Survey Report for 491593

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	491593	A. BUILDING __________ B. WING ______________	11/20/2019
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)
E0001
E0001	36946 Based on surveyor observation, document review, and interview it was determined the hospice failed to establish an emergency preparedness program that could be effectively implemented in the event of an emergency; the agency failed to maintain a list of active patients and their locations (see E018) and failed to have a system to preserve and/or access patient medical records in the event of the emergency (see E023). The cumulative effect of the lack of emergency planning resulted in the agency's overall inability to prepare for and respond to an emergency situation and jeopardized the quality of care provided to patients.
E0018
E0018	36946 Based on staff interview and document review, it was determined the agency failed to ensure its emergency preparedness plan contained a system to track the location of patients in the event of an emergency. Findings: During the entrance conference, the MFIs were informed by staff member #1, The Regional Vice President, that the agency's VPN (virtual private network) vendor had been subject to a ransomware attack on 11/17/2019. The staff member stated that the agency had no access to the electronic medical records at the time of entrance due to the VPN server being down. Staff member #1 stated there was no estimated timeframe given for restoration of service and access to the medical records. The MFI requested a list of the current active patients on 11/18/2019 at 12:00 PM. On 11/19/2019, the MFI again requested an active list of patients to include their location (facility or home) and what specialized assistance if any they might need in the event of an emergency. By the end of the day on 11/19/2019, the agency was unable to produce a list of their active patients or what specialized assistance the patients may need in the event of emergency. At the time of the exit conference on 11/20/19 the agency had not yet been able to produce a list of active patients and their locations. An interview was conducted with the Patient Care Manager (staff member #3) on 11/19/2019 at 2:00 PM. He/she stated that all of this information is stored in the electronic medical record system, which remained inaccessible for the duration of the survey. He/she stated that going forward, the agency plans to keep a paper copy that is printed each Friday with this information in the office. The Administrator acknowledged this deficiency during the exit conference on 11/20/19.
E0023
E0023	36946 Based on staff interview and document review it was determined the agency failed to ensure its emergency preparedness program contained a system of medical documentation that preserved patient information and a system of medical documentation that preserved patient information in the event of an emergency. Findings: During the entrance conference, the MFIs were informed by staff member #1 that the agency's VPN (virtual private network) vendor had been subject to a ransomware attack on 11/17/2019. The staff member stated that the agency had no access to the electronic medical records at the time of entrance due to the VPN server being down. Staff member #1 stated there was no estimated timeframe given for restoration of service and access to the medical records. The MFI requested a list of the current active patients on 11/18/2019 at 12:00 PM. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. Staff member #2 confirmed on November 17, 18, and 19 that the clinical staff had no access to the electronic medical record. He/she confirmed the staff was using paper to document their visit notes, but could not see the past record or access the electronic medical record. The agency's policy Cybersecurity Plan, a portion of the agency's Emergency Preparedness Plan, partially reads as follows: The Office Manager will contact Hospice IT. Corporate IT staff will be required for any interventions that may take place as well as escalating the issue if needed. In the event that the electronic medical record becomes inaccessible the Program Director will activate the emergency preparedness plan, During business hours, staff will return to the office and receive paper documentation to use until the system is operable once more. Visits will continue as scheduled. All paper documents will be uploaded to become part of the patient's medical record. The policy failed to address the process for backing up data in the event a cyberattack rendered the records inaccessible. An interview was conducted with the Regional Vice President (staff member #1) who stated that the agency's VPN vendor also was responsible for maintaining a backup of data. He/she stated that the back up server was in the same physical location as the main server and was also inaccessible. He/she stated that in the future, the agency would be looking for another way to back up data. The Administrator acknowledged this deficiency during the exit conference on 11/20/19.
L0500
L0500	36946 Based on staff interview and document review, it was determined the agency failed to promote and protect all patients' rights. The hospice failed inform each patient of their rights (see L501); failed to allow patients to exercise their rights if not adjudged as incompetent (see L507); failed to investigate all alleged violations involving neglect or physical abuse by anyone furnishing services on behalf of the hospice (see L509); and failed to provide adequate pain and symptom management to patients (see L512). The cumulative effect of this systemic problem resulted in the hospice programs inability to inform, promote, and protect patient rights.
