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
491584 A. BUILDING __________
B. WING ______________ 		09/28/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMEDISYS HOSPICE OF RICHMOND 9790 MIDLOTHIAN TURNPIKE, RICHMOND, VA, 23235
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)
L0505      
36944 Based on review of the agency's complaint log, clinical records and staff interview it was determined the agency failed to acknowledge a complaint voiced by a family member. Specifically, a complaint made by a family member for a patient was not documented in the agency's complaint log. The log failed to contain the complaint, investigation of the complaint or a resolution to the complaint. Client record #1. The findings: A review of the agency's complaint log on 9/27/2021 found an incomplete process for the acknowledgment of complaints, review of the investigation and complaint resolution. The agency's complaint log did not contain the complaints from patient #1's caregiver who was identified in the complaint for the certification period that services were rendered. 1. The clinical record for patient #1 was reviewed for the certification period of 3/19/2021 through 6/16/2021. The patient's sister was the primary caregiver. During the clinical record review several complaints were noted by the patient's sister in the SN (Skilled nurse) notes. Specific details: 3/23/2021 - CG (Caregiver) anxious and brought up issue with DME (Durable Medical Equipment) on admission and side rails yesterday. CG continues to be upset. CG left room and when she returned she was very upset that this RN (Registered Nurse) contacted (Hospice Medical Director) and not the patient's physician. Reported conserns [sic] with (Patient Case Manager) staff member #2. 3/24/2021 - CG reports that if proper side rails were in place this would not have happened (patient had fallen). 3/25/2021 - CG became angry and raised her voice, going back over everything that she felt or had discussed in prior visits. Felt this RN did not make medication changes appropriate the first day and that it was unacceptable. DME issues. MD (Medical Doctor) to get orders from PCP (Primary Care Physician) VS (verses) Hospice Medical Director. This MFI (Medical Facilities Inspector) interviewed the Area of Vice President of Operations on 9/28/2021 at 9:30 AM and asked why the complaints for patient #1 were not in the complaint log. The Area of Vice President Operations stated, at that time the Director of Operations (DOO) was not following our complaint process and did not follow up on complaints and so he was terminated. This MFI interviewed the Clinical Manager (staff member #2) on 9/28/2021 at 9:35 AM and asked why the complaints for patient #1 were not in the complaint log. The Clinical Manager stated, the patient's sister did call me and I notified the DOO of the complaints and he did not follow up and I did not document. The above noted findings regarding the deficient practice related to investigating complaints from the patient's family were acknowledged by the Area Vice President of Operations, Administrator and the Clinical Manager during the exit conference conducted on 9/28/2021.
L0531      
36944 Based on staff interview, clinical record review and the agency's bereavement policy it was determined the hospice failed to complete an initial bereavement assessment within five (5) calendar days of election of the hospice benefit in one (1) of six (6) clinical records reviewed in the survey sample. Clinical record # 1. The findings: Six (6) clinical records were reviewed in the agency on 9/27/2021 and 9/28/2021 with electronic read-only mode access. 1. The clinical record for patient #1 was reviewed for the certification period of 3/19/2021 through 6/16/2021. The clinical record failed to contain evidence an initial bereavement assessment had been completed. This MFI (Medical Facilities Inspector) interviewed the Area of Vice President Operations on 9/27/2021 at 1:30 PM and asked if the bereavement assessment had been done. The Area of Vice President Operations stated, it is not there. Select Agency Policy Review: A copy of the agency's comprehensive assessment policy and bereavement policy was provided on 9/27/2021 at 2:00 PM to the MFI (Medical Facilities Inspector). The policy was titled, "Core Services-Counseling Services TX-014" a select portion read as follows: "An initial bereavement assessment of the needs of the patient/family and other individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patient's death is performed within 5 days of admission and the information incorporated into hospice POC (plan of care) and considered in the bereavement POC". The lack of documentation of the initial bereavement assessment was confirmed during record review by the Area of Vice President Operations and again acknowledged during the exit conference on 9/28/2021 by the Area of Vice President Operations, Administrator and the Clinical Manager.
