Survey Report for 671768

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	671768	A. BUILDING __________ B. WING ______________	03/11/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
KINDER HEARTS HOSPICE OF AMARILLO	1901 MEDI PARK DR., SUITE 1030, AMARILLO, TX, 79106
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)
L0536
L0536	27748 Based on interview and record review, the hospice failed to ensure the RN member of the IDG provided coordination of care and ensured continuous assessment of each patient's and family's needs and ensured the implementation of the interdisciplinary plan of care for 1 of 11 (Patient #7) patient reviewed in that: The RN member of the IDG failed to coordinate care with the physician, or other appropriate practitioner, and the IDG and failed to obtain physician orders prior to changing Patient #7's medication regimen; The RN member of the IDG failed to coordinate care with the physician, or other appropriate practitioner, the IDG, and the NF and failed to provide hospice nursing assessment of Patient #7 during a period of time when the patient was experiencing increased behavioral issues; and The RN member of the IDG failed to conduct an assessment on Patient #7 to follow-up on a concern reported by the hospice aide regarding the patient's failure to have a bowel movement. The failure to coordinate care with the physician, or other appropriate practitioner, and the IDG and to obtain physician orders prior to changing Patient #7's medication regimen resulted in the patient receiving medications which had not been approved for the patient by the physician, or other appropriate practitioner, and which could have resulted in adverse outcomes to the patient, such as unwanted side effects or ineffective treatment. The failure to coordinate care with the physician, IDG, and the NF for Patient #7 during the period of time when he was experiencing increased behavioral issues resulted in the patient failing to receive assessment by the hospice nurse and failure to receive interventions from the hospice to address the patient's needs and the NF's concerns. This failure could have resulted in injury to the patient as he had a fall during this time period related to the behaviors. The failure to conduct an assessment to follow-up on the concern reported by the hospice aide regarding the patient's failure to have a bowel movement resulted in the patient experiencing constipation and requiring removal of the feces by the hospice nurse. This failure could have resulted in discomfort to the patient. Refer to L540
L0540
L0540	27748 Based on interview and record review, the hospice failed to ensure the RN member of the IDG provided coordination of care and ensured continuous assessment of each patient's and family's needs and ensured the implementation of the interdisciplinary plan of care for 1 of 11 (Patient #7) patient reviewed in that: The RN member of the IDG failed to coordinate care with the physician, or other appropriate practitioner, and the IDG and failed to obtain physician orders prior to changing Patient #7's medication regimen; The RN member of the IDG failed to coordinate care with the physician, or other appropriate practitioner, the IDG, and the NF and failed to provide hospice nursing assessment of Patient #7 during a period of time when the patient was experiencing increased behavioral issues; and The RN member of the IDG failed to conduct an assessment on Patient #7 to follow-up on a concern reported by the hospice aide regarding the patient's failure to have a bowel movement. The failure to coordinate care with the physician, or other appropriate practitioner, and the IDG and to obtain physician orders prior to changing Patient #7's medication regimen resulted in the patient receiving medications which had not been approved for the patient by the physician, or other appropriate practitioner, and which could have resulted in adverse outcomes to the patient, such as unwanted side effects or ineffective treatment. The failure to coordinate care with the physician, IDG, and the NF for Patient #7 during the period of time when he was experiencing increased behavioral issues resulted in the patient failing to receive assessment by the hospice nurse and failure to receive interventions from the hospice to address the patient's needs and the NF's concerns. This failure could have resulted in injury to the patient as he had a fall during this time period related to the behaviors. The failure to conduct an assessment to follow-up on the concern reported by the hospice aide regarding the patient's failure to have a bowel movement resulted in the patient experiencing constipation and requiring removal of the feces by the hospice nurse. This failure could have resulted in discomfort to the patient. The findings included: Patient #7: Review of the clinical record