospice agency failure to adhere to agency ' s policy and procedures in regard to effective pain management and symptom control. Patient #1 was admitted on 1/26/21 with a terminal diagnosis of malignant neoplasm of lower third of esophagus with a pain level of 7 (moderate) per admitting RN (however, SOC documentation directions indicates a pain level of 7-10 as severe pain). The RN documented occasional labored breathing, facial expression-frightened, unable to console, distract or reassure" based on the nurses ' observation. Per the patient ' s daughter, the pain issues had just started over the last few days. The nurse also documented "pain with movement". There was no documentation related to the nurse educating the family to pick up the pain medication that evening or when it would be available to pick up. The nurse did not follow up with the pharmacy to ensure they had received the order for the morphine after it had been faxed and to determine when it would be ready for the family to pick up. Nurses did not follow policy and procedures to ensure medications for pain and symptom management were available for the patient the day of admission. Additionally, they did not communicate with the pharmacy and hospice physician to ensure that the prescription for morphine was completed by the physician, sent to the pharmacy and received/filled by the pharmacy on the day of admission. The fax report shows the morphine prescription was faxed successfully, but there was no follow-up to ensure it was received. The RN made a second visit to the patient ' s home the day after admission and documented that the patient was moaning and groaning in pain, the family states they gave Tylenol supp. but had not picked up meds but planned to that day. There was no follow-up to ensure the script was ready for pick-up at the pharmacy and no education noting the nurse educated the family on the need to pick up the medication that afternoon to ensure the patient had the medication to help with his pain. Late that afternoon, following the visit, there was a call to triage from the family stating there is no morphine at the drug store for pick-up. The on-call nurse was notified, and she essayed the physician to send a script in for morphine and documented that no visit needed. MD sent script to pharmacy 1 hour after initial call to triage stating no morphine at the pharmacy and over an hour later pharmacy notified triage that script was received but had no dose - the on-call nurse was contacted by triage. On call nurse sent message by secure text to physician but did not ensure message was received and did not follow up with phone call. Patient died that evening (after 10pm when on call nurse was en route to the patient ' s home - pronounced at 11pm when on call nurse arrived). Script from physician was not sent to the pharmacy until 3:19 am on 1/28/21. There was a lack of follow-up by the RNs to the pharmacy and to the physician to ensure the needed medication was available for management of the patient ' s pain. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; a. Immediately, all nursing staff, hospice physicians and clinical leadership will attend education to address the provision and availability of pain and symptom management medications to hospice patients on admission and as needed throughout the course of care as evidenced by documentation of attendance of nurses, hospice physicians and clinical leadership staff. The education will include the following policies: 2-002 Patient Bill of Rights, 4-015 Pharmacy Services, 4-041 Initial Hospice Assessment, 4-042 Comprehensive Assessment, 4-043 Ongoing Assessment, and 4-046 Pain Assessment, 4-027 The Plan of Care, 4-028 Verification of Physician Orders (NOTE: physician ' s orders may be obtained via Qliqsoft secure texting, however if there is an immediate need or question regarding pain medication orders/prescriptions and the physician does not respond within 15 minutes then the nurse must initiate a phone call), 4-036 On Call/ Weekend Services, and On Call Response Process. We have 36 nurses, 10 hospice physicians and 15 clinical leaders that will be required to complete the training on 5/5/21 at 4pm presented by the Corporate Director of Survey and Regional Director of Clinical Services. (In-service documents attached of attendees and those who were unable to attend). Any staff that are unable to attend, on leave or vacation will complete the education upon return to work and will not be allowed to work until the training is completed. b. Immediately, all current patient medical records with pain identified as an active problem will be reviewed by clinical leadership to ensure a pain regimen is in place for the patient appropriate to their identified needs. Also, the records will be audited to ensure pain medications are in the home/available (as evidenced by narcotic counts documented in the nursing assessment or documentation showing other appropriate interventions, such as non-opioid medications or non-pharmacological interventions). Additionally, there should be documentation of coordination of care with the physician, pharmacy and patient/caregiver to ensure the medications were accessible in a timely manner. If the nurse identified a need that required report to the physician and is unable to contact that physician, he/she should contact another physician - by initiating a call to the hospice physician (if initial call is to the attending) or per the delegation of authority (if the initial call is to hospice physician). Any patient identified with possible pain management needs per audit findings will be assigned an RN visit for 5/6/21 for completion of a comprehensive pain assessment with medication orders received as indicated. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; a. All patients with a cancer diagnosis with pain management needs will have 100% review of the comprehensive pain assessment, and availability of medications to manage the pain. These audits will continue weekly until 95% or greater compliance is achieved and maintained for 4 consecutive weeks (see attached audit tool). b. The company will provide a team of clinical staff to be on site over the next 4 weeks until sufficient evidence of compliance is achieved and maintained. The clinical team on site will review all training and care that has been provided in this location and evaluate further needs for additional training. All processes associated with the location will be reviewed to assure ongoing compliance with the Conditions of Participation and updated or altered as necessary based on the findings. c. On-going compliance will be monitored by the Area Director of Education and Regional Director of Clinical Operations with periodic on-site/remote inspection of processes and clinical performance that will be completed weekly for 4 weeks. The title of the person responsible for implementing the acceptable plan of correction. o Administrator/Executive Directors