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
361584 A. BUILDING __________
B. WING ______________ 		04/11/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HEARTLAND HOME HEALTH CARE AND HOSPICE 4807 ROCKSIDE ROAD, SUITE 110, INDEPENDENCE, OH, 44131
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)
L0591      
22432 Based on record review, interview and policy review, the agency failed to ensure a nurse was present during a patient's death. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of Patient #1's medical record revealed the agency was notified by the Patient #1's friend on 01/23/22 at 3:23 PM that Patient #1 was transitioning to death, but had declined a hospice visit at this time. The friend was advised to notify the hospice if the patient expired. The agency email documentation on 01/23/22 at 6:50 PM documented Patient #1 had expired and that Staff Nurse F would do a phone visit. Interview with Administrative Staff B on 04/06/22 at 11:00 AM confirmed the RN did not physically go to the home of the Patient #1, pronounce the death or follow the agency's policy on Patient Death but only completed a telephone visit. Staff B verbalized there was inclement weather on 01/23/22 but the agency had not activated its emergency plan for weather so the expectation was for the RN to be present in the home of the deceased and completed the expected tasks per agency policy. Staff B verbalize he was not notified of the telephone visit until he arrived at the office the next day. Review of the job description of the registered nurse case manager revealed the registered nurse was to attend the death of patients to assist and support the family. Review of the agency's policy titled "Patient Death", dated February 2022, directed the registered nurse complies with state and local regulations regarding pronouncement of death; notifies the designated patient contact person; performed post mortem care; remains in the home until funeral home personnel arrive; and instructed daily members to discard all medications.
L0596      
22432 Based on record review, interview and policy review, the agency failed to ensure bereavement services were offered to a family after a patient expired. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of the medical record for Patient #1 revealed the natural son was documented as the first emergency contact with a grandson listed as a second emergency contact. The patient made her home with the grandson until 11/03/21 when the patient moved into a niece's home. The niece then became the patient's primary caregiver. The medical record revealed the the agency had completed the initial risk bereavement risk assessment for the grandson at the time of the initial start of care visit on 10/05/21 and who was assessed as no risk at that time. The medical record contained no other bereavement risk assessments, although the medical record documented the patient was living with a niece from 11/03/21 until the date of death on 01/23/22. The medical record contained no documentation of the nieces' full name and contact information. There medical record lacked documentation a bereavement risk assessment was completed for any additional family members or caregivers other than the grandson during the start of care visits. The immediate post death observation note documented a niece and family were present at the time of the death. The agency failed to make a death visit and no observations were made by the nurse to determine the identity of all the bereaved nor were any additional bereavement risk assessments completed other than for the grandson. During interview on 04/07/22 at 9:47 A.M., Staff D, the social worker, stated the agency process was to complete a bereavement risk assessment during the start of care. The bereavement risk assessment was usually completed by the social worker although the nurse could complete the assessment. This assessment was usually completed for the primary caregiver, in this case it was completed for the grandson who the patient lived with. There was a complex family dynamic with Patient #1 and her family. Bereavement risks assessments would then be completed as necessary during the course of the patient's care by the agency and as the agency staff became aware of the patient's close contacts and caregivers. The medical record would then be updated to reflect the identity of the potential bereaved who would be most effected by the patient's death and risk assessments should then be completed. This information should be updated and added to the medical record. If the medical record was not updated with this new information and bereavement risk assessments not completed, the bereavement plan of care, which goes into effect after the patient's death, would not capture these additional people. Staff D verified there were no additional contacts identified in the medical record for the niece and her significant other who the patient made her home until the time of the patient's death nor for the patient's primary emergency contact who was the natural son of the patient. Staff D confirmed there were no additional bereavement risks assessments completed except for the grandson at the start of care and after the patient had expired. Review of the agency's "Bereavement Coordinator Guidebook", dated September 2021, directed the bereavement risk assessment was completed by the registered nurse along with he social worker within five days and was part of the comprehensive assessment of the patient's admission to the agency. It further directed it was important to understand the assessment was not a single event, but rather a continuous process throughout contacts with the bereaved individual. At the time of death an Immediate Post Death Observation Coordination Note, was completed by the RN who attended the death to ensure the caregiver and family bereavement needs were identified. In order to be listed as a bereavement contact, a bereavement risk assessments needed completed at appropriate timepoints; A death event indicated in the electronic medical record (EMR) would generate a list of bereaved provided contacts were entered and the bereaved were selected for the contact.
L0696      
22432 Based on record review, interview and policy review, the staff failed to properly dispose of opioid medications or other controlled medications after a patient's death. This affected one (Patient #1) of three patients reviewed for nursing services. The agency census was 231. Findings include: Review of the Patient #1's medical record revealed the agency was notified by the Patient #1's friend on 01/23/22 at 3:23 PM that Patient #1 was transitioning to death. The friend declined a hospice visit at this time and was advised to notify the hospice if the patient expired. The agency email documentation on 01/23/22 at 6:50 PM documented Patient #1 had expired and that Staff Nurse F would do a phone visit. Review of the patient's medication profile revealed the patient had a physician's order for Morphine Sulfate Concentration (opioid medication) 100 milligrams in a 5 milliliter solution (20 milligrams per ml) for treatment of pain and shortness of breath and Ativan (anti-anxietal medication) 0.5 milligrams for agitation Interview with Administrative Staff B on 04/06/22 at 11:00 AM confirmed the RN did not physically go to the home of the Patient #1, pronounce the death or dispose of the controlled substances in the patient's home. Staff B confirmed the agency has no documentation of the amount of controlled medications remaining in the home, any documentation of the disposal of the medications or the final disposition of these medications. Staff B verbalized there was inclement weather on 01/23/22 but the agency had not activated its emergency plan for weather so the expectation was for the RN to be present in the home of the patient at the time of death or shortly after and complete the expected tasks per agency policy. Staff B verbalized he was not notified of the death visit via a telephone visit until he arrived at the office the next day. Review of the job description of the registered nurse case manager revealed the registered nurse was to attend the death of patients to assist support the family. Review of the agency's policy titled "Patient Death", dated February 2022, directed the registered nurse complies with state and local regulations regarding pronouncement of death; notifies the designated patient contact person; performed post mortem care; remains in the home until funeral home personnel arrive; and instructed daily members to discard all medications. Review of the agency's policy titled "Management and Disposal of Controlled Substances and Other Medications in the Patient's Home", dated February 2022, directed under the heading of Drug Disposal and item number 3, The nurse together with the household member, counts and documented the amount of each drug and verified against the patient's electronic medical record. Following disposal of the controlled substances the nurse documented the following, type of controlled substances/prescription drugs, dosage, dosage form, route of administration, quantity disposed of, and date time and manner of disposal. The household member reviewed, signed and dated the Drug Disposal and or Refusal Form FHL-12022 acknowledging witnessing drug disposal. This completed form was scanned into and maintained in the patient's electronic medical record. Drug disposal was performed by the facility staff or pharmacist per the nursing facility policy for facility patients. Review of the agency's policy titled Patient Death Policy 835 with a date of 02/22 directed that the agency procedures comply with respective state and local rules and regulations for pronouncement of death and provide emotional support of the bereaved. The procedure directed that the Registered Nurse (RN) was to notify the designated contact person, perform post mortem care, remain in the home until the funeral home personnel arrive, and for home health, instruct the family members to discard all medications.