Survey Report for 551755

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	551755	A. BUILDING __________ B. WING ______________	04/27/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
SUPPORTIVE HOSPICE CARE INC	1202 MONTE VISTA AVENUE SUITE #4, UPLAND, CA, 91786
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)
L0530
L0530	35183 Based on observation, interview, and record review, the agency failed to ensure a review of all medications the patients were taking was conducted for three of six sampled patients (Patients 23, 24, and 25) when: 1. For Patient 23, two medications were not administered as indicated on the medication profile (MP-a current list of all medications prescribed for a specific patient). 2. For Patient 24, one medication (Cholecalciferol (vitamin D supplement ) 8,000 units (unit of measure)) on the medication profile (MP - a current list of all medications prescribed for a specific patient) indicated the wrong dose, three medications (Zofran (an anti-nausea/vomiting medication) 4mg (milligrams-a unit of measure), Tylenol (a pain medication) 650 mg and Ativan (an anxiety medication) 0.5mg) were not administered as indicated on the MP, one medication (Atorvastatin (a cholesterol medication) 40mg) on the MP the patient was not taking and four medications (Thick-IT Powder (thickener powder), Diazepam (an anxiety medication) 5mg, Diflorasone (ointment for skin irritation) 0.05% Ointment apply 1 gram (gram-a unit of measure), and ZEGERID (a medication that decreases acid in the stomach) 1 packet) the patient was taking were not indicated in the MP. 3. For Patient 25, one medication (Loperamide (a medication for diarrhea) 1mg (milligram-a unit of measure) /5ml (milliliter-a unit of measure), 10 ml as needed twice a day) on the medication profile (MP - a current list of all medications prescribed for a specific patient) indicated the wrong dose and three medications (Tylenol (a pain medication) 650 mg, Zofran (an anti-nausea/vomiting medication) 4 mg and Ativan (an anxiety medication) 0.5 mg) were not administered as indicated on the MP. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 23's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 20, 2021, with a benefit period of May 20, 2021 to August 17, 2021 (First 90 day benefit period). Patient 23 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). During a home visit on July 7, 2021 with a Registered Nurse (RN 1) and in the presence of Patient 23's wife, an observation of Patient 23's actual medication bottles available in the home were compared with Patient 23's Medication Profile (MP - a current list of all medications prescribed for a specific patient). During an observation and concurrent interview with RN 1 on July 7, 2021 at 10:22 AM, RN 1 supplied a package of acetaminophen (a pain medication) 650 mg (milligrams-a unit of measure), one suppository rectally every 6 (six) hours as needed for pain/fever (date originally filled, May 20, 2021). Patient 23's MP indicated acetaminophen 650 mg, one suppository, rectally, every 4 (four) hours as needed for pain/fever. RN 1 verified Patient 23's prescription package's label indicated one suppository, rectally, every 4 (four) hours and Patient 23's MP indicated one suppository, rectally, every 6 (six) hours. During an interview with Patient 23's wife on July 7, 2021 at 10:42 AM, Patient 23's wife stated she had not given Patient 23 acetaminophen yet but when she did, she would follow the instructions on the medication's package or bottle. During an observation and concurrent interview with RN 1 on July 7, 2021 at 10:22 AM, RN 1 supplied a package of Zofran (an anti-nausea/vomiting medication ) 4 mg (milligrams-a unit of measure), one tablet under the tongue every 6 (six) hours as needed for nausea/vomiting (date originally filled, May 20, 2021). Patient 23's MP indicated Zofran 4 mg, one tablet under the tongue every 8 (eight) hours as needed for nausea/vomiting RN 1 verified Patient 23's prescription package's label indicated one tablet under the tongue every 6 (six) hours as needed and Patient 23's MP indicated one tablet under the tongue every 8 (eight) hours as needed. During an interview with Patient 23's wife on July 7, 2021 at 10:42 AM, Patient 23's wife stated she had not given Patient 23 Zofran yet but when she did, she would follow the instructions on the medication's package or bottle. During an interview with the Director of Patient Care Services (DPCS) on July 8, 2021 at 2:41 PM, the DPCS stated it was the RN's responsibility to reconcile all the patient's medications at admission and recertification. The DPCS stated the RNs should go over the discharge instructions from the hospital and have a discussion with the family about the medications. The DPCS stated the RNs are supposed to call the physicians to see what to continue or discontinue. The DPCS stated the medication packaging is to be physically looked at not just talked about with the family. The DPCS stated the Skilled Nurses (SNs) were provided the patients' Medication Profiles (MP) and are supposed to compare the MP with the bottles in the home. The DPCS stated, "This should happen every visit." 