indicated the patient had diagnoses of chronic obstructive pulmonary disease, congestive heart failure, and diabetes mellitus type 2. The record indicated the patient had a start of care date with the hospice of 01/07/20. A skilled nurse's note, dated 01/30/20, signed by the RN, Employee #65, indicated, "NF staff called to report pt is requesting Methocarbinol be restarted. "I have the medicine, I just don't have an order to give it." Request granted." There was no documentation to indicate the RN coordinated care by notifying the physician, or other appropriate practitioner, and/or the IDG regarding the request for an order for this medication and receiving an order from the physician prior to giving approval to the NF to restart the medication. A skilled nurse's note, dated 02/17/20, signed by the RN, Employee #65, indicated, " (name of an employee at the NF) called to report pt requesting Rx for n/v and won't take Zofran ... Reports rec'd from CNAs that pt has been sticking his fingers down his throat to make himself throw up ... Pt has been really demanding the last week and cursing at staff and throwing food at staff. New order for Thorazine 50 mg R tid ordered to be delivered by pharmacy." There was no documentation to indicate the RN coordinated care by notifying the physician, or other appropriate practitioner, and/or the IDG and receiving an order from the physician prior to advising the NF to make this change to the patient's medication regimen. During an interview conducted on 03/10/20 at 12:39 p.m., with the RN, Employee #65, when asked if she coordinated care by contacting the physician for orders prior to making changes to the patient's medication regimen, the RN, Employee #65, said she might call the physician first or she might just make the changes and then notify the physician afterwards. When asked about the NF's request to restart the patient's Methocarbinol on 01/30/20, the RN, Employee #65, said she did not ask the physician about this and just told the NF it was ok to restart it. When asked about the Thorazine ordered for Patient #7 on 02/17/20 and asked if she ordered this herself or if she contacted the physician for an order for this medication, the RN, Employee #65, said she ordered this medication herself and did not discuss it with the physician prior to ordering it. The RN, Employee #65, said the patient was refusing Zofran and Phenergan and so she said, "Ok, I'm going to slow you down, buddy." During an interview conducted on 03/10/20 at 3:51 p.m., the alternate administrator/supervising nurse, Employee #51, provided standing orders for the hospice. Review of the standing order form provided by the hospice did not indicate that the medications documented in these findings as having been ordered by the skilled nurse without first consulting the physician were included on the standing orders. No documentation was provided to indicate the physician had provided standing orders for the skilled nurse to order the medications listed in these findings as ordered by the skilled nurse without first consulting the physician. When informed that the skilled nurses were changing patients' medication regimens by adding, discontinuing, and changing medication without first contacting the physician for orders and approval, the alternate administrator/supervising nurse, Employee #51, said the nurses should be calling the physician for orders especially for medications which were not included on the standing orders. The surveyor attempted to contact the medical director, Employee #55, on the following dates and times: On 03/11/20 at 9:21 a.m., the surveyor attempted to contact the medical director, Employee #55, there was no answer other than a recorded message. The surveyor left a voicemail requesting a return phone call. On 03/16/20 at 8:54 a.m., the surveyor made a second attempt to contact the medical director, Employee #55, as no return phone call had been received. There was no answer other than a recorded message. The surveyor left a voicemail requesting a return phone call. On 03/19/30 at 1:48 p.m., the surveyor made a third attempt to contact the medical director, Employee #55, as no return phone call had been received. There was no answer other than a recorded message. The surveyor left a voicemail requesting a return phone call. There was no return phone call from the medical director, Employee #55, received. Also noted regarding Patient #7: A hospice form titled, "Active Care Plan Problems," for the time period of 01/21/20 - 02/27/20, indicated, "Problem Behavioral issues that lead to unsafe situations for pt and staff ... Start date 02/21/20 ... Care Plan Problem Interventions ... Be a calm presence to staff and pt." A skilled nurse's note, dated 02/22/20, 8:30 a.m. - 8:45 a.m., signed by the RN, Employee #65, indicated, "NF staff called to report pt's behavior not