L0501
L0501	36946 Based on staff interview and clinical record review it was determined that the hospice failed to inform the patient of his/her rights and to protect and promote the exercise of those rights in one (1) of five (5) records reviewed in the survey sample. Clinical record #3. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #3) assisting with the navigation of the electronic clinical record. The clinical record for patient #3 with an election of hospice benefit date of 09/04/2019 contained an Informed Consent and Election of Benefit form dated 09/04/2019. The form contained verification of receipt of the hospice's Notice of Privacy Practices, Hospice Service Guidelines, Patient Bill of Rights, Patient Concerns, and Management and Disposal of Controlled Drugs and Hazardous Waste. The patient's Power of Attorney signed the form. The Informed Consent and Election of Benefit form contained a section titled Reason Patient Unable to Sign. This section was blank with no documentation regarding why the patient was unable to sign. The Patient Care Manager stated that the marketer or liaison present for the signing of consents was supposed to document the reason the patient was unable to sign. He/she confirmed no documentation of the reason the patient was unable to sign was present in the clinical record. The MFI interviewed the Patient Care Manager regarding the process for obtaining patient consents for hospice at 1:55 PM on 11/19/2019. He/she stated that the marketers and liaisons obtain signatures on the consent forms. The MFI asked if the staff members who obtain consents had any procedures for determining a patient's ability to sign consents. The Patient Care Manager stated that the staff who obtain consents did not have a specific way to assess for orientation or cognition prior to obtaining consents. He/she stated if the patient had dementia-related diagnoses, the patient did not sign the consent. The clinical record contained a Do Not Resuscitate form dated 5/2/2019. The form reads as follows: the patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment of course of medical treatment. Patient #3 signed the Do Not Resuscitate form. The MFI reviewed the initial nursing visit assessment dated 09/05/2019. The nurse's assessment indicated that the patient was oriented to person, place, and situation. The nurse documented that the patient's verbalization was appropriate. The nurse documented that the patient received verbal instruction regarding musculoskeletal education and nutrition education and that patient demonstrated understanding through verbalization. The accompanying narrative nursing note reads as follows: answered questions appropriately ...patient knows date, president, and his surroundings. The initial social worker visit note dated 09/06/2019 reads as follows: patient was alert, oriented x 4. Orientation is determined by assessing the patient's ability to identify correctly person, place, time, and situation. The nursing assessment for the routine nursing visit dated 11/06/2019 reads as follows: oriented x 4. The patient care manager confirmed the clinical record contained no evidence of a reason that the patient did not sign the informed consents during record review on 11/19/2019. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0504
L0504	36946 Based on staff interview and clinical record review it was determined that the agency failed to obtain each patient's signature confirming that he/she had received a copy of rights and responsibilities in one (1) of five (5) clinical records reviewed in the survey sample. Clinical record #3. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The findings are as follows: 1. The clinical record for patient #3 with an election of hospice benefit date of 09/04/2019 contained an Informed Consent and Election of Benefit form dated 09/04/2019. The form contained verification of receipt of the hospice's Notice of Privacy Practices, Hospice Service Guidelines, Patient Bill of Rights, Patient Concerns, and Management and Disposal of Controlled Drugs and Hazardous Waste. The patient's legal representative, designated as his/her Power of Attorney, signed the form. The Informed Consent and Election of Benefit form contained a section titled, Reason Patient Unable to Sign. This section was blank with no documentation regarding why the patient was unable to sign. The Patient Care Manager stated that the marketer or liaison present for the signing of consents was responsible for documenting the reason the patient was unable to sign. He/she confirmed the record contained no documentation of the reason the patient was unable to sign. The MFI requested documentation of the patient's medical power of attorney at 1:00 PM on 11/19/2019 from the Patient Care Manager. He/She reported at 1:45 PM that the clinical record contained no evidence of a signed power of attorney. The MFI interviewed the Patient Care Manager regarding the process for obtaining patient consents for hospice at 1:55 PM on 11/19/2019. He/She stated that the marketers and liaisons get consents signed. The MFI asked if the staff members who obtain consents had any procedures for determining a patient's ability to sign consents. The Patient Care Manager stated that the staff who obtain consents did not have a specific way to assess for orientation or cognition prior to obtaining consents. He/She stated if the patient had dementia-related diagnoses, the patient did not sign the consent. The clinical record contained a Do Not Resuscitate form dated 5/2/2019. The form reads as follows: the patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment of course of medical treatment. Patient #3 signed the Do Not Resuscitate form. The MFI reviewed the initial nursing visit assessment dated 09/05/2019. The nurse's assessment indicated that the patient was oriented to person, place, and situation. The nurse documented that the patient's verbalization was appropriate. The nurse documented that the patient received verbal instruction regarding musculoskeletal education and nutrition education and that patient demonstrated understanding through verbalization. The accompanying narrative nursing note reads as follows: answered questions appropriately ...patient knows date, president, and his surroundings. The initial social worker visit note dated 09/06/2019 reads as follows: patient was alert, oriented x 4. Orientation is determined by assessing the patient's ability to identify correctly person, place, time, and situation. The nursing assessment for the routine nursing visit dated 11/06/2019 reads as follows: oriented x 4. The Administrator acknowledged the above noted deficiency during the exit conference on 11/20/19.
L0507