42896 2. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 24 had diagnoses that included Multiple Sclerosis (disabling disease that affects the brain and spinal cord). Patient 24 had a start of care on May 19, 2021, with a benefit period of May 19, 2021 to August 16, 2021 (First 90 day benefit period). During a home visit on July 7, 2021 with a Registered Nurse (RN 2) and in the presence of Patient 24's son, an observation of Patient 24's actual medication bottles and packets available in the home were compared with Patient 24's Medication Profile (MP). During an interview on July 7, 2021, at 12:40 PM, with Patient 24's son, Patient 24's son stated, his father stopped taking Atorvastatin (a cholesterol medication) a month before his stroke. He stopped taking it in the month of April this year. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 reviewed the MP and it indicated Atorvastatin 40 mg (milligrams-a unit of measure), one tablet oral QHS (bedtime) as current medication (Order date: May 19, 2021). RN 2 stated, "We continued it, but I don't remember having conversation with the MD to discontinue it." During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked a bottle of Vitamin D-3 (supplement) 5,000 unit (unit of measure), one tablet by mouth once a day (date originally filled, May 19, 2021). Patient 24's MP indicated Cholecalciferol (vitamin D supplement) 8,000 unit 1 tab oral daily supplement. RN 2 verified Patient 24's prescription bottle indicated Vitamin D-3 5,000 unit one tablet by mouth once a day and Patient 24's MP indicated Cholecalciferol 8,000 unit 1 tab oral daily. Doses does not match. During an interview on July 7, 2021, at 1:20 PM, with Patient 24's son, Patient 24's son stated, "I've given him 5,000 unit in the morning." Son also stated he's been giving 5,000 unit prior to hospice and never given 8,000 unit. MD order has been Vitamin D-3 5,000 unit 1 tablet by mouth once a day. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked a package of Ondansetron ODT (an anti-nausea/vomiting medication) 4 mg (milligrams-a unit of measure), dissolve one tablet on tongue every six hours as needed for nausea and vomiting (date originally filled, May 19, 2021). Patient 24's MP indicated Zofran (an anti-nausea/vomiting medication) 4 mg, oral/sublingual (under the tongue) one tablet every eight hours as needed for nausea and vomiting. RN 2 verified Patient 24's prescription package's label indicated of Ondansetron ODT 4 mg, dissolve one tablet on tongue every six hours as needed and Patient 24's MP indicated Zofran 4 mg, oral/sublingual one tablet every eight hours as needed. Frequency order does not match. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked a package of Acetaminophen (a pain medication) 650 mg (milligrams-a unit of measure), one suppository rectally, every six hours as needed for mild pain/fever (date originally filled, May 19, 2021). Patient 24's MP indicated Acephen (Tylenol) (a pain medication) 650 mg, one suppository rectally, every four hours as needed for mild pain/fever. RN 2 verified Patient 24's prescription package's label indicated Acetaminophen 650 mg, one suppository rectally, every six hours as needed and Patient 24's MP indicated Acephen (Tylenol) 650 mg, one suppository rectally, every four hours as needed. Frequency order does not match. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked a package of Lorazepam (an anxiety medication) 0.5 mg (milligrams-a unit of measure), one tablet by mouth every six hours as needed for anxiety/agitation (date originally filled, May 19, 2021). Patient 24's MP indicated Lorazepam 0.5 mg, oral/sublingual (under the tongue) one tablet every four hours as needed for anxiety. RN 2 verified Patient 24's prescription package's label indicated Lorazepam 0.5 mg, one tablet by mouth every six hours as needed and Patient 24's MP indicated Lorazepam 0.5 mg, oral/sublingual one tablet every four hours as needed. Frequency order does not match. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked the bottle of Thick-IT Powder (thickener powder) use as directed for nectar consistency (date originally filled, June 14, 2021). Patient 24's MP has no indication of the order Thick-IT Powder. RN 2 verified Patient 24's bottle of Thick-IT Powder has no record on MP. During an interview on July 7, 2021, at 1:20 PM, with Patient 24's son, Patient 24's son stated, his father started using Thick-IT Powder once admitted to hospice and uses it every time. "We serve a bottle of water 3-4 times a day." During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked the bottle of Diazepam (an anxiety medication) 5 mg (milligrams-a unit of measure), one tablet by mouth at bedtime for moderate anxiety. Patient 24's MP has no indication of the order Diazepam 5mg, one tablet by mouth at bedtime for moderate anxiety. RN 2 verified Patient 24's bottle of Diazepam 5mg, one tablet by mouth at bedtime for moderate anxiety has no record on MP. During an interview on July 7, 2021, at 1:20 PM, with Patient 24's son, Patient 24's son stated, "I've been giving Valium (an anxiety medication) every night and have been using it since admission to hospice." During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked the box of Diflorasone (ointment for skin irritation) 0.05% Ointment, apply 1 gram (gram-a unit of measure), twice daily to lower back for bedsores or arms for adhesive irritation as needed. Patient 24's MP has no indication of the order Diflorasone 0.05% Ointment, apply 1 gram, twice daily to lower back for bedsores or arms for adhesive irritation as needed. RN 2 verified Patient 24's box of Diflorasone 0.05% Ointment, apply 1 gram twice daily to lower back for bedsores or arms for adhesive irritation as needed has no record on MP. During a concurrent observation and interview on July 07, 2021, at 1:00 PM, with RN 2, RN 2 checked the box of Zegerid (medication that decreases acid in the stomach) Do not take every day, put 1 packet in eight ounce (ounce-a unit of measure) of water once daily by mouth as needed for acid reflux (heartburn). Patient 24's MP has no indication of the order "Zegerid Do not take every day, put 1 packet in eight ounces of water once daily by mouth as needed for acid reflux."(this medication is used for as needed basis) RN 2 verified Patient 24's box of Zegerid has no record on MP. During an interview on July 8, 2021, at 2:41 PM, with the Director of Patient Care Services (DPCS), the DPCS stated it was the RN's responsibility to reconcile all the patient's medication in admission and recertification. The DPCS stated the RNs should go over the discharge medication list from the hospital and discuss it with the family. The DPCS stated the RNs are suppose to go over all the medications to see what to continue and discontinue. The DPCS stated skilled nurses (SNs) were provided with patient's Medication Profiles (MP) and should be comparing the MP and the medication bottles. The DPCS stated, "This should happen every visit." During a review of the facility's policy and procedure (P&P) titled, "Medication Profile," undated, the P&P indicated, "Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Steps in the Procedure: 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list. 3. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care." 3. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 25 had diagnoses that included Senile degeneration of brain (mental deterioration with loss of intellectual ability). Patient 25 had a start of care on May 18, 2021, with a benefit period of May 6, 2021 to August 3, 2021. During a home visit on July 7, 2021 with a Hospice Aide (HA 1) and in the presence of Patient 25's caregiver, an observation of Patient 25's actual medication bottles and packets available in the home were compared with Patient 25's Medication Profile (MP). During a review of Patient 25's MP on July 07, 2021 at 2:15 PM, MP indicated Loperamide (a medication for diarrhea) 1mg (milligram-a unit of measure) /5ml (milliliter-a unit of measure), 10 ml as needed twice a day for Diarrhea. Checked the bottle prescription of Imodium A-D (a medication for diarrhea) 1mg/7.5ml, take 7.5 ml (1mg) by mouth two times a day as needed for Diarrhea (date originally filled, June 01, 2021). Doses does not match. During an interview on July 7, 2021, at 2:25 PM, with Patient 25's caregiver, Patient 25's caregiver stated, Patient 25 has been using Imodium A-D for a month. During a review of Patient 25's MP on July 07, 2021 at 2:15 PM, MP indicated Acephen (Tylenol) (a pain medication) 650 mg (milligrams-a unit of measure), one suppository rectally every four hours as needed for mild pain/fever. Checked a package of Acetaminophen (a pain medication) 650 mg unwrap and insert one suppository rectally, every six hours as needed for mild pain/fever (date originally filled, June 01, 2021). Frequency order does not match. During a review of Patient 25's