improving. "He's a one on one and we're not staffed for that, Sista." Reports he is not taking po or R meds. Informed NF staff that we may have to have the dtr come have a chat with him. Before I got to the NF for assessment, NF staff called again to say that they had notified ---------- (name of the medical director, Employee #55, who is also the physician who oversees the NF)'s NP who ordered Zyprexa IM and they needed the Rx ASAP. Pharmacist called out to fill the script and it was delivered by myself. Pt was in his room with his head against the belly of the ADON and hollering out that he is dying and "give me something please." Zyprexa 10 mg given IM by NF staff. Pt collapsed into the bed about 3 - 4 minutes later ... Pt was calm but moving around in bed on my leaving. NF staff did call dtr who states the reason he is in the facility is because she couldn't have him in her home any longer, but would call her husband to come home from work to watch the kids so she could drive to NF to visit with him. This offer declined by NF staff." There was no documentation to indicate the RN, Employee #65, conducted an assessment of Patient #7 during this visit. There was no documentation to indicate the RN, Employee #65, coordinated care by notifying the physician, or other appropriate practitioner, or the IDG of the patient's behaviors during this visit to discuss any possible hospice interventions. A skilled nurse's note, dated 02/22/20, 11:00 a.m. - 11:05 a.m., signed by the RN, Employee #65, indicated, "NF staff called to report, "Well that lasted all of 10 min." Pt is awake, alert and LOUD. I instructed her that I was with another pt and would have to call her back." A skilled nurse's note, dated 02/22/20, 1300 - 1400, signed by the RN, Employee #65, indicated, "Returned the call to NF after numerous attempts. NF staff report that the pt rolled off the bed ... felt to be intentionally ... but was not hurt. They have spoken with ----------- (name of the medical director, Employee #55) who ordered the mattress be placed on the floor; decrease Seroquel 50 mg at HS; add Zyprexa 5 mg po q am; stop Reglan. "We need you to bring more Seroquel 50 mg tabs because all we have is 100 mg tabs and we don't cut them in half here." Pharmacist called out to fill the script which I delivered. Pt is still hollering out occasionally, but is less aggressive and agitated than this am." There was no documentation to indicate the RN, Employee #65, conducted an assessment of Patient #7 during this visit. There was no documentation to indicate the RN, Employee #65, coordinated care by notifying the physician, or other appropriate practitioner, and the IDG of the patient's behaviors to discuss any possible hospice interventions. There was no documentation regarding the patient's behavioral issues or the medication and treatments changes implemented by the NF. There was no documentation to indicate the hospice had considered additional hospice interventions to address these issues. During an interview conducted on 02/27/20 at 9:00 a.m., with the charge nurse at the NF where Patient #7 resides, when asked if the hospice assisted her with the issue or resolved the issue when she called them with questions or concerns regarding the patient, the NF charge nurse said most of the time the hospice took care of the issue. When asked an example of an issue the hospice did not take care of, the NF charge nurse said last weekend the patient was having extreme behaviors and aggression, throwing himself out of bed, hitting at the staff, cursing at the staff, and refusing to take oral medications. The NF charge nurse said she called the on-call nurse for the hospice (the LVN, Employee #57, said this would have been the RN, Employee #65). The NF charge nurse said she reported the patient's behaviors to the hospice on-call RN and requested assistance to provide one-to-one supervision as the NF did not have the resources to provide this. The NF charge nurse said the RN told her they could not provide assistance with the supervision for the patient and told her to basically figure it out herself. When questioned further about this incident and asked if the hospice had ordered or provided any new medications or interventions to address the behaviors, the NF charge nurse said the first day the behaviors started the hospice gave two new orders for two new medications, however, these medications did not work and the patient was refusing oral medications at that time anyway. The NF charge nurse said the next day the hospice was called and notified that the new medications they had ordered were not working. The NF charge nurse said the hospice RN told them to call the patient's daughter. The NF charge nurse said the NF did call the patient's daughter but she lived out of town, hours away, and had small children and was unable to come and sit