L0507	36946 Based on staff interviews and clinical record review, it was determined that the hospice failed to correctly identify the legal representative designated by the patient in accordance with state law to exercise the patient's rights to the extent allowed by state law in one (1) of five (5) records reviewed in the survey sample. Clinical record #3. Findings Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #3) assisting with the navigation of the electronic clinical record. The clinical record for patient #3 with a start of care date of 09/04/2019 contained an Informed Consent and Election of Benefit form dated 09/04/2019. The form contained verification of receipt of the hospice's Notice of Privacy Practices, Hospice Service Guidelines, Patient Bill of Rights, Patient Concerns, and Management and Disposal of Controlled Drugs and Hazardous Waste. The patient's Power of Attorney signed the form. The Informed Consent and Election of Benefit form contained a section titled Reason Patient Unable to Sign. This section was blank with no documentation regarding why the patient was unable to sign. The Patient Care Manager stated that the marketer or liaison present for the signing of consents was responsible for documenting the reason the patient was unable to sign. He/she confirmed no documentation of the reason the patient was unable to sign was present in the clinical record. The MFI interviewed the Patient Care Manager regarding the process for obtaining patient consents for hospice at 1:55 PM on 11/19/2019. He/She stated that the marketers and liaisons get consents signed. The MFI asked if the staff members who obtain consents had any procedures for determining a patient's ability to sign consents. The Patient Care Manager stated that the staff who obtain consents did not have a specific way to assess for orientation or cognition prior to obtaining consents. He/She stated if the patient had dementia-related diagnoses, the patient did not sign the consent. The clinical record contained a Do Not Resuscitate form dated 5/2/2019. The form reads as follows: the patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment of course of medical treatment. Patient #3 signed the Do Not Resuscitate form. The MFI reviewed the initial nursing visit assessment dated 09/05/2019. The nurse's assessment indicated that the patient was oriented to person, place, and situation. The nurse documented that the patient's verbalization was appropriate. The nurse documented that the patient received verbal instruction regarding musculoskeletal education and nutrition education and that patient demonstrated understanding through verbalization. The accompanying narrative nursing note reads as follows: answered questions appropriately ...patient knows date, president, and his surroundings. The initial social worker visit note dated 09/06/2019 reads as follows: patient was alert, oriented x 4. Orientation is determined by assessing the patient's ability to identify correctly person, place, time, and situation. The nursing assessment for the routine nursing visit dated 11/06/2019 reads as follows: oriented x 4. The patient care manager confirmed the clinical record contained no evidence of a reason that the patient did not sign the informed consents during record review on 11/19/2019. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0509
L0509	36946 Based on staff interview, document review, and clinical record review, it was determined the agency failed to investigate all alleged violations involving neglect or physical abuse by anyone furnishing services on behalf of the hospice in one (1) of five (5) clinical records reviewed in the survey sample. Clinical record #1. Findings: 1. Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. The requested records were reviewed utilizing the offline version of the medical record. Selected information to include signed orders and data obtained from the last several days was not available to the surveyors for review. Additionally, staff member #2 stated that patients discharged for longer than six months would not appear in the offline record. 1. The clinical record for patient #1 contained a signed consent and an election of hospice benefit dated 07/26/2019. The patient's admission diagnosis was Alzheimer's disease. The clinical record contained documentation of a nursing visit made by the case manager on 08/23/2019. The nursing note indicated the patient had a pain level of 1 on a 0-10 scale. The nursing note dated 08/23/19 partially reads as follows: Nurse at facility calling to report change. Patient has had a change since yesterday, Lethargic, no intake today, temp 100; slightly increased HR (heart rate)...Patient in bed comfortable, declined need for narcotic tonight. The clinical record indicated the nurse made a visit on 08/24/2019 at 10:15 AM. The clinical record indicated the facility staff reported the patient had been "screaming all night." The nurse called the nurse practitioner at this visit and obtained an order for Morphine. The clinical record note for this visit contained no evidence a pain assessment was completed by the nurse. The on call log contained a call from the patient's family at 11:40 AM that reads as follows, "Morphine is not calming her." The log indicated the message was forwarded to the on call nurse. The clinical record indicated the nurse called the facility at 11:44 AM to check on the patient and morphine order. The facility staff indicated they were having trouble getting the medication from their own facility supply and the morphine for the patient had not yet arrived from the pharmacy. The clinical record contained evidence the nurse called the patient's family at 1:08 PM to check on the patient. The note from this time stated that the patient was rigid and yelling out every 15 minutes or so. The nurse documented he/she would call the nurse practitioner and have the morphine dose increased. The clinical record contained no documentation of another visit at this time or of a pain assessment for the patient. The clinical record contained a note from the nurse at 1:15 PM that stated the morphine had been ordered from the facility pharmacy but there is no guarantee when the morphine will get there. The hospice nurse offered to obtain the medication from an alternate pharmacy but the facility stated that was not allowed. The clinical record also contained documentation that the facility was having difficulty getting the morphine in the meantime from their own supply. A one time code was required to be released from the pharmacy each time a dose was needed and the nurses were having difficulty obtaining the code. The medical record failed to contain documentation as to whether or not any morphine had been administered at this time. The clinical record contained documentation that the patient's family member texted the nurse and "is very upset I have not called back - I explain through text (while on hold for a pharmacist) that I am stuck on the phone with pharmacy and that I had gotten new orders and am working on getting medication and will call when done." The clinical record contained documentation by the nurse timed for 1:45 PM on 08/24/19 that the nurse called the family to let them know medication was on the way but it may take some time and that the family is frustrated. The clinical record indicated the nurse made a second visit to the patient on 8/24/2019 at 3:30 PM. During this visit the patient was given 0.5mL of Morphine. The visit note failed to contain documentation of a pain assessment of the patient. The clinical record indicated the nurse called to check on the patient at 7:00 PM and that the Morphine and Ativan ordered for the patient had still not been delivered to the facility. The nurse called the nurse practitioner to request scheduling morphine, but the nurse practitioner declined to give morphine at scheduled doses and was "very upset" the morphine had not gotten to the facility. The note stated that the daughter stated the patient seemed comfortable. The clinical record contained notes from 9:00 PM to Midnight on 8/24/2019 indicating several continued attempts by the hospice nurse to obtain morphine and ativan from different pharmacies as the facility pharmacy had not delivered the medications. The record indicated that a nurse from the facility went to the hospital pharmacy after his/her scheduled shift and obtained the morphine for the patient at 10:56 P.M. The patient died on 08/25/2019 at 2:02 PM. The facility staff pronounced the patient's death and declined a visit from hospice staff according to the clinical record. Complaint Log Review: The complaint log from the last year was reviewed in the agency