MP on July 07, 2021 at 2:15 PM, MP indicated Zofran (ondansetron hydrochloride) (an anti-nausea/vomiting medication) 4 mg (milligrams-a unit of measure), oral/sublingual (under the tongue) one tablet every eight hours as needed for nausea and vomiting. Checked a package of Ondansetron ODT (an anti-nausea/vomiting medication) 4 mg take one tablet by mouth/sublingually every six hours as needed for nausea and vomiting (date originally filled, June 01, 2021). Frequency order does not match. During a review of Patient 25's MP on July 07, 2021 at 2:15 PM, MP indicated Ativan (Lorazepam) (an anxiety medication) 0.5 mg (milligrams-a unit of measure), oral/sublingual (under the tongue) one tablet every four hours as needed for anxiety. Checked a package of Lorazepam 0.5 mg one tablet by mouth/sublingually every six hours as needed for anxiety/agitation (date originally filled, June 01, 2021). Frequency order does not match. During an interview on July 8, 2021, at 2:41 PM, with the Director of Patient Care Services (DPCS), the DPCS stated it was the RN's responsibility to reconcile all the patient's medication in admission and recertification. The DPCS stated the RNs should go over the discharge medication list from the hospital and discuss it with the family. The DPCS stated the RNs are suppose to go over all the medications to see what to continue and discontinue. The DPCS stated skilled nurses (SNs) were provided with patient's Medication Profiles (MP) and should be comparing the MP and the medication bottles. The DPCS stated, "This should happen every visit." During a review of the facility's policy and procedure (P&P) titled, "Medication Profile," undated, the P&P indicated, "Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Steps in the Procedure: 1. For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient's current medications upon the patient's entry to the organization. A comparison of the medications ordered for the patient while under the organization's care will be made to those on the list. 3. A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. C. Using the medication profile as a communication tool for other clinicians involved in care." A review of the agency's policy and procedure titled, "Medication Profile," undated, indicated the following: "Purpose: To define the use of the medication profile in evaluating a patient's current medication regimen. Policy: Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Procedure: A drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: Using the medication profile to evaluate the use of the drugs in the home setting. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindications. Using the medication profile as a communication tool for other clinicians involved in care.
L0547
L0547	42896 Based on interview and record review, the agency failed to ensure visit frequencies were indicated in the plan of care and physician's orders for SN, HA and MSW for one (1) of six (6) sampled patient (Patient 26). This failure had the potential for Patient 26's needs to go unmet. Findings: A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 26 had diagnoses that included Acute Kidney Failure (kidney loses filtering ability). Patient 26 had a start of care on June 22, 2021, with a benefit period of June 22, 2021 to September 19, 2021 (First 90 day benefit period). During a review of Patient 26's electronic medical record visits from June 2021 to July 2021. There were four skilled nursing visits, five hospice aide visits and one medical social worker visits made without an order. A continued review of Patient 26's electronic medical record visits indicated skilled nursing visits were provided on June 22, 2021, June 29, 2021, June 30, 2021 and July 07, 2021. Medical social worker visit was provided on June 23, 2021. Hospice aide visits were provided on June 23, 2021, June 24, 2021, June 29, 2021, July 01, 2021 and July 06, 2021. During a concurrent interview and record review, on July 8, 2021, at 12:22 PM, with Regional Director of Operations/Administrator (RDO/Admin), the plan of care and physician's orders indicated no visit frequency orders for SN, HA and MSW as of June 22, 2021 to July 07, 2021. During a review of the facility's policy and procedure (P&P) titled, "The Plan of Care," revised August 2015, the P&P indicated, "Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to hospice program. The care provided to the patient must be in accordance with the plan of care. Steps in the Procedure:..12. The written plan of care will contain, but will not be limited to, the following: J. Frequency and type of services and 14. Care provided to the patient will be in accordance with the plan of care."
