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
341587 A. BUILDING __________
B. WING ______________ 		11/01/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PROMEDICA HOSPICE (RALEIGH) 4505 FALLS OF NEUSE ROAD, SUITE 650, RALEIGH, NC, 27609
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)
L0513      
44098 Based on policy review, clinical record review, caregiver interview, and staff interview, the allegation that the agency did not provide the patient and caregiver adequate notice for coordination of services at the time of discharge for 2 of 3 (Patients #1, #3) is substantiated. Findings included: Policy 881-H, Hospice Discharge/Discharge Planning, dated 06/16 and received from Employee #2, Director of Professional Services, on 11/01/21 at 12:45 PM, reads, "Review of patients on service due for re-certification begins one month prior to the due date ...The hospice obtains a written physician order from the hospice physician for discharge prior to discharging a patient for any reason ...Discharge planning includes plans for any necessary family counseling, patient education, other services and community referrals before the patient is discharged." The policy further reads, "Patients are discharged from hospice for the following reasons: ...Hospice determines the patient is no longer terminally ill ...IDG (interdisciplinary group) develops and documents the discharge plan which may require an ad hoc meeting of the respective group members to facilitate the discharge planning process. If proper discharge planning has not occurred, the patient continues to receive care until required discharge planning is complete." 1. Patient #1 was admitted to the agency on 03/28/19 with a principle hospice diagnosis of chronic diastolic congestive heart failure. Hospice IDG Comprehensive Assessment and Plan of Care Update Report of 09/16/21 revealed the orders for the following hospice services: skilled nursing 1 time per week with 3 PRN (as needed), home health aide 1 time per week, and spiritual care counselor 1 time every 30 days and 3 PRN (as needed). Further review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 09/16/21 revealed discrepancies regarding the upcoming plan for the plan for the next two weeks for Patient #1 documented by the registered nurse, Employee #4, as, "MONITOR WEAKNESS AND FUNCTION, MONITOR PULMONARY FUNCTION, MONITOR CARDIAC FUNCTION, MONITOR COGNITIVE IMPAIRMENT," by the pastor/counselor as, "SCC WILL CONTINUE TO REVIEW SCHEDULE AND PLAN OF CARE FOR PATIENT. CURRENTLY SCC WILL MAINTAIN AS SCHEDULED. WILL CONFIRM WITH IDGE TEAM FOR ANY CHANGES THAT MIGHT BE NEEDED," and by the social worker, Employee #6, as, "NOT ELIGIBLE-DISCHARGING." Clinical Coordination Note Report from the registered nurse case manager, Employee #4, revealed, "(First name of Employee #7) PCM (patient care manager) SENT AN EMAIL ON WEDNESDAY 9/8 TIME STAMPED 6:16 PM. SAW THE PATIENT EARLIER THAT DAY, HOWEVER WAS UNAWARE OF NEEDING LABS UNTIL LATE THAT NIGHT. (Name of Patient #1) LABS WERE DRAWN ON 9/10 FRIDAY AND SENT STAT. THEY RESULTED ON 9/13 ALL WERE WNL (within normal limits). PATIENT WAS SEEN BY NEW HIRE (First name of Employee#8), RN ON 9/14. ADDITIONAL INFORMATION WAS VERBALIZED TO THIS WRITER AND (First name of Employee #8), RN ABOUT INCREASE IN SLEEPING DURING THE DAY AND SEVERAL EPISODES OF DIZZYNESS [sic] WITH INCREASED LASTING GARBLED SPEECH WITH INCREASED TIA'S/SEIZURES EPISODES 4-5 A WEEK ...ON 9/15 I WAS TOLD BY THE PCM TO VERBALIZED [sic] THE PATIENT WAS GOING TO BE DISCHARGED, NO DISCUSSION WAS GOING TO TAKE PLACE IN IDG ON 9/16. SO I CALLED THE DAUGHTER AND EXPLAINED ABOUT THE DISCHARGE PROCESS AS I WAS INSTRUCTED BY (First name of Employee #7 ) TODAY. I THEN CALLED (First name of caregiver) TO GET INFORMATION ABOUT THE PALLIATIVE CARE