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
361635 A. BUILDING __________
B. WING ______________ 		12/03/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
KINDRED HOSPICE 112 HARCOURT ROAD, SUITE 3, MOUNT VERNON, OH, 43050
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)
L0501      
21893 Based on record review and staff interview, the agency failed to ensure the patient's authorized representative was informed of his or her rights and failed to protect and promote the exercise of those rights for one of six medical records reviewed (Patient #1). The agency census was 187. Findings include: Review of the "Advance Directive Information Statement" from the agency's admission packet revealed "valid advance directives, such as living wills, healthcare powers of attorney....will be followed to the extent permitted and required by law." Review of the medical record for Patient #1 revealed an admission date of 05/31/2020 and a diagnosis of Alzheimer's. Review of the health care power of attorney (HCPOA) dated 10/14/15 designated one of Patient #1's adult children as the primary agent (the HCPOA), a second adult child (the Caregiver) as the first alternate agent, and a third adult child as the second alternate agent. The document also stated "should my agent named above not be immediately available or be unwilling or unable to make decisions for me, then I name, in the following order of priority, the following persons as my alternate agents:" with the names, addresses, and phone numbers of the first and second alternate agents listed. The admission paperwork and consents were signed by Patient #1's adult child (the Caregiver) that he/she was living with on that date. The admission paperwork noted that Patient #1 had recently moved in with the Caregiver, and that another adult child was the power of attorney. The HCPOA had contacted the Caregiver and informed him/her that Patient #1 would be moving in as he/she could not care for Patient #1 any longer after a hired caregiver quit. The admissions nurse also noted that the Caregiver was overwhelmed and stressed, needed much support, and possible placement in facility would be needed. There was also a notation that the Caregiver had legal questions. On 06/04/2020, a nurse noted that they spoke with the HCPOA on 06/02/2020, had received the power of attorney paperwork, and had sent the HCPOA a copy of the plan of care as requested. The medical record documented orders for medication changes on 06/04/2020, 06/19/2020, 07/16/2020, 08/14/2020, 08/21/2020, 08/24/2020, and 09/11/2020; orders for blood work on 06/12/2020; and orders for wound care on 08/21/2020, 08/24/2020, and 09/02/2020. The medical record contained documentation the Caregiver was updated with all changes in condition. With the exception of a communication note dated 07/16/2020 that noted the HCPOA will be notified of changes to medication, the medical record lacked documentation the HCPOA was notified of any of the above orders for changes in care or medication or had been contacted on admission for consent to treat. The medical record lacked documentation of attempts to reach the HCPOA regarding admission or these changes or that any messages were left. Staff F documented updating the HCPOA on respite needs and placement. The medical record revealed on 06/30/2020, the Caregiver filed for guardianship of Patient #1. Shortly after that the HCPOA also filed for guardianship of Patient #1. On 11/10/2020, the guardianship hearing was held with the final verdict filed on 11/16/2020, with the HCPOA awarded guardianship. The medical record contained documentation on 11/23/20, that the HCPOA revoked hospice and Patient #1 was discharged from this agency. On 12/02/2020 at 9:15 AM, Staff A, Staff F, Staff G, and Staff H were interviewed by video conference. Staff A stated the medical record indicated that Staff I spoke to the HCPOA on 06/02/2020 and confirmed receipt of the power of attorney paperwork and sent the requested plan of care to the HCPOA. The Administrator stated that the agency contacted the HCPOA when they learned Patient #1 had one and provided the plan of care as requested which would indicate consent for care. Patient #1's primary alternate signed the consent as he/she was present on admission so they followed their policy regarding who could sign the consents. Staff F and H stated that both of Patient #1's adult children were updated, although they had to leave messages for the HCPOA who did not always return calls. Staff A stated that the HCPOA never stated he/she did not want hospice care or requested revocation of benefits until after the guardianship was settled and Patient #1 was discharged as requested. On 12/03/2020 at 3:25 PM, Staff A stated the medical record for Patient #1 did not state the HCPOA wanted updated on Patient #1's condition. In addition, Patient #1 was living with the first alternate health care power of attorney, who was updated and who was authorized to make health care decisions when the health care power of attorney was not available, so they were following their notification process. Staff A stated that the staff who took care of Patient #1 stated the HCPOA was not easily reached and did not return calls when they did attempt to reach him/her. Staff A acknowledged that the attempts to reach the HCPOA were not documented well. This substantiates Substantial Allegation OH00117191.