VERMONT AGENCY OF HUMAN Sl RVICES DEPARIMENT OF DISABILITIES AND INDEPENDENT LIVING November 22, 2013 Tracey Cliellis, Administrator Bayada Hospice 316 Main Street Unit Eli-6 Norwich, VT 05055-4428 Provider ID #1471510 Dear MS. Division olLiccnsing and Protection 103 South Main Street, Ladd I-Iall aterbury' VT 05671 {3.3 06 Voice/TTY (802) 871?33] 7 To Report Adult Abuse: (800) 564-16 l2 Fax (802)871-3318 Enclosed is a copy of your acceptable plans of c01rection the surveyr conducted on. August 7, 2013. Follow?up may occur to verify that substantial compliance has been achieved and maintained. Sincerely, Lap/L - . .I [Ari/V" Frances L. RN, MSN, DBA Assistant Division Director State Survey Agency Director 1:th Disability and Aging Sewices Licensing and Protection Blind and'Visually Impaired Ir'ocational Rehabilitation RECEIVED Division of . TED: 09 069013 DEPARTMENT OF HEALTH AND HUMAN SERVICES 5.13 FORMAPRROVED CENTERS FOR MEDICARE 8.: MEDICAID OMB NO. 0938?0391 STATEMENT OF (Xi) MULTIPLE CONSTRUCTION Licensing and ore) DATE SURVEY AND PLAN or CORRECTION NUMBER: A BUMING Protection COMPLETED 471510 8- - .. oe/omots NAME OF PnovIoEn on suppose smear ADonEss, Cnv. STAT E, 316 MAIN STREET EH-s BAYADA NORWICH, VT 05055 (X4) :3 SUMMARY STATEMENT OF l0 PLAN or cons ECTION rxo PREFIX (EACH DEFICIENCY MUST as PHECED Eo av FULL PREFIX IEACH connECnVE ACTION SHOULD BE COMPLETION mt; REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE L000 INITIAL COMMENTS L000 I An unannounCed on~site complaint investigation was Conducted on and cempleted on by the Division of Licensing and Protection. The following are Hospice regulatory findings. 509 (ii) EXERCISE OF 509 During survey process all hospice clinical managers RIG HTSIR ES PE CT FOR PROP RTYIPERSON and directors in hospice parent and multi locations reviewed policy 0-933 Reporting and . documentationt 0-4595 Vermont State Law Reporting [The hDSpice mQSt-i . Requirements Child Adult AbuselNegtect and policy (Ii) Immediately InvestIgate all alleged violations 0273 Theft dams, involving anyone furnishing Services on behalf of Area Director and Asaocme Director further the hospice and immediatelytake action to investigated the chart and loond the Clinical manager prevent further potential violations while the visited the home on 4t26 to investigate the missing - - - - . - medication. Documentation shows evidence that the aileged ?ma?a? IS Pemg verified. Investigations care kitwas intact on 4t22. Clinical manager was and/0r documentation 01 an alleged Y'alamns reminded to encourage clientfcaregiver to contact must be conducted in accordance pom for suspected the? eSIabIIShed procedures, A audit of 100% of all incident reports and complaints will be conducted by the office directors through 1Q 2014 to ensure that incidents or complaints are reported to the state in accordance . . . ll -- This STANDARD is not met as evrdenced by: ?swat?" an? to co" "m azpropnale ?p Based on record reView and interviews the T: for implementing HospIce failed to Immediately Investigate and/or the plan of correction with oversight by the area document of all alleged Violations conducted In . . . directory aCCOrdance Wlih established procedures for applicable client (Client 1) Findings includeanonymous telephone call to the ?3 I of Licensing and Protection (DLP) on 04/30/13reported that "someone took [clientirlt morphine and Lorazepan from [the] Comfort Care Kit. 7 S) iZA-i Client's morphine was missing and discovered on I .1 04/2513 at 9:30 Per record review on 08]05/15 and 08/07f13 a narrative note from the on-call nurse dated 04/25/13 at 9:45 PM states "Help line of breath (SOB) I TU RE ?l?l TLE (X6) DAT IEDORATDRY it i?lil3 Any de?ciency statement end?g den'ghs a deficiency which the institution may be excused from correcting providing it is dctenniried that other safeguards provide sufficient protection to the patients (See instructions.) Except for nursing homes, the ?ndings stated above are disclosable 90 days following the date oi survey whether or not a plan of correction is provided For nursing homes, the above ?ndings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. It de?ciencies are tzlted. an approved plan of correction is red uisilc to continued program participation. FORM Previous Versions Obsolete Event ID: Facility lD: 471510 Ii continu?rion sheet Page 1 01 11 PRINTED: 09l0612013 DEPARTMENT OF I HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOFI MEDICARE MEDICAID SERVICES . OMB NO. 0938-0391 STATEMENT OF {x1} PROVIDERTSUPPLIERJCLIA MULTIPLE CONSTRUCTION (xs) DATE SURVEY AND PLAN OF CDRRECTION