PROGRAM WHICH I CALLED THE DAUGHTER BACK AND GAVE HER INFORMATION ABOUT HOW IT WORKS. THEN LATER I WAS INFORMED BY EMAIL THE PATIENT NEEDS TO SIGN THE DISCHARGE PAPERWORK TODAY. I WILL BE WILLING TO SPEAK TO THE FAMILY ON 9/15 [sic] AFTER IDG AND EXPLAIN OPTIONS AND HAVE THEM SIGN PAPERWORK. THE DAUGHTER VERBALIZED THAT IT WOULD BE OK IF I COME TOMORROW." There was no evidence in the clinical record of discharge coordination with the patient or her caregiver prior to 09/15/21. There was no evidence in the clinical record of referrals for other services at the time of discharge. In an interview on 11/01/21 at approximately 3:35 PM, Patient #1's caregiver stated that her concern with the agency was, "the way the discharge was handled." Patient #1's caregiver stated that a nurse and nurse practitioner from the agency had been to the home to complete the patient's recertification visit on 09/14/21 and there was no discussion regarding discharge during that visit. Patient #1's caregiver said that the patient is, "on oxygen and needs to have a doctor's order for insurance to pay for it." Patient #1's caregiver stated that she had to call the patient's primary care physician herself to schedule an appointment for the doctor to give the order. Patient #1's caregiver also stated that she did receive verbal information regarding palliative care from Employee #4 but did not receive any referral information for or contact from the palliative care program. In an interview on 11/01/21 at approximately 4:00 PM, Employee #1 stated that the practice for a live discharge is "During the IDG meeting at least two weeks before, they would be discussing recertifications at that IDG meeting ...If the doctor (hospice physician) wants to order lab work or anything of that nature that would occur at that time or that week of IDG ..." Employee #1 agreed that the documentation in the clinical record is confusing and contradictory related to the plan for recertifying or discharging the Patient #1. 2. Patient #3 was admitted to the agency on 04/18/21 with a principle diagnosis of unspecified sequelae of cerebral infarction. Hospice IDG Comprehensive Assessment and Plan of Care Update Report of 09/16/21 revealed the orders for the following hospice services: skilled nursing 1 time per week with 3 PRN (as needed), and spiritual care counselor 1 time every 30 days and 3 PRN (as needed). Clinical Coordination Note Report from Employee #7 of 09/16/21 revealed, "9/15/2021, THE PATIENTS SON ROY WAS NOTIFIED OF THE PATIENTS DISCHARGE FROM HOSPICE, BY (name of Employee #8) SCC. AT THAT TIME HE REFUSED TO SIGN THE DOCUMENT AND HE TOLD THE SCC TO CALL HIS DAUGHTER LAURA. WHEN I LOOKED AT THE PATIENTS CONSENTS, THEY WERE SIGNED BY ROY, SO HE IN FACT NEEDED TO SIGN THE DISCHARGE PAPERWORK. I CALLED AND NOTIFIED HIM, HE DID NOT ANSWER, I LEFT A VOICE MESSAGE WITH MY NAME, THE NUMBER FOR THE OFFICE AND THE INFO FOR THE APPEALS PROCESS TO INCLUDE THE NUMER FOR KEPPRO (the name of the agency contacted to initiate a discharge appeal). I MADE A FOLLOW UP CALL TODAY, HE DID NOT ANSWER AND I LEFT THE SAME INFORMATION AGAIN." There was no evidence in the clinical record of discharge coordination with the patient or caregiver prior to 09/15/21. There was no evidence of referrals for other services at the time of discharge. In an interview on 11/01/21 at approximately 4:00 PM, Employee #1 confirmed that there was not evidence of discharge coordination with the patient or caregiver in the clinical record prior to 09/15/21 Employee #1 agreed that discharge coordination should have taken place and stated that live-discharge patients would typically be referred for palliative care services to ensure that the patient is being monitored for changes or a decline that may make him/her eligible for hospice services again.