on 11/18/19. The complaint log failed to contain evidence of documentation of any complaints related to patient #1, despite nursing documentation stating the family was "very upset" regarding the patient's unmanaged pain. Interview: An interview with staff member #2, the Patient Care Manager was conducted on 11/19/19 at 12:00 PM regarding the patient's unmanaged pain not being documented as investigated in the complaint log. The Patient Care Manager stated that he/she was aware of the family's concern, but did not document it in the complaint log. He/she stated that the family member could not "decide if it was our fault [the hospice's] or the nursing home's fault. They kept going back and forth on who was to blame." The complaint was not documented in the log because "it was not an official complaint" and the family requested no further contact from the hospice. Personnel File Review: The personnel file for the nurse (staff member #5) caring for patient #1 was reviewed in the agency on 11/18-19/2019. The personnel file contained a form, Employee Warning Notice stating that the agency received a complaint regarding the nurse from the facility patient #1 resided in. The form contained documentation of multiple issues with the pharmacy, a delay in receiving medications, and stated the nurse was "rude and poorly managed patient with lacking emotional support." The form contained documentation that the Administrator spoke with the family member of patient #1 who was "hysterical" and "very upset." Policy and Procedure Review: The policy, Patient Complaint /Grievance Reporting was reviewed on 11/19/2019. The policy partially reads as follows: any employee or volunteer receiving a complaint /grievance will complete and submit the complaint/grievance form and submit to the Director of Clinical Services within 24 hours. If the complaint/grievance is received after business hours, the manager on call will be notified verbally and the complaint/grievance from will be submitted the next business day. All complaints are documented in a complaint log by the Director of Clinical Services no more than five (5) business days from the date the complaint was first received. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0512
L0512	36946 Based on staff interview and clinical record review, it was determined the agency failed to ensure each patient received effective pain management and symptom control from the hospice in one (1) of five (5) clinical records reviewed in the survey sample. Clinical record #1. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. The requested records were reviewed utilizing the offline version of the medical record. Selected information to include signed orders and data obtained from the last several days was not available to the surveyors for review. Additionally, staff member #2 stated that patients discharged for longer than six months would not appear in the offline record. 1. The clinical record for patient #1 contained a signed consent and an election of hospice benefit dated 07/26/2019. The patient's admission diagnosis was Alzheimer's disease. The clinical record contained documentation of a nursing visit made by the case manager on 08/23/2019. The nursing note indicated the patient had a pain level of 1 on a 0-10 scale. The nursing note dated 08/23/19 partially reads as follows: Nurse at facility calling to report change. Patient has had a change since yesterday, Lethargic, no intake today, temp 100; slightly increased HR (heart rate)...Patient in bed comfortable, declined need for narcotic tonight. The clinical record indicated the nurse made a visit on 08/24/2019 at 10:15 AM. The clinical record indicated the facility staff reported the patient had been "screaming all night." The nurse called the nurse practitioner at this visit and obtained an order for Morphine. The clinical record note for this visit contained no evidence a pain assessment was completed by the nurse. The on call log contained a call from the patient's family at 11:40 AM that reads as follows, "Morphine is not calming her." The log indicated the message was forwarded to the on call nurse. The clinical record indicated the nurse called the facility at 11:44 AM to check on the patient and morphine order. The facility staff indicated they were having trouble getting the medication from their own facility supply and the morphine for the patient had not yet arrived from the pharmacy. The clinical record contained evidence the nurse called the patient's family at 1:08 PM to check on the patient. The note from this time stated that the patient was rigid and yelling out every 15 minutes or so. The nurse documented he/she would call the nurse practitioner and have the morphine dose increased. The clinical record contained no documentation of another visit at this time or of a pain assessment for the patient. The clinical record contained a note from the nurse at 1:15 PM that stated the morphine had been ordered from the facility pharmacy but there is no guarantee when the morphine will get there. The hospice nurse offered to obtain the medication from an alternate pharmacy but the facility stated that was not allowed. The clinical record also contained documentation that the facility was having difficulty getting the morphine in the meantime from their own supply. A one time code was required to be released from the pharmacy each time a dose was needed and the nurses were having difficulty obtaining the code. The medical record failed to contain documentation as to whether or not any morphine had been administered at this time. The clinical record contain documentation that the patient's family member texted the nurse and "is very upset I have not called back - I explain through text (while on hold for a pharmacist) that I am stuck on the phone with pharmacy and that I had gotten new orders and am working on getting medication and will call when done." The clinical record contained documentation by the nurse timed for 1:45 PM on 08/24/19 that the nurse called the family to let them know medication was on the way but it may take some time and that the family is frustrated. The clinical record indicated the nurse made a second visit to the patient on 8/24/2019 at 3:30 PM. During this visit the patient was given 0.5mL of Morphine. The visit note failed to contain documentation of a pain assessment of the patient. The clinical record indicated the nurse called to check on the patient at 7:00 PM and that the Morphine and Ativan ordered for the patient had still not been delivered to the facility. The nurse called the nurse practitioner to request scheduling morphine, but the nurse practitioner declined to give morphine at scheduled doses and was "very upset" the morphine had not gotten to the facility. The note stated that the daughter stated the patient seemed comfortable. The clinical record contained notes from 9:00 PM to Midnight on 8/24/2019 indicating several continued attempts by the hospice nurse to obtain morphine and ativan from different pharmacies as the facility pharmacy had not delivered the medications. The record indicated that a nurse from the facility went to the hospital pharmacy after his/her scheduled shift and obtained the morphine for the patient at 10:56 P.M. The patient died on 08/25/2019 at 2:02 PM. The facility staff pronounced the patient's death and declined a visit from hospice staff according to the clinical record. The clinical record failed to contain evidence that a pain assessment was completed at any time during the visits and calls made by the nurse on 8/24/2019. The clinical record failed to contain evidence that comfort medications were provided in a timely manner to the patient. Interview: An interview was conducted with the on call nurse (staff member #5) caring for patient #1 on 11/19/2019 at 2:00 PM regarding patient #1 and the weekend of August 24, 2019. The nurse stated that the facility had recently switched pharmacies in order to get medications faster and that the new pharmacy was taking a long time to get medicine. The nurse stated that he/she offered to obtain morphine from another pharmacy but the facility stated it was against their rules. The nurse stated that the facility pharmacy was supposed to send the morphine "stat" but gave no estimated time of arrival. The nurse stated he/she had not worked with this pharmacy before. The MFI asked if the patient was in pain on Saturday August 24 with the nurse visited the patient. He/she stated that the patient would yell out and cry every fifteen (15) minutes or so, but it appeared the patient's pain was emotional, not physical. An interview with staff member #2, the Patient Care Manager was conducted on 11/19/19 at 12:00 PM regarding obtaining medication after hours for facility patients. The Patient Care Manager stated that the hospice does not use comfort kits as this is the preference of their medical director and most of the team physicians. The hospices practice is to not have pre-ordered medication, but they will "prep in advance." He/she stated by the end of the week case managers ensure that all medications are refilled and some facilities will allow outside pharmacies to sent in STAT pain medication, but other facilities will only use their own pharmacy. He/she stated at the time that particular facility did not allow medication from outside pharmacies in the facility. He/she stated since this occurrence, there was a meeting with that facility and outside medications are now permitted. Policy and Procedure Review: The policy Pain and Symptom Management was reviewed on 11/19/2019. The policy partially reads as follows: pain is reassessed during every home visit, any time a patient states that/his her pain level has changed, and whenever pain medications or dosages are changed. This information is documented in the patient's clinical record. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0558
L0558	36946 Based on staff interview and document review, it was determined the agency failed to ensure coordination of care to include ongoing sharing of information with non-hospice providers furnishing services to patients in one (1) of five (5) clinical records reviewed in the survey sample. Clinical record #1. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. The requested records were reviewed utilizing the offline version of the medical record. Selected information to include signed orders and data obtained from the last several days was not available to the surveyors for review. Additionally, staff member #2 stated that patients discharged for longer than six months would not appear in the offline record. 1. The clinical record for patient #1 contained a signed consent and an election of hospice benefit dated 07/26/2019. The patient's admission diagnosis was Alzheimer's disease. The clinical record contained documentation of a nursing visit made by the case manager on 08/23/2019. The nursing note indicated the patient had a pain level of 1 on a 0-10 scale. The nursing note dated 08/23/19 partially reads as follows: Nurse at facility calling to report changed. Patient has had a change since yesterday, Lethargic, no intake today, temp 100; slightly increased HR (heart rate)...Patient in bed comfortable, declined need for narcotic tonight. The clinical record indicated the nurse made a visit on 08/24/2019 at 10:15 AM. The clinical record indicated the facility staff reported the patient had been "screaming all night." The nurse called the nurse practitioner at this visit and obtained an order for Morphine. The clinical record note for this visit contained no evidence a pain assessment was completed by the nurse. The on call log contained a call from the patient's family at 11:40 AM that reads as follows, "Morphine is not calming her." The log indicated the message was forwarded to the on call nurse. The clinical record indicated the nurse called the facility at 11:44 AM to check on the patient and morphine order. The facility staff indicated they were having trouble getting the medication from their own facility supply and the morphine for the patient had not yet arrived from the pharmacy. The clinical record contained evidence the nurse called the patient's family at 1:08 PM to check on the patient. The note from this time stated that the patient was rigid and yelling out every 15 minutes or so. The nurse documented he/she would call the nurse practitioner and have the morphine dose increased. The clinical record contained no documentation of another visit at this time or of a pain assessment for the patient. The clinical record contained a note from the nurse at 1:15 PM that stated the morphine had been ordered from the facility pharmacy but there is no guarantee when the morphine will get there. The hospice nurse offered to obtain the medication from an alternate pharmacy but the facility stated that was not allowed. The clinical record also contained documentation that the facility was having difficulty getting the morphine in the meantime from their own supply. A one time code was required to be released from the pharmacy each time a dose was needed and the nurses were having difficulty obtaining the code. The medical record failed to contain documentation as to whether or not any morphine had been administered at this time. The clinical record contained documentation that the patient's family member texted the nurse and "is very upset I have not called back - I explain through text (while on hold for a pharmacist) that I am stuck on the phone with pharmacy and that I Had gotten new orders and am working on getting medication and will call when done." The clinical record contained documentation by the nurse timed for 1:45 PM on 08/24/19 that the nurse called the family to let them know medication was on the way but it may take some time and that the family is frustrated. The clinical record indicated the nurse made a second visit to the patient on 8/24/2019 at 3:30 PM. During this visit the patient was given 0.5mL of Morphine. The visit note failed to contain documentation of a pain assessment of the patient. The clinical record indicated the nurse called to check on the patient at 7:00 PM and that the Morphine and Ativan ordered for the patient were had still not been delivered to the facility. The nurse called the nurse practitioner to request scheduling morphine, but the nurse practitioner declined to give morphine at scheduled doses and was "very upset" the morphine had not gotten to the facility. The note stated that the daughter stated the patient seemed comfortable. The clinical record contained notes from 9:00 PM to Midnight on 8/24/2019 indicating several continued attempts by the hospice nurse to obtain morphine and ativan from different pharmacies as the facility pharmacy had not delivered the medications. The record indicated that a nurse from the facility went to the hospital pharmacy after his/her scheduled shift and obtained the morphine for the patient at 10:56 P.M. The clinical record failed to contain evidence that care was coordinated with the nursing facility to include the process for obtaining medications to alleviate patients symptoms when needed. Interview: An interview was conducted with the on call nurse (staff member #5) caring for patient #1 on 11/19/2019 at 2:00 PM regarding patient #1 and the weekend of August 24, 2019. The nurse stated that the facility had recently switched pharmacies in