NTIFICATION NUMBER: COMPLETED 471510 a. WING 08107/2013 NAME or: DR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP cDoE BAYADA HOSPICE 316 MAIN STFIEET UNIT EH-G NORWICH, VT 05055 (my SUMMARY STATEMENT OF DE ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MU sT BE PHECEDFD eY FULL PREFIX (EACH ACTION SHOULD BE COMPLETEDN TAG REGULATORY OR IDENTIFYING TAG To THE APPROPRIATE DATE DEFICIENCY) 509 Continued From page 1- 509 to give morphine, none In house, no pharmacy open, oxygen on, suggested 0.5 mg Lorazepam Per a care coordination note dated 04/26/13 {no time} the physician wrote "spoke with [staff] at Hospice who reports that family reported missing bottle of morphine Iast night and suggests it may have been taken by an aidethat Is no longer working in home, this is first such incident field staff should continue to be vigilant about reported frequency of med vs remaining amounts and counsei family to store controlled substances in locked cabinet or box." A care coordination note written by the Associate Area Director on 04/26/13,{ no time noted} states called [sister] at 9:30 AM to verify morphine is missing from Comfort had not checked comfort kit recently and does not know when it went missing, she does not know who took the morphine, comfort kit expires May 7 so I advi3ed we will ask [physician] to order new one. I suggested she put the kit In a different location and check it regularly when the nurSe visits." Per the Client Occurrence Report dated 04/26/13 at 12:41 PM a ?family called Hospice evening of 04/25/1310 report morphine was missing from comfort care kit, ativan was given used to relieve SOB on call nurse notified me on evening of 04/25/13 ..notified 04/26/13 attending [not in office today] medical director notified new orders for comfort care Only property involved is morphine, reviewed plan with [nurses]". Per review of the HOSpice's policy 0-983 Incident Reporting and Documentation #23 medications/property. The staff are instructed per #50 inform the clinical manager immediately, S/he makes a home visit within a reasonable amount of timc.. completes an incident report on site and follows the policies FORM Previous Versions Obsolete Event ID: MP2011 Facifity ID: 4?1510 If continuation Sheet Page 2 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 09/06/2013 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CDRRECTIUN PROVI DE IDENTIFICATION NUMBER: 471510 MULTIPLE CONSTRUCTIO A. BUILDING B. WING (X31 DATE SURVEY COMPLETED 08/07/2013 NAME OF PROVIDER DR SUPPLIER BAYADA HOSPICE "Ernest ADDRESS. any, STATE. ZIP CODE 316 MAIN STREETUNIT EH43 NORWICH, VT 05055 (X4) lo PREHX TAG SUMMARY STATEMENT DF DEFICIENCIES (EACH DEFICIENCY MUST BE PHECEDED BY FULL REGULATORY OR LSC IDENTIFYING ID PREFIX TAG PROVIDERS PLAN OF CDRR ECTION (EACH CORRECTIVE AU SHOULD BE RE PERENCED TD THE APPROPRIATE (X5) COMPLETION DATE L509 L513 Continued From page 2 for specific follow?up and reporting procedures: f. Theft claims #0-273 Perthe poiicy0-278 Theft Claims #1.1 gather facts [who,what,when,where, why] surrounding the alleged loss. 1.2 the client/caregiver should be encouraged to contact focal police. 2.2 Client service manger, clinical manager ctr-Office Director should attempt to gather more facts or determine what may have occwred by speaking with any family, other caregiversand any third Per interview the Associate Director on 08/05/ 13 at 10:45 AM stated "we had no idea when the medication went missing or who took it" and acknowledged that s/he did not go out to the home or further investigate how the medication went missing by speaking with other witnesses, employees, caregivers or any third parties. S/he does not recall if the caregiver was encouraged to make a police report. S/he confirmed that the alleged violations were not investigated in accordance with established procedures. Per telephone interview on 08/08/13 at 4:16 PM a family member confirmed that the nurse went over the comfort care kit when the client was first admitted [on 05/23/12] but had not checked the kit since that time. The manager did not Come out to investigate nor was there a suggestion of making a report with the police or a follow up noted. The family member stated that "we never knew what came of it and that bothered me? Per interview on 08/07/18 at 1:33 PM the Hospice Director confirmed that the alieged violations of missing property were not investigated in accordance with established procedures. RIGHTS OF THE PATIENT [The patient has a right to the following:] 509 L513 The Plan and Discharge summary did not contain as to who will be