with her father. The NF charge nurse said Patient #7's physician, who is the patient's physician for both hospice and the NF, called in an order for Zyprexa as an injection. The NF charge nurse said the Zyprexa injection worked for only 8 minutes. The NF charge nurse said the patient fell asleep immediately after the injection, but it only last 8 minutes before his behaviors began again. The NF charge nurse said they called the hospice again to inform them of this, but nothing new was ordered for the patient by the hospice after the Zyprexa. The NF charge nurse said the NF ADON spoke with the physician (the medical director, Employee #55, who was also the physician for the NF) and the physician adjusted the patient's other medications. The NF charge nurse said she thought this occurred on Saturday. The NF charge nurse said the patient's behavior began to improve on Monday (02/24/20) in that the patient was speaking English again. The nursing facility charge nurse said the prior to Monday the patient had been speaking word salad. The NF charge nurse said on Monday the patient was speaking coherent sentences although they were still not relevant to what the patient was being asked. The NF charge nurse said on Tuesday (02/25/20) the patient improved and began to be more coherent again and began to take his oral medications again. The NF charge nurse said the hospice basically told her that she needed to figure the situation out and did not provide any assistance with the client's behaviors during this time period. During an interview conducted on 03/10/20 at 12:39 p.m., with the RN, Employee #65, when asked regarding the events for 02/22/20 with Patient #7, the RN, Employee #65, said the documentation was correct and said the NF did an assessment and called her and told her the findings. The RN, Employee #65, said she took the NF medications. When asked if she had conducted an assessment on Patient #7 on 02/22/20, the RN, Employee #65, said she did not try to get the patient's vital signs or anything like that while she was at the NF to deliver the medications. The RN, Employee #65, said she could see the patient while in the room and could assess whether he was sleeping or awake and could see his skin color and things like this. When asked if she had contacted the physician regarding the patient's behaviors, the RN, Employee #65, said the NF contacted the NP and got the order for the Zyprexa. When asked about the phone call with the NF on 02/22/20, from 11:00 a.m. - 11:05 a.m., the RN, Employee #65, said the patient was awake again. The RN, Employee #65, said she was with another patient at the time this phone call occurred. When asked about the note for 02/22/20, for 1300 - 1400, the RN, Employee #65, said that she has two NFs she can call and may or may not get an answer at and the NF Patient #7 resides in is one of these. The RN, Employee #65, said she called but received no answer. The RN, Employee #65, said the NF observed the patient to throw himself off of the bed. The RN, Employee #65, said the medical director, Employee #55, took the bed away. The RN, Employee #65, said the patient had fall mats. When asked if she had coordinated care or communicated with the NF regarding Patient #7 after this contact on 02/22/20 at 1300 - 1400, the RN, Employee #65, said no, and said, "If they don't call me, I don't call them." The RN, Employee #65, said the patient's behavior improved on Monday (02/24/20) and he was back to his baseline on Tuesday (02/25/20). When asked if she had coordinated care with the physician or IDG regarding the patient's behaviors during the time frame of 02/22/20 - 02/25/20, the RN, Employee #65, said she discussed it during the IDG meeting on 02/25/20. The RN, Employee #65, said she and the physician and his NP all knew what was going on with the patient. When asked if the hospice IDG had considered increasing the level of the patient's hospice care to include consideration of provision of continuous care or GIP care, the RN, Employee #65, said the patient had refused a psychological evaluation in the past and has refused to be transferred to another facility in the past. When asked if these options were considered or discussed during the time period of 02/22/20 - 02/25/20, the RN, Employee #65, said they were discussed but she was not sure if it was on those particular days. Further noted regarding Patient #7: A hospice aide visit note, dated 01/15/20, indicated, "RN, (name of the RN, Employee #65) notified that patient ... has not had a bowel movement in five days." A hospice aide visit note, dated 01/17/20, indicated, "RN, (name of the RN, Employee #65) notified that patient has not had a bowel movement in seven days." There was no documentation to indicate the hospice skilled nurse conducted an assessment regarding the patient's bowel movements during the time period of 