order to get medications faster and that the new pharmacy was taking a long time to get medicine. The nurse stated that he/she offered to obtain morphine from another pharmacy but the facility stated it was against their rules. The nurse stated that the facility pharmacy was supposed to send the morphine "stat" but gave no estimated time of arrival. The nurse stated he/she had not worked with this pharmacy before. The MFI asked if the patient was in pain on Saturday August 24 with the nurse visited the patient. He/she stated that the patient would yell out and cry every fifteen (15) minutes or so, but it appeared the patient's pain was emotional, not physical. An interview with staff member #2, the Patient Care Manager was conducted on 11/19/19 at 12:00 PM regarding obtaining medication after hours for facility patients. The Patient Care Manager stated that the hospice does not use comfort kits as this is the preference of their medical director and most of the team physicians. The hospices practice is to not have pre-ordered medication, but they will "prep in advance." He/she stated by the end of the week case managers ensure that all medications are refilled and some facilities will allow outside pharmacies to sent in STAT pain medication, but other facilities will only use their own pharmacy. He/she stated at the time that particular facility did not allow medication from outside pharmacies in the facility. He/she stated since this occurrence, there was a meeting with that facility and outside medications are now permitted. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0625
L0625	36946 Based on staff interview and clinical record review, it was determined the hospice failed to ensure hospice aides had accurate and complete written patient care instructions prepared by a registered nurse (RN) who is responsible for the supervision of the hospice aide in one (1) of three (3) records reviewed in the survey sample receiving care from a hospice aide. Three (3) of five (5) records reviewed contained orders for hospice aide services. One (1) of three (3) of these records failed to contain complete written care instructions to the aide. Clinical record #3. Findings: The clinical record for patient #3 and an election of hospice benefit date of 09/04/2019 contained a care plan for the aide written by the RN for the benefit period of 09/04/2019-12/02/2019. The aide care plan contained a list of tasks for the aide to perform. The aide care plan contained no frequencies for these tasks. Additionally, the aide care plan tasked the aide with the following; "Assess patient/family ability to provide effective personal care." The task of patient assessment was inappropriately delegated to the aide by the RN. (According to Va Code §54.1-3005(12) and Virginia Board of Nursing Regulations, delegation of nursing tasks by the RN to unlicensed personnel cannot include activities or procedures involving assessment, evaluation or nursing judgment.) The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0648
L0648	36946 Based on staff interview and document review, it was determined the hospice failed to organize and administer services to ensure the highest quality care to patients. The hospice failed to ensure drugs were available on a 24/7 basis to alleviate patient's symptoms (see L653); failed to ensure its lines of authority were clearly delineated (see L658); failed to monitor and manage all services to ensure that services are delivered in a safe and effective manner (see L660); and failed to assess the skills and competence of all individuals furnishing care (see L663). The cumulative effect of this systemic problem resulted in the overall inadequate management and organizational environment limiting the hospice's ability to provide quality care to its patients.
L0653
L0653	36946 Based on staff interview and clinical record review, it was determined the agency failed to ensure drugs and biologicals were made available on a 24 hour basis, 7 days per week in one (1) of five (5) clinical records reviewed in the survey sample. Clinical record #1. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. The requested records were reviewed utilizing the offline version of the medical record. Selected information to include signed orders and data obtained from the last several days was not available to the surveyors for review. Additionally, staff member #2 stated that patients discharged for longer than six months would not appear in the offline record. 1. The clinical record for patient #1 contained a signed consent and an election of hospice benefit dated 07/26/2019. The patient's admission was diagnosis Alzheimer's disease. The clinical record contained documentation of a nursing visit made by the case manager on 08/23/2019. The nursing note indicated the patient had a pain level of 1 on a 0-10 scale. The nursing note dated 08/23/19 partially reads as follows: Nurse at facility calling to report changed. Patient has had a change since yesterday, Lethargic, no intake today, temp 100; slightly increased HR (heart rate)...Patient in bed comfortable, declined need for narcotic tonight. The clinical record indicated the nurse made a visit on 08/24/2019 at 10:15 AM. The clinical record indicated the facility staff reported the patient had been "screaming all night." The nurse called the nurse practitioner at this visit and obtained an order for Morphine. The clinical record note for this visit contained no evidence a pain assessment was completed by the nurse. The on call log contained a call from the patient's family at 11:40 AM that reads as follows, "Morphine is not calming her." The log indicated the message was forwarded to the on call nurse. The clinical record indicated the nurse called the facility at 11:44 AM to check on the patient and morphine order. The facility staff indicated they were having trouble getting the medication from their own facility supply and the morphine for the patient had not yet arrived from the pharmacy. The clinical record contained evidence the nurse called the patient's family at 1:08 PM to check on the patient. The note from this time stated that the patient was rigid and yelling out every 15 minutes or so. The nurse documented he/she would call the nurse practitioner and have the morphine dose increased. The clinical record contained no documentation of another visit at this time or of a pain assessment for the patient. The clinical record contained a note from the nurse at 1:15 PM that stated the morphine had been ordered from the facility pharmacy but there is no guarantee when the morphine will get there. The hospice nurse offered to obtain the medication from an alternate pharmacy but the facility stated that was not allowed. The clinical record also contained documentation that the facility was having difficulty getting the morphine in the meantime from their own supply. A one time code was required to be released from the pharmacy each time a dose was needed and the nurses were having difficulty obtaining the code. The clinical record failed to contain documentation as to whether or not any morphine had been administered at this time. The clinical record contained documentation that the patient's family member texted the nurse and "is very upset I have not called back - I explain through text (while on hold for a pharmacist) that I am stuck on the phone with pharmacy and that I had gotten new orders and am working on getting medication and will call when done." The clinical record contained documentation by the nurse timed for 1:45 PM on 08/24/19 that the nurse called the family to let them know medication was on the way but it may take some time and that the family is frustrated. The