L0559
L0559	35183 The agency failed to ensure that the Condition of Participation: L 559 418.58 Quality assessment and performance improvement (QAPI) was in compliance as follows: 1. Based on interview and record review, the agency failed to track, measure and analyze quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) in order to assess the agency's processes of care, services, and operations, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. (Refer to L 562) 2. Based on interview and record review, the agency failed to use quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data to monitor the effectiveness and safety of services, quality of care or identify opportunities for improvement, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. (Refer to L 564) 3. Based on interview and record review, the agency failed to track adverse patient events (harm from medical care rather than an underlying disease), for seven (7) of seven (7) months reviewed, in a universe of 79 patients. (Refer to L 569) 4. Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. (Refer to L 571) 5. Based on interview and record review, the agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. (Refer to L 574) The cumulative effect of these systemic practices resulted in the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unresolved.
L0562
L0562	35183 Based on interview and record review, the agency failed to track, measure and analyze quality indicators (a measurable element of the agency's practice that can be used to assess the quality of care provided) in order to assess the agency's processes of care, services, and operations, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: A review of the agency's Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021 to July 8, 2021 was conducted. Contained within the QAPI binder was the agency's QAPI Plan, undated. The agency's QAPI Plan indicated the following quality indicators would be tracked, measured and analyzed: a. Chart audit for antibiotics with a care plan: The agency's QAPI binder did not contain data on Chart audit for antibiotics with a care plan. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze the Chart audit for antibiotics with a care plan. b. Patient Falls: The agency's QAPI binder did not contain data on Patient Falls. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Patient Falls. c. Infection Reports: The agency's QAPI binder did not contain data on Infection Reports. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Infection Reports. d. Pain brought under control in 48 hours: The agency's QAPI binder did not contain data on Pain brought under control in 48 hours. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Pain brought under control in 48 hours. During an interview with the Quality Assessment Performance Improvement Coordinator (QAPI Coordinator) and Administrator (Admin) on July 8, 2021 at 3 PM, the QAPI Coordinator stated she was responsible for the QAPI Program. The QAPI Coordinator stated the agency had not tracked, measured and analyzed the quality indicators since January 1, 2021 to present. The QAPI Coordinator stated the QAPI Committee had not held a meeting since January 1, 2021. During a continued interview with the Admin, the Admin stated she was a member of the agency's Governing Body (GB). The Admin stated the GB had been unaware the QAPI program had not been maintained. A review of the agency's "Quality Assessment Performance Improvement Plan," undated, indicated, "A performance improvement plan is developed through the program's comprehensive Quality Assessment and Improvement (QAPI) Program that will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Through the monitoring and evaluation process, data will be collected, analyzed and evaluated."
L0564
L0564	35183 Based on interview and record review, the agency failed to use quality indicator (a measurable element of the agency's practice that can be used to assess the quality of care provided) data to monitor the effectiveness and safety of services, quality of care or identify opportunities for improvement, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unaddressed. Findings: A review of the agency's Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021 to July 8, 2021 was conducted. Contained within the QAPI binder was the agency's QAPI Plan, undated. The agency's QAPI Plan indicated the following quality indicators would be tracked, measured and analyzed: a. Chart audit for antibiotics with a care plan: The agency's QAPI binder did not contain data on Chart audit for antibiotics with a care plan. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze the Chart audit for antibiotics with a care plan. b. Patient Falls: The agency's QAPI binder did not contain data on Patient Falls. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Patient Falls. c. Infection Reports: The agency's QAPI binder did not contain data on Infection Reports. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Infection Reports. d. Pain brought under control in 48 hours: The agency's QAPI binder did not contain data on Pain brought under control in 48 hours. The agency's QAPI binder did not contain QAPI Committee meeting minutes, indicating the QAPI Committee had met to measure and analyze Pain brought under control in 48 hours. During an interview with the Quality Assessment Performance Improvement Coordinator (QAPI Coordinator) and Administrator (Admin) on July 8, 2021 at 3:15 PM, the QAPI Coordinator stated she was responsible for the QAPI Program. The QAPI Coordinator stated the agency had not tracked, measured and analyzed the quality indicators since January 1, 2021 to present. The QAPI Coordinator stated the QAPI Committee had not held a meeting since January 1, 2021. The QAPI Coordinator stated data had not been used to monitor the effectiveness and safety of services, quality of care or to identify opportunities for improvement. During a continued interview with the Admin, the Admin stated she was a member of the agency's Governing Body (GB). The Admin stated the GB had been unaware the QAPI program had not been maintained. A review of the agency's "Quality Assessment Performance Improvement Plan," undated, indicated the following: "A performance improvement plan is developed through the program's comprehensive Quality Assessment and Improvement (QAPI) Program that will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Through the monitoring and evaluation process, data will be collected, analyzed and evaluated. Monitoring performance through data collection: Quality indicator data are collected to monitor existing processes, Identify opportunities and priorities for improvement, Sustain improvement..."