following up with the client or family for identified issues. FORM Previous Versions Obsolete Event Facility ID: 471510 if continuation sheet Page 3 of 1t DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 09r'06l2013 FORM APPROVED 0MB NO. 0938?0391 client was ?not significantly declining'. Per review (2) Be involved in developing his or her hospice plan of care; This STANDARD is not met as evidenced by: Based on interview and record review the Heepice failed to involve one applicable client and/or client's legal representative in developing his or her HoSpice plan of care for discharge. (Client Findings include: 1. Per record review on 08/05/13 per a care coordination note by the Associate Director on 06/04/13 at 2:48 PM ?i spoke to [p hysician?s] nurse and eXplained the patient no longer meets medicare eligibility since last bleeding episode and EH treatment [client] has not had significant decline, will continue to have aides for daily assistance through other medical programs, discharge order obtained". Per the 06/04/13 nursing narrative note states "patient sitting on couch stouched to left side. [family] reports [client] has been suffering from diarrhea since on lett ankle continues to heal nervous but capable to continue to care without Heepice Service. Reviewed ABN documentation with [family] and explained that it [they] see changes in [client] to call noted that discharge will be effective Friday June 7, MUAC [Mid upper arm circumference] remains unchanged at 22." Per interview on 08/05/13 at 10:45 AM the Associate Director stated that the octor gave orders (06/04/13) prior to letting the family know services were being discontinued and prior to the (interdisciplinary group) meeting because the of the Assessment and Plan of Care update report dated 06/05/13 notes pertrom the physician states "suggested changes to current organization's division was notified and worked with the Elvira vendor to correct. Effective Dctober 22, 2013. the discharge coordination note will pull the needed information to the discharge summary. An education module will be developed for broader training on completing and documenting the discharge coordination note and summary, and executed by November 30, 2013. Education to medical director, clinical manager and manager to teach speci?c documentation when client no longer meets eligibility criteria completed on October 4, 2013 by Area Director. Area Director and Associate Director further intrestigated the chart and found discharge instructions written on a home instruction sheetwhich was signed by caregiver on date of discharge. ABN was isSued 3 days prior to discharge and signed by caregiver. . A audit of 20% of discharged client records will be conducted through 10 2014 for documented evidence that the client or legal representative has been involved in the discharge planning process and that referrals and services for ongoing care needs as stated on Distinct Outoo mes have been arranged and documented. The case managing clinicians, clinical managers and are responsible for the plan of correction with oversight by the director. Ore/duped (Poo. L: 61 STATEMENT OF DEFICIENCIES PFIOVIDEWSUPPLIEWCLIA MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED . A. BUILDING 471510 13- WING 08/07/2013 NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE. ZIP CODE BAYADA HOSPICE 316 MAIN STREET UNIT NORWICH, VT 05055 (X4) in SUMMARY STATEMENT OF ID Peovroen-s PLAN OF connecriorv rxsi (EACH NCY MUST BE PRECEDED BY FULL (EACH SHOULD BE COMPLETION TAG REGULATORY 0e LSC IDENTIFYING TAG TO THE APPROPRIATE DATE DEFICIENCY) Based an investigation into ?ndings by the . organization, it was identified that the EMR is not 013 From page 3 513 pulling accurate discharge planning information. The FORM Previous Versions Obsolete Event IDLMP2CI11 Facllity to: 471510 If continuation sheet Page 4 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 3 FORM APPROVED OMB NO. 0988-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIEFUCLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 471510 (X2) MULTIPLE CONSTRUCTION A. _m e. WING (X3) DATE SURVEY COMPLETED 08X07X2013 NAME OF PROVIDER OR SUPPLIER BAYADA HOSPICE STREETADDRESS, CITY, STATE, ZIP CODE 315 MAIN STREET UNIT NORWICH, VT 05055 in TAG SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 10 PLAN OF CORRECTION (X5) PREFIX CORRECTIVE ACTION SHOULD RE COMPLETION TAG CHOSS-HEFERENGED To THE WE L518 Continued From page 4 plan as follows: discharge visit planned for this Friday, [client] was given notice yesterday,ch needs met". However, the social worker