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
491593 A. BUILDING __________
B. WING ______________ 		09/14/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
LEGACY HOSPICE 650 PETER JEFFERSON PARKWAY SUITE 310, CHARLOTTESVILLE, VA, 22911
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)
L0500      
36944 Based on clinical record reviews and staff interviews, it was determined the agency failed to ensure each patient received their medication for effective symptom management (refer to L512); The agency also failed to ensure each patient will be free from neglect (refer to L517). This condition was associated with a finding of Immediate Jeopardy identified by the MFI (Medical Facilities Inspector), was reported to the Office of Licensure and Certification (OLC), and reviewed by OLC management staff on September 9, 2021 at 11:00 AM. The Immediate Jeopardy (IJ), was related to a patient who did not receive their routine (daily) medications for 5 days while in respite care. The first instance of neglect, potential harm and the date immediate jeopardy began was documented in the clinical record of patient #1 on 2/17/2021. The patient's clinical record failed to contain fax transmittal documentation to verify the plan of care and medications were sent to the facility providing respite care. In addition, the patient's caregiver reported to the Skilled Nurse (SN) on 2/22/2021 (the 1st day back in routine care), that the patient did not receive any medications during time spent in respite care and the patient "seems off". The hospice agency submitted an acceptable plan for removal of the IJ at 1:33 PM on September 13, 2021. The Plan of Removal consisted of a revision to the previous respite policy to include; collaboration and communication of the patient's current hospice plan of care, current medication list and treatment orders will occur between the RN (Registered Nurse) Case Manager and the facility staff either in person or by phone on the day of transfer to the respite level of care. The hospice agency will also confirm with the facility providing respite care that in-person access will be granted 24/7 to the hospice team during the respite stay. A respite checklist shall be completed on all respite care patients the day of transfer to ensure communication and collaboration has occurred. The hospice agency will monitor implemented changes through supervisory visits to all patients receiving respite care. This will be reviewed daily on the team stand up call to ensure appropriate communication with facility. In addition, education was conducted with all agency clinicians via Microsoft Teams (virtual conference) to review the policy revisions, address communication and collaboration between the hospice agency and the facility providing respite care. All education has been completed by the exit conference except for the clinicians who are on vacation, medical leave or currently not working. Those employees will be required to complete the education before visiting patients. The QAPI manager will monitor the clinical records of patients who are identified as respite patients to ensure the revised policies are being followed until 100% compliance is achieved. This MFI confirmed that the agency has completed the plan for removal and the Immediate Jeopardy was abated on September 14, 2021 at 3:30 PM. The cumulative effect of these systemic problems resulted in the agency's inability to promote and protect patient rights.
L0512      
36944 Based on staff interviews and clinical record reviews, it was determined the agency failed to ensure each patient received their medication for effective symptom control/management from the hospice in one (1) of (5) clinical records for patients who were receiving respite care and were reviewed in the survey sample. Clinical record #1. The Findings: Fifteen (15) clinical records were reviewed in the agency on September 7-8 with staff member #3 as the electronic medical records navigator, and again on September 13-14, 2021 with staff member #6 as the electronic medical records navigator. Five (five) of the records reviewed were of patients who received respite care. The clinical record for patient #1 was reviewed for the certification period of 1/24/2021 through 3/12/2021 and contained diagnoses of COPD (Chronic Obstructive Pulmonary Disease) and Heart Failure. The clinical record contained Skilled Nurse (SN) documentation on 2/16/2021 of the patient's upcoming stay in respite care beginning 2/17/2021 at 10 AM. The next SN visit documentation was on 2/22/2021 when the patient returned to routine care from respite care (5 days later), and contained documentation of the caregiver's report that no medications were given to the patient during respite care and the patient "seems off". On 2/24/2021, the SN made another visit to see the patient and documented that the patient had a recent emergency department (ED) visit on 2/23/2021. The ED visit was due to caregiver wanting the patient checked out for a possible recent fall and not receiving medications during their recent