01/15/20 - 01/20/20. There was no documentation to indicate the RN coordinated care by notifying the physician, or other appropriate practitioner, or the IDG regarding the patient's failure to have a bowel movement during this time period. There was no documentation to indicate the hospice skilled nurse implemented any interventions to address the patient's failure to have a bowel movement during this time period. A skilled nurse's note, dated 01/21/20, signed by the RN, Employee #65, indicated, "Constipation Yes - large soft stool removed from the rectum ... Diarrhea Yes - 2 large watery stools today which was going around the impaction ... small amt bright red blood noted with removal of impaction. pt and NF staff notified ... Impaction removed." During an interview conducted on 03/10/20 at 12:39 p.m., with the RN, Employee #65, when asked regarding Patient #7 the RN, Employee #65, said she could not recall if the hospice aide told her about the patient not having a bowel movement or not. The RN, Employee #65, said the NF called her and said the patient had an impaction. The RN, Employee #65, said she could not recall if any interventions were implemented to address the patient's constipation between when the hospice aide first reported the issue and the date she removed the impaction. A policy titled, "Interdisciplinary Team, Coordination of Care and Services," dated 01/15/09, indicated, "The IDT will prepare a written plan of care for each patient/family, which specifies the care and services necessary to meet the patient/family-specific needs identified in the comprehensive assessment ... the IDT, in its entirety, will supervise the care and services ... A registered nurse, who is a member of the IDT, will be designated to provide coordination of care and will ensure continuous assessments of each patient's/family's needs, and implementation of the IDT plans of care ... All hospice care and services furnished to patients/families will follow an individualized written POC established by the hospice IDT in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's needs ... Content of the Plan of Care will reflect patient/family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation/management of the terminal illness and related conditions ... Interdisciplinary Team Conferences will be held during the course of patient care to monitor and evaluate the patient's progress, at least every fifteen (15) days, or more frequently if warranted by the patient's condition. Communication regarding the patient's plan of care is not restricted to the formal case conference, but includes informal verbal and written communication among all staff members providing care. This will serve as documentation of effective interchange and reporting, as well as coordination of care. Documentation in the clinical record will also reflect coordination with community resources, as well as other care providers ... The intervals for Interdisciplinary Team Conferences are dependent on the patient's condition, response to care, and the frequency of care provided ... A revised POC will include information from the patient's updated comprehensive assessment and will note the patient's progress toward outcomes and goals specified in the POC."
L0579
L0579	27748 Based on observation and record review, the hospice failed to ensure staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases including the use of standard precautions for 1 of 1 (Patient #7) in that the skilled nurse failed to ensure equipment used to assess Patient #7 was appropriately cleaned prior to using the equipment on the patient. This failure resulted in the skilled nurse using equipment to assess Patient #7 which had not been appropriately cleaned prior to use and could have resulted in the transmission of infection or infectious agents. The findings included: During an observation conducted on 02/27/20 at 9:00 a.m., the surveyor observed the LVN, Employee #57, place her nursing bag on a table in a common area in the nursing facility where Patient #7 resided and take out her thermometer, pulse oximeter, and blood pressure cuff. The surveyor observed the LVN, Employee #57, to clean this equipment and then place the cleaned equipment directly onto the table with no barrier between the clean equipment and the table. The LVN, Employee #57, was then observed to proceed into Patient #7's room and assess the patient using the thermometer, pulse oximeter, and blood pressure cuff without cleaning the equipment again prior to using it on the patient. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Infection Control Plan," dated 01/01/18, indicated, "The Agency will follow accepted standards of practice, including the use of standard precautions, and as needed transmission-based precautions, to prevent the transmission of infections and communicable diseases."