states "problems: patient remains dependent on [family] for feeding and transfers experiences decreased appetite and mobility bUt may need to be Considered for discharge". Per the ?Distinct OutcOmes' for goats states 1) "patient transitions peacefully through the dying process-Not Met -additional time required to meet interventionigoal" 2) patientfcaregiveds) has decreased fearXanxiety regarding death and dying process-Not Met-additional time required to meet intervention/goatl 3) patients stress/anxiety is reduced to level of comfort - Not Met additional time required to meet intervention/goal". Per review of the the Plans and Discharge Summary there is no further information as to who will be following up with the client or family for identified issues as noted above, what other services are being referred and any coordination with other health and non-health professionals. Per interview on 8 at 4:15 PM the legal representative for Client #1 stated that the client andxor legal representative were not part of the discharge planning and stated "it was news to me, they just came in one day and said [client?s] arm was bigger and [client] was off service, no warning, no help after that, i really felt they left us high and dry, it was upsetting". The family member also stated that they were told that" [client] could come back on service if [client] got worse and when the [client] did get worse it took weeks to get help after calling for help". Per record review the family called on 07/03/13, the client was admitted on and died on Per interview on OBKOYKTS at 1:33 PM the Hospice Director confirmed that the legal L518 FORM Previous Versions Obsolete Event Facility ID: 471510 if continuation Sheet Page 5 of 11 PRINTED: USIUGKEUTB DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS MEDICARE MEDICAID SERVICES OMB NO. 0938-039_1_ STATEMENT OF DEFICIENCIES. (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED 471510 B. 08/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY.. STATE, ZIP CODE 316 STFIEET UNIT EH-G BA ADA SPICE NORWICH, VT ososs (xii) to SUMMARY STATEMENT OF ID PLAN OF- CORRECTION (EACH DEFICIENCY MUST BE PRECEOEO BY FULL PREFIX (EACH CORRECTIVE SHOULD BE TAG REGULATORY on LSC IDENTIFYING TAO CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 513 Continued From page 5 513 representative/Client were not involved in the care planning process for diSCharge, which would have included referrals for services and follow ups with health and non-health professionals. also 3' ea 551 CONTENT PLAN DF CARE 551 The Plan and Discharge summary did not contain Infomtatton as to who will be folloWIng up with the [The plan of care must include a? services client or family for identi?ed issues. . . Based on investigation into ?ndings by the necessary f0! The palliation and management Of organization. it was identi?ed that the EMR is not the terminal in? ass .8 nd related Gond?lonsj puf?ng accurate discharge pfanning information The Including the toilowmg? organization?s tT division was noti?ed and worked with (E) The interdisciplinary grou p?s documentation of the EMR ?end 0' 10 (wired- Effective October 22. the patients Dr representative's level Of 2013, the discharge coordination note will pull the needed information to the discharge summary. An mVOlvememt and agreement Wm] education module will be developed for broader the plan Of care, in accordance With the hospice training on completing and documenting the discharge own pOliCieS, in the clinical record. coordination note and summary, and executed by November 30. 2013. Education to medical director, clinical manager and This STANDARD is not met as evidenced by' manager to teach specific documentation Based on record reviews and imam; the when client no longer meets eligibility criteria . . . . . . completed on October 4, 2013 by Area Director. Interdis crpiinary group tailed document . . . . . 1 Area Director and AssoCIate Director further I 9 patients or representative 5 lave . investigated the chart and found discharge instructions understanding, involvement, and agreement With written on a home instruction sheetwhich was signed the plan of care, in accordance with the hospice?s by caregiver on date oldischarse- ABN was issued 3 own OiicieS, in the clinical record for 1 a piicable days prior to discharge and signed by care ive r. 9 Client (Client#1) Findings include: audit or20% of discharged client records rill be. conducted through 10 2014 for documented . . . vidence that the client or legal representative has 1- Per the DENY-04554 can involved in the discharge planning process