L0569
L0569	35183 Based on interview and record review, the agency failed to track adverse patient events (harm from medical care rather than an underlying disease), for seven (7) of seven (7) months reviewed, in a universe of 79 patients. This failure had the potential to cause patients to suffer repeated harm from inferior medical care. Findings: A review of the agency's Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021 to July 8, 2021 was conducted. There was no documented evidence to show a procedure had been put in place to monitor for, or track adverse patient events. There was no documented evidence to show the agency had defined an adverse patient event to aid in tracking, analyzing and implementing preventive actions. During an interview with the Quality Assessment Performance Improvement Coordinator (QAPI Coordinator) and Administrator (Admin) on July 8, 2021 at 3:15 PM, the QAPI Coordinator stated she was responsible for the QAPI Program. The QAPI Coordinator stated the agency had not defined an adverse patient event or set up a procedure to monitor for and track adverse patient events. During a continued interview with the Admin, the Admin stated she was a member of the agency's Governing Body (GB). The Admin stated the GB had been unaware the QAPI program had not been maintained. A review of the agency's "Quality Assessment Performance Improvement Plan," undated, indicated the following: "A performance improvement plan is developed through the program's comprehensive Quality Assessment and Improvement (QAPI) Program that will objectively and systematically monitor and evaluate the effectiveness and safety of services and quality of care provided for patient/families. Through the monitoring and evaluation process, data will be collected, analyzed and evaluated. Analyzing current performance: Data are aggregated [put together] and analyzed on an on-going basis, appropriate statistical techniques are used, performance is compared over time and with external sources and adverse patient events, undesirable patterns or trends and sentinel events will be analyzed to identify their causes."
L0571
L0571	35183 Based on interview and record review, the agency failed to conduct and document performance improvement projects (PIP - a concentrated effort on a particular problem in one area of the agency or agency wide; it involves gathering information systematically to clarify issues or problems, and intervening for improvements) the agency had undertaken, the reasons for conducting the PIP and measurable goals to show progress achieved, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care to go unaddressed and continue. Findings: A review of the agency's Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021 to July 8, 2021 was conducted. There was no documented evidence to show a problem area had been identified and a PIP initiated. During an interview with the Quality Assessment Performance Improvement Coordinator (QAPI Coordinator) and Administrator (Admin) on July 8, 2021 at 3:30 PM, the QAPI Coordinator stated she was responsible for the QAPI Program. The QAPI Coordinator stated the agency had not identified a problem area for a PIP. The QAPI Coordinator stated she could not show documentation of a PIP. During a continued interview with the Admin, the Admin stated she was a member of the agency's Governing Body (GB). The Admin stated the GB had been unaware the QAPI program had not been maintained. A review of the agency's "Quality Assessment Performance Improvement Plan," undated, indicated the following: "...a measurement tool will be developed to determine whether or not acceptable levels of care/service are being met. This process requires development of outcome criteria that are measurable statements about structure, process or outcome of care that are compiled by knowledgeable experienced experts and clinicians. Hospice staff will review both established indicators of care as well as outcome criteria and accept them or suggest modification. Through monitoring and evaluating, the QAPI committee will determine whether or not the care/service delivered is in accordance with the predetermined indicators of care/service as well as the specific criteria identified. When the care/service delivered does not match the pre-determined indicators and specific criteria, the discrepancy will be identified as a problem and methods of resolving the problem will be determined. Corrective action will be implemented and documented."