L0645
L0645	27748 Based on interview and record review, the hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers for 1 of 1 (2019) year reviewed. This failure could have contributed to the hospice providing volunteer services in an amount that equaled less than 5% of the total patient care hours of all paid hospice employees and contract staff for the year of 2019 and could have resulted in patients and families failing to receive volunteer services necessary to meet the patients' and families' needs. The findings included: Review of the hospice's volunteer percentage documentation, for the year of 2019, indicated the hospice had only provided volunteer services at or above the 5% level for one month during the year of 2019 (January 2019). The surveyor provided the hospice with a note asking the yearly percentage for the hospice's volunteer services for the year of 2019. The hospice returned the note with additional documentation by hospice staff which indicated the yearly percentage of volunteer services for the year of 2019 was, "2.5%." There was no documentation provided to indicate the hospice attempted to recruit or retain volunteers during the year of 2019. During an interview conducted on 02/26/20 at 1:36 p.m., the volunteer coordinator, Employee #56, said she has only been in the volunteer coordinator position since mid-December 2019. The volunteer coordinator, Employee #56, said the hospice provided volunteer hours at 2.5% of the hours provided by employees and contractors for the year of 2019. The volunteer coordinator, Employee #56, said she was not aware of and had no documentation of efforts to recruit more volunteers or to implement other interventions to ensure the 5% requirement was met prior to her taking the position in December 2019. During an interview conducted on 03/04/19 at 1:04 p.m., with the administrator, Employee #50, when asked regarding the hospice's failure to meet the requirement to provide volunteer services in an amount that equaled 5% of the total patient care hours of all paid hospice employees and contract staff, the administrator, Employee #50, said the hospice had no other documentation/information regarding the volunteer percentage of hours for 2019. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Volunteers," dated 06/01/08, which indicated, "Agency will document and maintain a Volunteer staff sufficient to provide administrative and direct client care staff in an amount that at a minimum, equals to 5.0% of the total patient care hours of all paid hospice employees and contract staff ... Agency will document the following ... Volunteer recruitment and retention efforts."
L0647
L0647	27748 Based on interview and record review, the hospice failed to ensure volunteers provided services that at a minimum equaled 5% of the total patient care hours of all paid hospice employees and contract staff for 1 of 1 (2019) year reviewed. This failure resulted in the hospice providing volunteer services at a lower rate than required and could have resulted in patients and families failing to receive volunteer services necessary to meet the patients' and families' needs. The findings included: Review of the hospice's volunteer percentage documentation, for the year of 2019, indicated the hospice had only provided volunteer services at or above the 5% level for one month during the year of 2019 (January 2019). The surveyor provided the hospice with a note asking the yearly percentage for the hospice's volunteer services for the year of 2019. The hospice returned the note with additional documentation by hospice staff which indicated the yearly percentage of volunteer services for the year of 2019 was, "2.5%." During an interview conducted on 02/26/20 at 1:36 p.m., the volunteer coordinator, Employee #56, said she has only been in the volunteer coordinator position since mid-December 2019. The volunteer coordinator, Employee #56, said when the individual who was previously in this position left employment with the hospice she took many of the hospice's volunteers with her. The volunteer coordinator, Employee #56, said the hospice is currently in the process of putting out flyers and advertisements to find new volunteers. The volunteer coordinator, Employee #56, said the hospice provided volunteer hours at 2.5% of the hours provided by employees and contractors for the year of 2019. The volunteer coordinator, Employee #56, said she was not aware of and had no documentation of efforts to recruit more volunteers or to implement other interventions to ensure the 5% requirement was met prior to her taking the position in December 2019. During an interview conducted on 03/04/19 at 1:04 p.m., with the administrator, Employee #50, when asked regarding the hospice's failure to meet the requirement to provide volunteer services in an amount that equaled 5% of the total patient care hours of all paid hospice employees and contract staff, the administrator, Employee #50, said the hospice had no other documentation/information regarding the volunteer percentage of hours for 2019. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Volunteers," dated 06/01/08, which indicated, "Agency will document and maintain a Volunteer staff sufficient to provide administrative and direct client care staff in an amount that at a minimum, equals to 5.0% of the total patient care hours of all paid hospice employees and contract staff."