and Early Client Discharge HOS DICE BWICG #30 If hat referrals and services for ongoing care needs as the determin es that the client no longer tated on Distin cl Outcomes have been arranged and meets eligibility requirements for hospice services ocumertted. discharge planning occurs as follows: the CiiOi'llFir caregiver are i?ClUded in the discharge The case managing clinicians, clinical managers and planning process and members of the DG are responsible for the plan of correction with provide Discharge Instructions'. versight by [h director. . Per interview on 08/065113 at 4:16 PM the legal . $61. (90 L, 5 I representative for Client #1 stated that the Client FORM Previous versions Obsolete Event to: MPEDH Facility 10:471510 if continuation sheet Page 6 of 11 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: cores/2013' FonM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES AND FUN 0F (er NUMBER: 471510 MULTIPLE CONSTRUCTION A. BUILDING B- WING (X3) DATE SURVEY COMPLETED 08/0772013 NAME OF ROVIDER 0R SUPPLIER BAYADA HOSPICE ADDRESS. CITY, STATE, ZIP CODE 316 MAIN STREET UNIT EH-G NORWICH, VT 05055 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OFI. LSC IDENTIFYING ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE L551 57 accordance with the hospice's own policies and Continued From page 6 andior legal representative were not'part oi the discharge planning and stated "it was news to me, they just came in one day and said [client's] arm was bigger and [client] was off service, no warning, no help after that, I really felt they Ielt us high and dry, it was upsetting". The lamiiy member also stated that they were told that [client] could come back on service it [client] got worse. Per interview on 08/07/13 at 1:33 PM the Hospice Director stated that there is no documentation of the plan of care for discharge from the IDS. S/he confirmed that the legal representative/client were not involved in the care planning process for discharge in accordance with the hospice?s own policies. also see L-513 COORDINATION OF SERVICES [The hospice must deveIOp and maintain a system of communication and integration, in procedures, to?] (4) Provide for and ensure the ongoing shan'ng of information between all disciplines providing care and services in all settings, whether the care and Services are provided directly or under arrangement. This STANDARD is not met as evidenced by: Based on record review and staff interview, Hospice start failed to assure that the ongoing sharing of information to assist with the care and services provided had occurred consistently for 1 applicable client. (Client 1. Per record review on Client #1 had L551 L557 Project committee was assembled on September 13, 2013 including Area Director, Associate Director. Clinical Manager RN, Manager MSW to create a standard operating procedure to document coordination of services including care plan oversight and communication and coordination of care with other non-hospice hearth care providers. Effective November 1, 2013, the standard precedure will be as Iollows and will be fully implemented by December 31, 2013: 1. Choices for care case managers will be entered under facilities in client reocrd so social workers and other team members know which agency and case manager ls involved. 2. Social werker will document communication with Choices care manager in notes andior :oordination notes. 3. RN case managers will compare non?hospice care alans with hospice care plan to ensure consistency of care. 4. Coordination of services question added to internal quality audit tool. FORM Previous Versions Obsolete Event Facility 471510 liycontinuation sheet Page 7 cl 11 DEPARTMENT OF HEALTH AND PRINTED: carols/2013 FORM APPROVED OMB NO. 0988?0391- CENTERS FOR 8: SERVICES STATEMENT OF DEFICIENCIEs on} MULTIPLE CONSTRUCTION txai SURVEY AND PLAN OF CORRECTION NUMBER: A COMPLETED . 471510 e. wr~c__ 08/07/2013 NAME oF PROVIDER OR SUPPUER STREET ADDRESS, CITY. STATE. come A AD HOSPICE 316 MAIN STREET UNIT EH43 A NORWICH, VT 05055 9(4) iD SUMMARY STATEMENT or DERCIENCIES Io PLAN OF CORRECTION (x5) PRE nx DEFICIENCY MUST BE BY FULL PREFEX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY on LSC IDENTIFYING lN TO THE APPROPRIATE DAV: A audit of 20% Ofdischarged client records - . will be conducted through 1Q 2014 for documented 557 Oommued From page 7 0?37 evidence that other providers of care serving the personal care services with the Bayada ChOiCes client have been notified ofdischalge from Hopsice for Care (OF C) program. There was no Care plan when it has occurred. noted in