clinical record indicated the nurse made a second visit to the patient on 8/24/2019 at 3:30 PM. During this visit the patient was given 0.5mL of Morphine. The visit note failed to contain documentation of a pain assessment of the patient. The clinical record indicated the nurse called to check on the patient at 7:00 PM and that the Morphine and Ativan ordered for the patient had still not been delivered to the facility. The nurse called the nurse practitioner to request scheduling morphine, but the nurse practitioner declined to give morphine at scheduled doses and was "very upset" the morphine had not gotten to the facility. The note stated that the daughter stated the patient seemed comfortable. The clinical record contained notes from 9:00 PM to Midnight on 8/24/2019 indicating several continued attempts by the hospice nurse to obtain morphine and ativan from different pharmacies as the facility pharmacy had not delivered the medications. The record indicated that a nurse from the facility went to the hospital pharmacy after his/her scheduled shift and obtained the morphine for the patient at 10:56 P.M. The clinical record contained documentation that it took approximately 12 hours from the time the morphine was ordered for the hospice to obtain the medication for the patient's comfort. Interview: An interview was conducted with the on call nurse (staff member #5) caring for patient #1 on 11/19/2019 at 2:00 PM regarding patient #1 and the weekend of August 24, 2019. The nurse stated that the facility had recently switched pharmacies in order to get medications faster and that the new pharmacy was taking a long time to get medicine. The nurse stated that he/she offered to obtain morphine from another pharmacy but the facility stated it was against their rules. The nurse stated that the facility pharmacy was supposed to send the morphine "stat" but gave no estimated time of arrival. The nurse stated he/she had not worked with this pharmacy before. The MFI asked if the patient was in pain on Saturday August 24 with the nurse visited the patient. He/she stated that the patient would yell out and cry every fifteen (15) minutes or so, but it appeared the patient's pain was emotional, not physical. An interview with staff member #2, the Patient Care Manager was conducted on 11/19/19 at 12:00 PM regarding obtaining medication after hours for facility patients. The Patient Care Manager stated that the hospice does not use comfort kits as this is the preference of their medical director and most of the team physicians. The hospices practice is to not have pre-ordered medication, but they will "prep in advance." He/she stated by the end of the week case managers ensure that all medications are refilled and some facilities will allow outside pharmacies to sent in STAT pain medication, but other facilities will only use their own pharmacy. He/she stated at the time that particular facility did not allow medication from outside pharmacies in the facility. He/she stated since this occurrence, there was a meeting with that facility and outside medications are now permitted. Policy Review The policy Availability 24/7 was reviewed in the agency on 11/19/2019. The policy partially reads as follows, "Physician services, nursing services, including home visits when needed, drugs and biological's are available 24 hours a day/7 days a week. Legacy Hospice maintains a contract with a pharmacy or pharmacies in order to assure that medication is available 24/7. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0658
L0658	36946 Based on staff interview and document review, it was determined the agency failed to ensure that its lines of authority and professional and administrative control were clearly delineated in the hospice's organizational structure and in practice. Findings: During the entrance conference, staff member #1, Regional Vice President stated that he/she was the Alternate Administrator for all of the hospice's multiple locations. The MFI's reviewed an undated organizational chart provided by the agency that indicated this employee was the Alternate Administrator. During an interview with staff member #3, the Patient Care Manager at 2:00 PM on 11/19/2019 he/she stated that he/she was the Alternate Administrator. The MFI stated that during the entrance conference staff member #1 stated he/she was the Alternate Administrator. Staff member #3 stated that was incorrect. The personnel file for the Regional Vice President (staff member #1) was reviewed and failed to contain evidence of a job description for the Alternate Administrator. The personnel file for the Clinical Manager (staff member #2) contained a signed job description for the Alternate Administrator. This was not reflected on the agency's organizational chart. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0660
L0660	36946 Based on staff interview and clinical record review, it was determined the agency failed to ensure services were delivered in a safe and effective manner to ensure each patient receives necessary services in one (1) out of five (5) clinical records reviewed in the survey sample. Clinical record #1. Findings: Five (5) clinical records were reviewed in the agency on 11/19/2019 with the Patient Care Manager (staff member #2) assisting with the navigation of the electronic record. The agency had no live access to any clinical records during the survey due to inability to access the VPN and electronic record because of a cyberattack. On 11/19/2019 staff member #2 stated that two on call nurses had the ability to access an offline version of the clinical records. He/she stated this method of viewing the record was being phased out, but on call nurses still had their access. The remainder of the clinical and supervisory staff were completely unable to access patient records. The requested records were reviewed utilizing the offline version of the medical record. Selected information to include signed orders and data obtained from the last several days was not available to the surveyors for review. Additionally, staff member #2 stated that patients discharged for longer than six months would not appear in the offline record. 1. The clinical record for patient #1 contained a signed consent and an election of hospice benefit dated 07/26/2019. The patient's admission diagnosis Alzheimer's disease. The clinical record contained documentation of a nursing visit made by the case manager on 08/23/2019. The nursing note indicated the patient had a pain level of 1 on a 0-10 scale. The nursing note dated 08/23/19 partially reads as follows: Nurse at facility calling to report changed. Patient has had a change since yesterday, Lethargic, no intake today, temp 100; slightly increased HR (heart rate)...Patient in bed comfortable, declined need for narcotic tonight. The clinical record indicated the nurse made a visit on 08/24/2019 at 10:15 AM. The clinical record indicated the facility staff reported the patient had been "screaming all night." The nurse called the nurse practitioner at this visit and obtained an order for Morphine. The clinical record note for this visit contained no evidence a pain assessment was completed by the nurse. The on call log contained a call from the patient's family at 11:40 AM that reads as follows, "Morphine is not calming her." The log indicated the message was forwarded to the on call nurse. The clinical record indicated the nurse called the facility at 11:44 AM to check on the patient and morphine order. The facility staff indicated they were having trouble getting the medication from their own facility supply and the morphine for the patient had not yet arrived from the pharmacy. The clinical record contained evidence