L0665
L0665	27748 Based on interview and record review, the hospice failed to ensure a physician designated by the hospice assumed the same responsibilities and obligations as the medical director for 1 of 1 (02/25/20 - 03/11/20) time period reviewed. This failure resulted in the hospice having no back up physician designated to meet the responsibilities and obligations for patient care in the event the medical director was unable to provide services. This failure could have resulted in the hospice being unable to meet patient medical needs and could have resulted in harm to patients or patient/family dissatisfaction with services. The findings included: During the survey conducted from 02/25/20 - 03/11/20 the surveyor made multiple requests to review the hospice's documentation regarding the alternate or backup medical director designated by the hospice to assume the responsibilities and obligations of the medical director in the event the medical director was unable to fulfill these responsibilities and obligations. There was no documentation provided by the hospice regarding an alternate or backup medical director. During an interview conducted on 03/04/19 at 1:04 p.m., the administrator, Employee #50, said the hospice does not have an alternate medical director. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Agency Statement," not dated, which indicated, "----------- (name of the hospice) ... will participate and be in compliance with federal, state, and local laws and regulations." A policy titled, "Responsibilities of the Administrator," dated 01/01/18, indicated, "The Agency defines the responsibilities of the Administrator, to include, but not be limited to ... Ensuring the Agency ... is/are in compliance with all applicable federal, state, and local laws and regulatory agencies related to the health and safety of patients."
L0781
L0781	27748 Based on interview and record review, the hospice failed to provide the SNF/NF with the required information for 4 of 4 (Patient #4, Patient #5, Patient #7, and Patient #12) patients for whom the surveyor reviewed the hospice's documentation in the SNF/NF in that: The hospice failed to provide the nursing facility where Patient #7 resided with the following documentation: the patient's most recent update to the IDG plan of care; and The hospice failed to provide the nursing facility where Patient #4, Patient #5 and Patient #12 resided with the following documentation: the patients' certifications or recertifications of terminal illness and the patients' care plans, plans of care, or IDG updates to the plan of care. This failure resulted in the SNF/NF having incomplete documentation regarding the hospice's services and plan for these patients and could have resulted in an inability to effectively coordinate care between the hospice and the SNF/NF to ensure the patient's goals were met and care was provided in an appropriate and effective manner. The findings included: Patient #7: On 02/27/20 at 9:00 a.m., the surveyor conducted a visit with Patient #7. Following the interview with Patient #7 the surveyor requested to review the documentation provided to the SNF/NF by the hospice for this patient. The hospice LVN, Employee #57, and the SNF/NF charge nurse for Patient #7 both said they were not sure where this documentation would be located as both the SNF/NF and the hospice use electronic medical records. When asked if the hospice had access to the SNF/NF's EMR or if the SNF/NF had access to the hospice's EMR both the SNF/NF charge nurse and the LVN, Employee #57, said, no. When asked if the hospice had a designated place in the nursing facility's records where the hospice included their documentation, the SNF/NF charge nurse said if the hospice had a section where the hospice's documentation was included in the SNF/NF's EMR she did not know where this was located and did not know how to access it. The SNF/NF charge nurse reviewed the SNF/NF's EMR with the LVN, Employee #57, and the surveyor. There was no documentation from the hospice included in the SNF/NF's EMR other than orders for medications which the SNF/NF charge nurse said had been given by the hospice staff on paper orders and then transcribed by the SNF/NF into the EMR. The LVN, Employee #57, did then locate a hospice binder at the nursing station. The SNF/NF charge nurse said the only documentation she knew about having from the hospice in this binder was the patient's DNR order. The surveyor then reviewed the hospice binder. The surveyor noted that all the documentation included in this binder was either dated as having been printed on 02/27/20, the date of the surveyor's visit to the facility, or did not have a date it was printed included on the form. The