L0545      
36944 Based on clinical record review and staff interview it was determined the hospice agency failed to ensure each patient had an individualized plan of care based on the patients' needs and problems identified in the comprehensive assessment. Specifically, patients who were identified as falls risk in the initial comprehensive assessment failed to have interventions and goals added to the care plan for three (3) of six (6) clinical records in the survey sample. Clinical record #'s 1, 3, and 5. The findings: Six (6) clinical records were reviewed in the agency on 9/27/2021 and 9/28/2021 with electronic read-only mode access. The agency utilized falls risk factors that are categorized as follows: a. Low Risk..............0-6 points b. Moderate Risk......7-12 points c. High Risk...............13 and above 1. The clinical record for patient #1 was reviewed for the certification period of 3/19/2021 through 6/16/2021. The comprehensive initial assessment identified the patient as being a falls risk and the plan of care listed fall precautions however the plan of care failed to contain interventions and goals related to falls. In addition, the clinical record contained a comprehensive assessment on 3/19/2021 by the SN (Skilled Nurse) of a falls risk score of an 8 (moderate risk). On 3/24/2021 the clinical record contained a note of a reported fall and the SN documented the falls risk score of a 4 (low risk), and another reported fall on 3/25/2021 with a falls risk score of a 7 (moderate risk). The clinical record failed to contain the correct rating of the falls risk score according to the agency's policy and procedure. The rating should have been documented as a high risk after the reported patient falls. 2. The clinical record for patient #3 was reviewed for the certification period of 4/24/2021 through 7/22/2021. The comprehensive initial assessment identified the patient as being a falls risk and the plan of care listed falls precautions however the plan of care failed to contain interventions and goals related to falls. 3. The clinical record for patient #5 was reviewed for the certification period of 3/11/2021 through 6/08/2021. The comprehensive initial assessment identified the patient as being a fall risk and the plan of care listed fall precautions however the plan of care failed to contain interventions and goals related to falls. This MFI (Medical Facilities Inspector) interviewed the Area of Vice President Operations (AVPO) on 9/28/2021 at 9:35 AM and asked why was the falls risk on the comprehensive assessment but no interventions and goals on the plan of care related to falls. The AVPO stated, a nurse has to prompt the safety measures to carry over for subsequent visits. The AVPO agreed that the nurses had not prompted the falls risk. The lack of activating the falls risk was confirmed during record review by the Area of Vice President Operations and again acknowledged during the exit conference on 9/28/2021 by the Area of Vice President Operations, Administrator and the Clinical Manager.
L0548      
36944 Based on clinical record review and staff interview it was determined the hospice agency failed to ensure the documentation of measurable outcomes for each problem were documented on the plans of care for six (6) of six (6) records in the survey sample. Clinical record #'s 1-6. The findings: Six (6) clinical records were reviewed in the agency on 9/27/2021 and 9/28/2021 with electronic read-only mode access. 1. The clinical record for patient #1 was reviewed for the certification period of 3/19/2021 through 6/16/2021. The plan of care failed to contain measurable goals/outcomes. This MFI (Medical Facilities Inspector) interviewed the Area of Vice President Operations (AVPO) on 9/27/2021 at 4:00 PM and asked if she noticed the goals were not measurable. The MFI and AVPO reviewed patient #1's goals that were listed on the plan of care as follows: Pain will be managed at a level of acceptance to the patient (Identify acceptable pain level). There was no acceptable pain level documented. In addition, the other goals listed on the plan of care were as follows: A nursing plan of care will be established that meets the patient's needs; A Medical Social Worker plan of care will be established; A Chaplain plan of care will be established and patient will transition peacefully through the dying process. Again, the plan of care failed to contain measurable goals/outcomes and the AVPO agreed. 2. The clinical record for patient #2 was reviewed for the certification period of 6/24/2021 through 9/21/2021. The plan of care failed to contain measurable goals/outcomes. 3. The clinical record for patient #3 was reviewed for the certification period of 4/24/2021 through 7/22/2021. The plan of care failed to contain measurable goals/outcomes. 4. The clinical record for patient #4 was reviewed for the recertification period of 9/18/2021 through 11/16/2021. The plan of care failed to contain measurable goals/outcomes. 5. The clinical record for patient #5 was reviewed for the certification period of 3/11/2021 through 6/08/2021. The plan of care failed to contain measurable goals/outcomes. 6. The clinical record for patient #6 was reviewed for the recertification period of 5/17/2021 through 7/15/2021. The plan of care failed to contain measurable goals/outcomes The AVPO confirmed these finding during the record review and again acknowledged during the exit conference on 9/28/2021 by the Area of Vice President Operations, Administrator and the Clinical Manager.
L0552      
36944 Based on clinical record reviews and the agency's comprehensive assessment policy, it was determined the agency failed to ensure the hospice interdisciplinary group (IDG) revised each individualized plan of care as frequently as the patient's condition required in one (1) of six (6) clinical records reviewed in the survey sample. Clinical record 1. The findings: Six (6) clinical records were reviewed in the agency on 9/27/2021 and 9/28/2021 with electronic read-only mode access. 1. The clinical record for patient #1 was reviewed for the certification period of 3/19/2021 through 6/16/2021. The clinical record contained SN (Skilled Nurse) notes that the patient was continent of urine from 3/19/2021 (initial comprehensive assessment) to 3/22/2021. On 3/23/2021 the SN documented urinary incontinence, and again on 3/24/2021, 3/25/2021 and 3/26/2021. In addition, no caregiver urinary incontinence education was documented until the visit of 3/26/2021. The SN visit on 3/26/2021 contained documentation of the caregiver not wanting to move the patient around to clean up due to may cause patient to become uncomfortable. The SN educated the caregiver on the harsh effects of urine on the skin and assisted to give the patient a bed bath, apply clean clothes and perform a total bed change. The agency failed to revise the plan of care as needed to reflect the patient's condition change to incontinence. Select Agency Policy Review: A copy of the agency's comprehensive assessment policy was provided on 9/28/2021 to the MFI (Medical Facilities Inspector). The policy was titled, "Assessments AA-003" a select portion read as follows: "Updates to the comprehensive assessments are completed by the IDT (in collaboration with the patient's attending physician (if any) and considers changes that have taken place since the initial or last comprehensive assessment". The Area of Vice President Operations, Administrator and the Clinical Manager acknowledged these findings during the exit review on 9/28/2021.