the Client's home record to indicate what Where The One?! was The case managing clinicians, clinical managers and discharged on 08/07/13 from Hospice however IDG are responsible for the pian ofcorrection with there is no documentation that this information oversight by the director. was also communicated with the CFC program. Per interview at 10:45 AM on 08/05/13 Q) 0 LS Associate Area Hospice Director stated that the personal care was provide ?on the home care side it {3 3W9 i? so they took care of [Client's] care" and" we didn't . if provide the aides but that occasionally there is communications with CFC, which in not evident in the records". S/he further stated "we as3umed the care plan was in the home and care is being provided and supervised? and confirmed that there waS no ongoing sharing of information regarding care provided under arrangement. Also see . - 5 Protect committee was assembled on September 13. 5?58 COORDINATION OF SERVICES . L5 8 2013 including Area Director. Associate Director. . . Ctinical Manager RN, Manager MSW to [The hospice must develop and maintain a create a standard operating procedure to document system of communicatiOn and integration, in coordination ofservices including care plan oversight accordance with the hospice's own policies and and communication and coordination Ofcare with 1 other non?heapice health care providers. Effective prOCe Utes. . . November1,2013, the standard procedure will be as (5) Provide for an ongoing sharing of information follows and wilt be fully Implemented by December 31, with other non?hospice healthcare providers 2013: furnishing Services unrelated to the terminal illness and related conditions. anag 9?9" are under facilities in client record 50 social workers and other team members know which agency and case This STANDARD is not met as evidenced by: - manager is involved. Basgd on record review and the 2. Social worker will document communication with Hospice Agency, failed to maintain ongorng Ch be IDG d; Communication and coordination of care with 0' 5 [fare manager "0 ?b a? or other non-hoSpice healthcare providers for one comma?? applicable client (Client Findings inCiUdB.? 3. RN case managers will compare no n?hospice care care plan to ensure consistency of care. FORM Previous Versions Obsolete Event IBIMPQOH Facimy 4r151o if continuation sheet Page of 11 OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 09f06l'2013 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF {x1} PROVIDERISUPPLIEFUCLEA (X2) CONSTRUCTION (st DATE SURVEY AND PLAN or CORRECTION IDENTIFICATION NUMBER: BUILDING 471510 8- WING carer/2013 NAME OF OR SUPPLIER STREET CITY. STATE, ZIP CODE BAYADA HOSPICE 316 MAIN STREET UNIT NORWICH, VT 05055 0(4) r0 SUMMARY TATEMFNT OF ID PLAN OF CORRECTION pREprx DEFICIENCY MUST BE PRECEDED eY FULL PREFIX CORRECTIVE AC I ION SHOULD BE COMPLETION TAG REGULATORY on ISO IDENTIFYING INFORMATION) TAG CROSS-REFERENCE: TO THE APPROPRIATE DATE DEFICIENCY) 4? Coordination of services question added to internal 558 Continued From page 8 558 quaIIty audit toolaudit Dr?ZD?irtr ofdischarged dient records [118ng?! .On 081013.} at ?sgt?rv: 1 S: will be conducted through 10 2014 for documented anagg a entor 80 Ions a 8 a 8 W3 evidence that other providers ofcare serving the client not noti?ed by Hospice that the client was have been noti?ed of discharge from Hospice when it discharged from services. Per record review on has occurred. 08/05/13 08/07/13 Client #1 had personal Care servIces with-the Bayada Chorces for Care. The case managing dinicians? mica! managers and (CFO) program With a case manager from Senior IDG are responsible for the plan of correction with Solutions. The ?clIent was discharged on 06/07/13 the dyed?. howeverthere Is no evrdence that the Case A . Manager was notified nor the CFC program. a Q30 Le 5.56 Per interview at 10:45 AM on 08/05/13 Associate Area Hospice Director stated that the 2} 9 ED @t personal care was not provided by Hospice "although there Was occasIOnal communiCation with the Case manage". S/he confirmed there was no evidence of com munications or conferences, of especially the to other Other heatthcare and non?health care prOviders furnishing services to the patient Also see 894 418.106 (9X2) (3) LABEL DISPOSE STORAGE 894 All stall were educated on the organization's policy for DRUGS Administration, labeling, Storage and Disposal of Controlled Substances {Tl?.282 by October 4, 2013. (2) Disposin Safe use and GIS rose! of Working group including Chief Nursing Of?cer, 9' . Director of Regulatory and QuaIIty SL1 port, Clinical conirplled