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
361690 A. BUILDING __________
B. WING ______________ 		08/26/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MIDWEST HOSPICE INC 8050 BECKETT CENTER DRIVE, SUITE 220, WEST CHESTER, OH, 45069
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)
L0512      
21957 Based on medical record review and staff interview it was determined the agency failed to ensure the patient's rights to have effective symptom control specifically for the elimination process. This affected one of three (Patient #1) patient medical records reviewed. The patient census was 14. Findings include: During the review of Patient #1's medical record and specifically the nurse visits notes, it was found that the nurse visit notes dated 12/18/19 reveal Staff B provided the care and services that day. Staff B noted the "patient has not had a bowel movement in four days and the family is thinking about buying over the counter suppository to possibly relieve any pain. Patients abdomen is distended". The nurse visit notes do not document that Staff B contacted the physician to notify the physician of the problems identified and/or to received orders for comfort measures in regard to the patient's bowel regimen. A review of the medications for Patient #1 reveals Morphine Sulfate, a narcotic used for indications of pain or shortness of breath and Lorazepam Intensol used to relieve anxiety and restlessness. Both medications have as one of it's side effects, constipation. Phone interview with Staff A was conducted on 08/19/20 at 10:11 AM regarding the reason why the agency did not supply Patient #1 with stool softener medications as comfort measures to assist with the patients bowel regimen. Staff A explained the previous Medical Director neglected to order the stool softeners. A review of the care plan problems / interventions form dates on 12/18/19 the patient's family / caregivers were instructed in initial bowel regime as medication needs change but there was no mention of the agency providing those medications to assist Patient #1 with his bowel regimen. On the form Care Plan Problem Details last updated on 12/21/19 is a section that states "Hospice to assist in obtaining orders and coordinating care with patient, family, with facility staff and primary physician as well as hospice team". These findings were shared with Staff A on 08/24/20 at approximately 12:25 PM. Staff A confirmed this finding.
L0591      
21957 Based on medical record review and staff interview it was determined the agency failed to provide a skilled nurse for the majority of daily continuous care services. This affected one of three (Patient #1) patient medical records reviewed. The patient census was 14. Findings include: The medical record revealed Patient #1's physician ordered continuous care on 12/18/19. The continuous care log and time sheets reveal on 12/20/19 Staff D (former aide) provided services from 8:00 AM to 5:30 PM for a total of 9.5 hours. A visit note documented by Staff B (skilled nurse) reveals a visit was made on 12/20/19 from 3:45 PM to 4:30 PM for a total of 45 minutes. Review of the agency policy #806, original date July 2015, reveals the skilled nurse is to provide at least 51% of services during the daily continuous care services of whatever amount of hours of service are provided. This finding was shared with Staff A on 08/24/20 at approximately 2:30 PM. Staff A confirmed this finding.