the nurse called the patient's family at 1:08 PM to check on the patient. The note from this time stated that the patient was rigid and yelling out every 15 minutes or so. The nurse documented he/she would call the nurse practitioner and have the morphine dose increased. The clinical record contained no documentation of another visit at this time or of a pain assessment for the patient. The clinical record contained a note from the nurse at 1:15 PM that stated the morphine had been ordered from the facility pharmacy but there is no guarantee when the morphine will get there. The hospice nurse offered to obtain the medication from an alternate pharmacy but the facility stated that was not allowed. The clinical record also contained documentation that the facility was having difficulty getting the morphine in the meantime from their own supply. A one time code was required to be released from the pharmacy each time a dose was needed and the nurses were having difficulty obtaining the code. The medical record failed to contain documentation as to whether or not any morphine had been administered at this time. The clinical record contain documentation that the patient's family member texted the nurse and "is very upset I have not called back - I explain through text (while on hold for a pharmacist) that I am stuck on the phone with pharmacy and that I had gotten new orders and am working on getting medication and will call when done." The clinical record contained documentation by the nurse timed for 1:45 PM on 08/24/19 that the nurse called the family to let them know medication was on the way but it may take some time and that the family is frustrated. The clinical record indicated the nurse made a second visit to the patient on 8/24/2019 at 3:30 PM. During this visit the patient was given 0.5mL of Morphine. The visit note failed to contain documentation of a pain assessment of the patient. The clinical record indicated the nurse called to check on the patient at 7:00 PM and that the Morphine and Ativan ordered for the patient had still not been delivered to the facility. The nurse called the nurse practitioner to request scheduling morphine, but the nurse practitioner declined to give morphine at scheduled doses and was "very upset" the morphine had not gotten to the facility. The note stated that the daughter stated the patient seemed comfortable. The clinical record contained notes from 9:00 PM to Midnight on 8/24/2019 indicating several continued attempts by the hospice nurse to obtain morphine and ativan from different pharmacies as the facility pharmacy had not delivered the medications. The record indicated that a nurse from the facility went to the hospital pharmacy after his/her scheduled shift and obtained the morphine for the patient at 10:56 P.M. The clinical record contained documentation that it took approximately 12 hours from the time the morphine was ordered for the hospice to obtain the medication for the patient's comfort. Interview: An interview was conducted with the on call nurse (staff member #5) caring for patient #1 on 11/19/2019 at 2:00 PM regarding patient #1 and the weekend of August 24, 2019. The nurse stated that the facility had recently switched pharmacies in order to get medications faster and that the new pharmacy was taking a long time to get medicine. The nurse stated that he/she offered to obtain morphine from another pharmacy but the facility stated it was against their rules. The nurse stated that the facility pharmacy was supposed to send the morphine "stat" but gave no estimated time of arrival. The nurse stated he/she had not worked with this pharmacy before. The MFI asked if the patient was in pain on Saturday August 24 with the nurse visited the patient. He/she stated that the patient would yell out and cry every fifteen (15) minutes or so, but it appeared the patient's pain was emotional, not physical. An interview with staff member #2, the Patient Care Manager was conducted on 11/19/19 at 12:00 PM regarding obtaining medication after hours for facility patients. The Patient Care Manager stated that the hospice does not use comfort kits as this is the preference of their medical director and most of the team physicians. The hospices practice is not not have pre-ordered medication, but they will "prep in advance." He/she stated by the end of the week case managers ensure that all medications are refilled and some facilities will allow outside pharmacies to sent in STAT pain medication, but other facilities will only use their own pharmacy. He/she stated at the time that particular facility did not allow medication from outside pharmacies in the facility. He/she stated since this occurrence, there was a meeting with that facility and outside medications are now permitted. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0663
L0663	36946 Based on staff interview and document review, it was determined the hospice failed to ensure competency of all individuals furnishing care in one (1) of nine (9) personnel files reviewed in the survey sample. Personnel file #8. Findings: Nine (9) personnel files were reviewed in the agency on 11/18-19/2019. The personnel file for the agency's Regional Vice President/Alternate Administrator failed to contain a signed job description for the Alternate Administrator. The personnel file contained a performance evaluation from 2014. The personnel file failed to contain evidence the staff member's competencies, skills, or performance had been evaluated in 2015, 2016, 2017, 2018, and 2019. The Administrator confirmed the above noted deficiency during the exit conference on 11/20/2019.
L0685
L0685	36946 Based on staff interview and surveyor observation, it was determined the agency failed to make clinical records readily available upon request. Findings: During the entrance conference, the MFIs were informed by staff member #1 that the agency's VPN (virtual private network) vendor had been subject to a ransomware attack on 11/17/2019. The staff member stated that the agency had no access to the electronic medical records at the time of entrance due to the VPN server being down. Staff member #1 stated there was no estimated timeframe given for restoration of service and access to the medical records. During the entrance conference, the MFIs requested an admission package, list of active patients, a list of patients discharged in the last six months, the agency's complaint log, after hours on call log for the last six months, list of all personnel, emergency preparedness plan, and QAPI (quality assessment, performance improvement) information for the last year . By the end of the survey on 11/20/19 at 12:00 PM, the agency had been unable to produce a list of active patients or discharged patients and the VPN and electronic medical records remained inaccessible. Complaint Log Review: The complaint log from the last year was reviewed in the agency on 11/18/19. Two (2) complaints in the complaint log contained similar allegations to the complaint currently being investigated. One (1) of these related complaints had already been investigated by the OLC in January 2019. The medical record for the patient named in the second complaint with similar allegations to this complaint was requested by the MFIs at 2:00 PM on 11/18/2019. The agency was unable to produce this medical record by the end of the survey on 11/20/2019. The Patient Care Manager (staff member #2) was interviewed in the agency on 11/19/2019 at 2:00 PM. He/she stated confirmed that the agency had no access to the record and there was no estimated time frame for the record to be available. The Administrator acknowledged the above noted deficiency during the exit conference on 11/20/2019.