SNF/NF charge nurse looked through the hospice binder and said in a surprised tone that there was documentation in there. The surveyor noted the following regarding the hospice binder - a care plan dated for 01/07/20, the patient's start of care date, was present in the binder. There was no date included to indicate when this form was printed. This was the only care plan or plan of care found for the patient. There were no updated plans of care, care plans, or IDG updates to the plan of care located in the binder or in the EMR at the SNF/NF for Patient #7. Review of the hospice's clinical record for Patient #7 indicated the patient had a start of care date with the hospice of 01/07/20 and had IDG updates to the plan of care conducted on 01/15/20, 01/29/20, 02/12/20, and 02/25/20. Review of the documentation provided by the hospice to the NF for Patient #4, Patient #5, and Patient #12, located in hospice binders kept at the SNF/NF's nursing station, did not include the following documents for these patients: There were no certification or recertifications of terminal illness; and There were no care plans, plans of care, or IDG updates to the plan of care. During an interview conducted on 02/27/20 at 3:35 p.m., with the SNF/NF charge nurse, when asked regarding the nursing facility's record keeping system, the SNF/NF charge nurse indicated the SNF/NF uses paper records and does not utilize an EMR at this time. When asked if there was anywhere other than the hospice binders where the hospice documentation might be located, the SNF/NF charge nurse allowed the surveyor to review the SNF/NF patient records to ensure no hospice records were included in these records and said she would check with the SNF/NF's ADON to see if there was any other place the hospice documentation might be located. The SNF/NF charge nurse left briefly and upon returning said she had spoken with the ADON for the SNF/NF and the SNF/NF ADON said any documentation provided by the hospice would be included in the hospice binders provided to the surveyor for review by the SNF/NF and there was no other place the hospice documentation for these patients would be located in the SNF/NF. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Hospice Care in a SNF/NF or ICF/IID," dated 08/01/15, which indicated, "The Hospice will provide the Facility with the following hospice information/documentation on admission and on-going ... The most recent hospice plan of care specific to each patient ... The physician certification and recertification of the terminal illness specific to each patient ..."
L0798
L0798	27748 Based on interview and record review, the hospice failed to maintain current licensure as required by state law for 1 of 1 (11/01/19 - 03/11/20) time period reviewed. The hospice's failure to maintain current licensure resulted in the hospice failing to comply with state and law and could have resulted in client's being dissatisfied with services in the event they were not aware they were receiving services from a hospice which was not currently licensed. The findings included: Review of the hospice's current licensure status in TULIP, the electronic record keeping system for DADS, indicated the hospice's license had an expiration date of 10/31/19. The hospice's license status was listed as, "Expired." Review of the hospice's license posted in the hospice's office indicated the license had an expiration date of 10/31/19. During an interview conducted on 02/25/20 at 1:20 p.m., with the administrator, Employee #50, when asked the reason the hospice's license had not been renewed after the expiration date of 10/31/19, the administrator, Employee #50, said she may have forgotten to do this and she would check to see if the hospice had done anything about this. During an interview conducted on 02/25/20 at 2:15 p.m., the administrator, Employee #50, said several months ago the hospice had attempted to renew their license and at that time they were told they could not renew the license as it was too soon. The administrator, Employee #50, said, it was "my bad" that the license was not renewed. Review of the hospice's policy and procedure manual indicated the hospice had adopted a policy titled, "Agency Statement," not dated, which indicated, "----------- (name of the hospice) ... will participate and be in compliance with federal, state, and local laws and regulations." A policy titled, "Responsibilities of the Administrator," dated 01/01/18, indicated, "The Agency defines the responsibilities of the Administrator, to include, but not be limited to ... Ensuring the Agency ... is/are in compliance with all applicable federal, state, and local laws and regulatory agencies related to the health and safety of patients."