drugs In the patientshome. The Support Specialist from Clinical Standards and Quality hospice must have Written policies and orrtota, Division Director of Policy Development, procedures for the management and disposal of Difleclor of Policy Pevelopment and Accrediiation controlled drugs in the patient's home. At the time 0: ?ce, ??9550" and 2 Dlledors discussed and review current policy for controlled when controlled drugs are first ordered the drugs on September 20' 2013 A hospice Speci?c hosptce must: policy to provide clear guidance to hos pice ?eld stall to ensure safety of clients and community in labeling disposal and storage of controlled substances is being . . . . eto ed for review th ot'c 'ew IDG nd This STANDARD :5 not met as evIdenced by:re; 2013 a Based on interview and record review. the ?prothe Chief Of?cer, DIvIsIon Dtrectorof Policy, i Agency faded 10 matmam COl'ltl?O ed degs In Area Director and policy review IDG are responsibte tor the plan of correction. FORM Elvis-256710299] Previous Versions Obsolete Event ID: Facility ID: 47'1510 WW L: I I3 Snow 9? tf continuationleet Page 9 of 11 DEPARTMENT OF t-iEALTi?i AND HUMAN SERVICES CENTERS MEDICARE 8i. MEDICAID PRINTED: 09/08/2013 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DE {x1} NUMBER: (X21 MULTIPLE CONSTRUCTION SURVEY COMPLETED accordance to the written policy and procedures for 1 applicable Client with the potential that effected all Hospice clients. (Cilentili) Findings include: 1. Per interview on 08/0/5113 at 9:30 AM The Hospice Director stated "no medication counts are done because it is their home". The nurse surveyor then asked about Schedule ll drugs narcotics such as morphine and how the medications are disposed. of. The Hospice Director then stated i'll have to look in our policy but I believe we do not need to do counts and we tell the client?s family how to get rid of the medications. Sometimes we witness and sometimes we?re not in the home when the tamily gets rid of medications. we should go out and witness but not always, we tell the family what to do and it is in the hand book?. Per record review Client #1 had a physician order dated 05/07/ 12 for a comfort kit which included the drug morphine. Per review of the of the Hospice's Policy under Bayada 0-282 Controlled Substances Administration and DiSposal 33.0 'The only medications that must be counted are scheduled ll substances. nurse is responsibietor noting that the count is correct or incorrect on the Narcotic Record #758." Also, #8 states In the event of the client?s death. controlled substances that were prescribed for the client sh0uld be inventoried and prOperiy a witness present. The nurse and the witness should sign Narcotic Record #758 in the appropriate secthn for disposal of medications." Per review of Client #1'5 chart there is no indication that nursing was performing a narcotic count for that medication nor checking to see if AND PLAN OF COHRECTION BUILDING 471510 e. WING 08/07/2013 NAME or: PROVIDER on suppose STREET ADDRESS. CITY, STATE. ZIP CODE BAYADA HOSPICE 316 MAIN STREET UNIT EH-s NORWICH, VT 05055 {xii} lD SUMMARY STATEMENT or: DEFICIENCIES lD PROVIDERS PLAN OF (x5) pngpix (EACH DEFICIENCY MUST as PRECEDED BY FULL PREFIX CORR ACTION SHOULD BE COMPLETION me oR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIE 694 Continued From page 9 894 FORM Previous Versions Obsolete Event ID: MPEOH Facility ID: 4T151O ll continuation sheet Page 10 of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PR INTED: 'l 3 FORM AP PROVE OMB No. STATEMENT OF DEFICIE NCIES (X1) PROVIDE (X2) MULTIPLE CONSTRUCTION DATE SURVEY FORM Previous Versions Obsolete MAN or IDENTIFICATION NUMBER: A. ENDING COMPLETED (3 471510 e. WING 08r07x2013 NAME or PROVIDER oR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE BAYADA HOSPICE 315 MAIN STREET UNIT EH-B NORWICH, VT 05055 W) In SUMMARY STATEMENT OF DE FICIENCIES ID PLAN OF CORRECTION {Ks} PREFIX DEFICIENCY MUST BE PHECEDED BY FULL PREFIX CDRHECTNE ACTION SHOULD BE COMPLETION m3 REGULATORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 694 Continued From page 10 694 the other medications. which included drugs, were outdated or otherwise unusable. The Narcotic Record #758 was not found in the client's record Per interview at 1:32 PM the Hospice Director Confirmed that per poiicy we should be doing narcotiC counts and that did not happen for[ Client as well as other clients at that time" and that the narcotic record was not used nor the witnessing of disposal of medications. . Event Facility iD: 471510 If continuation sheet Page 11 OT 11