respite stay. According to the emergency department visit on 2/23/2021, the documentation included diagnosis of: fall, confusion, weakness of both lower extremities and a urinary tract infection with an antibiotic prescription. On 9/7/2021, the hospice agency provided this MFI with the agency's call log for February of 2021. The call log revealed a call from a SN at the facility providing respite care to patient #1 on 2/18/2021 at 1:33 PM. The nurse was requesting all paper work for patient #1, this was day 2 of a 5 day stay. On 2/19/2021, at 8:52 AM another call was received requesting a hard copy of medications (referring to the comfort care medications that hospice uses to treat pain, anxiety and shortness of breath), this was day 3 of a 5 day stay. The MFI interviewed the Hospice Program Director on 9/7/2021 at 6:30 PM via telephone and asked what the process or procedure the hospice uses to ensure a patient going into respite care has their plan of care including their medications sent to the facility providing respite care. The Program Director stated, staff go into the office and fax it, but because of the weather the office was closed 2/17/2021 to 2/18/2021. The nurse said she sent the medication list through our software Netsmart, but this system does not have the capability to do that, so we asked her how she did it, and she said a HIPAA (Health Insurance Portability and Accountability Act) compliant app (software application designed to run on a mobile device such as a tablet) was downloaded to fax these records. In addition, the Program Director stated, we asked for the fax confirmation page from the nurse but she was unable to provide that. On 9/8/2021 at 12:00 PM the MFI requested the patient's records from the facility providing respite care to patient #1 to include everything sent by the hospice agency. The facility providing respite care to patient #1 provided a copy of the hospice agency's fax transmittal dated 2/18/2021 at 12:41 PM that was titled "Hospice Patient Order Form". The form included, oxygen at 2 lpm PRN (as needed) for dyspnea and medications for comfort care but no daily medications or a plan of care were included in the fax. There was no documented evidence to demonstrate the hospice agency provided the facility furnishing respite care to patient #1 a hospice plan of care or a daily/routine medication list for the time frame of 2/17/201 to 2/22/2021. The findings were reviewed with agency management to include the Regional Vice President (via telephone), the Program Director, and the Patient Care Manager in the agency on September 9, 2021 at 11:07 AM.
L0517      
36944 Based on staff interview and a review of clinical records it was determined the agency failed to ensure patients' rights were protected against neglect during a respite stay for one (1) of (5) patients who received respite care and whose records were in the survey sample. Clinical record #1. The findings: Fifteen (15) clinical records were reviewed in the agency on September 7-8 with staff member #3 as the electronic medical records navigator, and again on September 13-14, 2021 with staff member #6 as the electronic medical records navigator. Five (five) of the records reviewed were of patients who received respite care. The clinical record for patient #1 was reviewed for the certification period of 1/24/2021 through 3/12/2021. The clinical record contained Skilled Nurse (SN) documentation of the patient's upcoming respite stay beginning 2/17/2021 and returned home from respite care on 2/22/2021. On 9/7/2021, the hospice agency provided this MFI with the agency's call log for February of 2021. The call log revealed a call from a nurse at the facility providing respite care to patient #1 on 2/18/2021 at 1:33 PM. The nurse was requesting all paper work from the hospice agency for patient #1, this was day 2 of the 5 day stay. On 2/19/2021, at 8:52 AM another call was received requesting a hard copy of medications (referring to the comfort care medications that hospice uses to treat pain, anxiety and shortness of breath), this was day 3 of a 5 day stay The clinical records for patient #1 failed to contain evidence of any follow-up assessment during the 5 day respite stay even after becoming aware of the needed paperwork (plan of care and medication list) and a hard copy of medications via the call log. The MFI interviewed the Patient Care Manager (PCM) on 9/7/2021 at 3:45 PM regarding any SN visits or telephone calls to follow up on the patient were made to the respite care facility for patient #1. The PCM stated, respite patients meet their regular frequency as ordered but the facility would not let anyone in due to COVID-19 at that time. According to the clinical record no hospice nursing visits were made during the patient's stay in respite. The clinical record failed to contain a documented phone call or telehealth visit from the hospice agency to follow-up on the patient's care for the following respite days of 2/17/2021 to 2/21/2021 after becoming aware of medication issues per the hospice agency's call log.