L0574
L0574	35183 Based on interview and record review, the agency's Governing Body (GB) failed to ensure a Quality Assessment and Performance Improvement (QAPI) Program was implemented, maintained and evaluated for effectiveness, for seven (7) of seven (7) months reviewed, in a universe of 79 patients. This failure had the potential to cause problems in health outcomes, patient safety and quality of care, to go unrecognized and unresolved. Findings: A review of the agency's Quality Assessment and Performance Improvement (QAPI) binder from January 1, 2021 to July 8, 2021 was conducted. There was no documented evidence to show the QAPI Committee held and attended meetings for the first two quarters of 2021. There was no documented evidence to show the QAPI Committee developed and submitted a quarterly report, to the Governing Body (GB), summarizing QAPI activities and results of actions taken. A review of the agency's GB meeting minutes from January 1, 2021 to July 8, 2021 was conducted. There was no documented evidence the GB evaluated and maintained the QAPI Program. During an interview with the Quality Assessment Performance Improvement Coordinator (QAPI Coordinator) and Administrator (Admin) on July 8, 2021 at 3:45 PM, the QAPI Coordinator stated she was responsible for the QAPI Program. The QAPI Coordinator stated the QAPI Committee had not held a meeting for the first two quarters of 2021. And had not developed and submitted a quarterly report, to the Governing Body (GB), summarizing QAPI activities and results of actions taken. During a continued interview with the Admin, the Admin stated she was a member of the agency's Governing Body (GB) and served on the QAPI Committee. The Admin stated the GB had not received a quarterly report, from the QAPI Committee, summarizing QAPI activities and results of actions taken. The Admin stated she had not attended a QAPI Committee meeting in the first two quarters of 2021. The Admin stated the GB had not defined, implemented, maintained or evaluated the QAPI Program. A review of the agency's "Quality Assessment Performance Improvement Plan," undated, indicated the following: "The QAPI Committee will meet quarterly and will be composed of representatives from the following: 1. Governing Board, 2. Director of Patient Care Services ..., 3. Administrator, 4. Nursing Services, 5. Social Services, 6. Medical Director, 7. Spiritual Counselor Authority and Responsibility for Program The Governing Body maintains ultimate authority and responsibility for the QAPI program. The authority and responsibility for the overall implementation and management of the QAPI Program is delegated to the Administrator. Specific functions include: 1. Utilizing an interdisciplinary approach to design the performance improvement process. 2. Ensuring that monitoring and evaluation processes are performed systematically and according to the established QAPI calendar that will include monthly, quarterly and annual QAPI activities. 3. Initiating action(s) when problems are identified, and communicating course of action to agency administrator and appropriate department heads. 4. Monitoring to assure that action taken results in measurable, sustained improvement with respect to identified problems. 5. Gathering and aggregating [to put together] data to prepare statistical analysis and reports."
L0664
L0664	35183 The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical director was in compliance as follows: Based on interview and record review the agency failed to ensure the Medical Director certified the patients' terminal illnesses (a prognosis of six months or less life expectancy if the disease runs its normal course) for the first 90-day benefit period (hospice services are provided in two 90-day periods and an unlimited number of 60-day periods) with two physician signatures and a physician's terminal illness summary for three (3) of six (6) sampled patients (Patients 23, 24 and 27). (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 23, 24 and 27 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon.
