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
391707 A. BUILDING __________
B. WING ______________ 		08/31/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VIAQUEST HOSPICE, LLC 610 PARK AVENUE, MONONGAHELA, PA, 15063
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)
L0545      
37775 Based on a review of agency policy, clinical record (CR), and staff interview, the facility failed to ensure the plan of care interventions included all services necessary for the management of a patient related condition based on the problems identified in the initial, comprehensive assessment for one (1) clinical record reviewed (CR1). Review of facility policy on 8/31/20 revealed the following: "...IDG (Interdisciplinary Group) CARE PLANNING PROCESS...PROCEDURE...2. The plan of care specifies the care and services necessary to meet the patient and family needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions...8. An individualized written plan of care is developed for each patient...includes all services necessary for the palliation and management of the terminal illness and related conditions..." Review of CR1 on-site on 8/28/20 and off site on 8/31/20 revealed the following: "...Hospice Initial Assessment...Date of Visit 3/15/2020...NUTRITION...Diet, Tube Feedings, and Supplements...Tube Feedings/Enteral (administration of feeding/fluid via a tube into the gastrointestinal tract)...Tube Feedings, Vital 1.5; 30 ml/hr (milliliters/hour)...Appetite...Poor..." Plan of Care (POC) Certification period 3/15/2020 to 6/12/2020: "...Primary Diagnosis:...Acute and chronic respiratory failure with hypoxia...Supplies:..Feeding Bags; Tubing...Dietary/Feeding Supplement...Nutrition: Tube Feeding; Other Vital 1.5; 30ml/hr...Orders Treatments:...Additional Services:...Enteral feeding 30cc/hr, Vital 1.5 plus 1 packet ProSource. Flush with water 200ml q6hrs (every 6 hours)..." POC Certification Period 6/13/2020 TO 9/10/2020: "...Primary Diagnosis:...Acute and chronic respiratory failure with hypoxia...Nutrition: Other Vital 1.5...Orders Treatments:...Additional Services:...Enteral feeding 30cc/hr, Vital 1.5 plus 1 packet ProSource. Flush with water 200ml q6hrs..." POC's reviewed did not identify documentation of interventions to manage/monitor patient Enteral-Tube/Enteral-tube feedings. Surveyor was unable to determine who was to manage/monitor Enteral-tube/Enteral-tube feedings. An exit interview was conducted via telephone on 8/31/2020 at approximately 1:20 PM with the facility administrator (EMP2) and regional director (EMP1). The above findings were reviewed.
L0550      
37775 Based on a review of agency policy, clinical record (CR), and staff interview, the facility failed to ensure documentation on the plan of care included the medical supplies and appliances necessary to meet the needs of the patient for one (1) clinical record reviewed (CR1). Findings included: Review of facility policy on 8/31/20 revealed the following: "...IDG (Interdisciplinary Group) CARE PLANNING PROCESS...PROCEDURE...2. The plan of care specifies the care and services necessary to meet the patient and family needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions...8. An individualized written plan of care is developed for each patient...includes all services necessary for the palliation and management of the terminal illness and related conditions...9. The IDG...reviews, revises and documents the individualized plan as frequently as the patient's condition requires...The revised plan of care includes information from the patient's updated comprehensive assessment..." Review of CR1 on-site on 8/28/20 and off site on 8/31/20 revealed the following: "...Hospice Initial Assessment...Date of Visit 3/15/2020... RESPIRATORY ...Findings/treatment ...Ventilator ...Oxygen Use...Frequency of use, Continuous, Equipment, Concentrator...NUTRITION ...Diet, Tube Feedings, and Supplements ...Tube Feedings/Enteral (administration of feeding/fluid via a tube into the gastrointestinal tract)...Tube Feedings, Vital 1.5; 30 ml/hr (milliliters/hour)..." Plan of Care (POC) Certification period 3/15/2020 to 6/12/2020: "...Primary Diagnosis:...Acute and chronic respiratory failure with hypoxia...Supplies: Hospital Bed; Skin Prep Wipes, Criticais; Trach Sponges: Catheters - Foley; Catheter Insertion Tray; feeding Bags; Tubing; Bed Rails; Dietary/Feeding Supplement; Pressure Release Mattress; Syringes; Toothettes; Moisture barrier (Cream/Ointment); Oxygen; Trach Care Kit; Gloves...Blue pads...Adult Diapers...Overbed Table; Other: Shampoo..deodorant...Nutrition: Tube Feeding; Other Vital 1.5; 30ml/hr...Orders Treatments:...Additional Services: Trilogy ventilator FiO2...Enteral feeding 30cc/hr, Vital 1.5 plus 1 packet ProSource. Flush with water 200ml q6hrs (every 6 hours)..." POC Certification Period 6/13/2020 TO 9/10/2020: "...Primary Diagnosis:...Acute and chronic respiratory failure with hypoxia...Supplies: Oxygen; Gloves - Non Sterile...Nutrition: Other Vital 1.5...Orders Treatments:...Additional Services: Trilogy ventilator FiO2...Enteral feeding 30cc/hr, Vital 1.5 plus 1 packet ProSource. Flush with water 200ml q6hrs..." POC certification periods reviewed above (3/15/2020 to 6/12/2020 and 6/13/2020 to 9/10/2020) did not identify the following DME under the heading of " Supplies ": Ventilator, Oxygen concentrator, and/or medical device for patient Enteral Tube Feeding that administered tube feedings at ordered rate of 30ml/hour. Additional review of POC certification period 6/13/2020 to 9/10/2020 revealed the POC did not document Durable Medical Equipment (DME) and supplies under the heading "Supplies" that was identified in the previous certification period 3/15/2020 to 6/12/2020. There was no documented evidence the POC was revised and/or updated that identified equipment and supplies from POC certification period 3/15/2020 to 6/12/2020 had been removed/discontinued. An exit interview was conducted via telephone on 8/31/2020 at approximately 1:20 PM with the facility administrator (EMP2) and regional director (EMP1). The above findings were reviewed.