L0667
L0667	35183 Based on interview and record review the agency failed to ensure the Medical Director certified the patients' terminal illnesses (a prognosis of six months or less life expectancy if the disease runs its normal course) for the first 90-day benefit period (hospice services are provided in two 90-day periods and an unlimited number of 60-day periods) with two physician signatures and a physician's terminal illness summary for three (3) of six (6) sampled patients (Patients 23, 24 and 27). This failure had the potential to cause Patients 23, 24 and 27 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon. Findings: 1. A review of Patient 23's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of May 20, 2021, with a benefit period of May 20, 2021 to August 17, 2021 (First 90 day benefit period). Patient 23 had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 23's physician's order (by Physician 1) dated April 28, 2021, indicated, "...Patient needing Hospice eval [evaluation]." A review of Patient 23's "Hospice Benefit Election," dated May 20, 2021 indicated, "The physician I have chosen as my attending physician is: Hospice MD [Medical Director] and please keep [name of Physician 1] updated @ [at] [Physician 1's phone number] ..." A review of Patient 23's "Physician's Certification for Hospice Benefit," (physician's signature number one) dated May 20, 2021 was signed by the Medical Director (MD) and indicated the following: "RN [Registered Nurse] Prognosis Summary: Patient is an 80 y/o [year old] male with primary dx [diagnosis] Alzheimer's dementia [a group of conditions characterized by memory loss and judgment]... "Certifying Physician Summary: Patient is an 80 y/o [year old] male with primary dx [diagnosis] Alzheimer's dementia [a group of conditions characterized by memory loss and judgment]..." During an interview with the Director of Patient Care Services (DPCS) on July 8, 2021 at 2:11 PM, the DPCS stated that the content of the "RN Prognosis Summary" and the "Certifying Physician Summary" for Patient 23 was identical. A review of Patient 23's "Physician's Certification for Hospice Benefit," (physician's signature number two) dated May 20, 2021 and was signed by the MD. During an interview with the MD on July 8. 2021 at 1:41 PM, the MD stated he was the Medical Director for the agency. The MD stated the second physician signature for Patient 23's "Certification of Terminal Illness" should have been Physician 1's not his. The MD stated it was his responsibility to write a certifying physician summary for Patient 23 and he had not. 2. A review of the patient profile (a document that gives a summary of patient's information), undated, indicated Patient 24 had diagnoses that included Multiple Sclerosis (disabling disease that affects the brain and spinal cord). Patient 24 had a start of care on May 19, 2021. The attending physician is (Physician 3) and hospice physician designee is Medical Director (MD 2). During a review of Patient 24's Physician's Certification for Hospice Benefit from May 19, 2021 to August 16, 2021. There's one physician signature for the first 90 days by MD 2 dated May 19, 2021 under Referring Physician Attestation. The second signature is by the same physician, MD 2 dated May 19, 2021 under Medical Director Attestation/Certification. During a further review of "Hospice Services: Continuous Care:" dated May 19, 2021, "The physician I have chosen as my attending physician is: Physician 3." During an interview on July 08, 2021, at 2:05 PM, with the Medical Director, MD 2 confirmed he signed both signatures and Physician 3 should have signed the second signature. MD 2 verified that he did not add his own summary on the section "Certifying Physician Summary." During a concurrent interview and record review, on July 8, 2021, at 2:34 PM, with the Director of Patient Care Services (DPCS), DPCS verified that both signatures on Certification of Terminal Illness (CTI) was signed by MD 2. DPCS verified that Physician 3 should have been the second signature. During a review of the facility's policy and procedure (P&P) titled, "Certification of Terminal Illness," revised August 2015, the P&P indicated, "Policy: At the time a patient and family caregiver chooses hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. Steps in the Procedure:..1. At the time of admission to hospice, the hospice Medical Director of the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, of applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms)." 3. A review of Patient 27's face sheet (a document that gives a summary of patient's information), undated, indicated a start of care date of June 16, 2021, with a benefit period of June 16, 2021 to September 13, 2021 (First 90 day benefit period). Patient 27 had diagnoses that included non-traumatic intracranial hemorrhage (bleeding in the brain). A review of Patient 27's physician's order (by Physician 2) dated June 16, 2021, indicated, "May have Hospice evaluation." A review of Patient 27's "Hospice Benefit Election," dated June 16, 2021 indicated, "The physician I have chosen as my attending physician is: [name of Medical Director]." A review of Patient 27's "Physician's Certification for Hospice Benefit," (physician's signature number one) dated June 16, 2021 was signed by Physician 3. A review of Patient 27's "Physician's Certification for Hospice Benefit," (physician's signature number two) dated June 16, 2021 and was unsigned. During an interview with the Director of Patient Care Services (DPCS) on July 8, 2021 at 2:11 PM, the DPCS stated Patient 27's "Physician's Certification for Hospice Benefit," for a second signature was unsigned. During an interview with the MD on July 8. 2021 at 1:41 PM, the MD stated the second physician signature for Patient 27's "Certification of Terminal Illness" should have been his. The MD stated Patient 27 did not have two physician signatures certifying his terminal illness. A review of the agency's policy and procedure titled, "Certification of Terminal Illness," dated August 2015 indicated, "Purpose: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. Procedure: ...Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim." A review of the agency's policy and procedure titled, "Physician Services-Medical Director," dated August 2015 indicated, "Purpose: To ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the Medical Director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. Policy: ...Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods..."