PRINTED: OGIOQJZM 8 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF OEFICIENCIES (XI) PROVIOEWSUPFLIEWCLM (X2) MULTIFLE CONSTRUCTION (X3) DATE SURVEY rm PLAN OF connacnon A BUILDING common 0 251514 9- WW3 05i2512016 NAME OF PROVIDER OR STREETADDHESS. CITY. STATE, ZIP CODE PO BOX 502 TWIN LAKES HOSPICE. INC CLINTON, MO 54735 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x3) mam DEFICIENCY MUST as nasceoeo BY FULL enenx connacnve ACTION SHOULD as common TAG REGUMTORY 03 L30 IDENTIFYING INFORMATION) TAG To THE APPROPRMTE DAVE 000 i. 000 INITIAL COMMENTS -- A complaint investigation 5053 was completed on at Twin Lakes Hospice, 1 Interviews were conducted. The agency's . complaint log and policies were rewewed. The ailegations reported were veri?ed and Bureau a] Home Care and deficiencies are cited related to the ailegations Rehabilitative Standards Inc.. Four ciinicai records were reviewed and JUN 172015 complalnt is substantiated. One or more oi the being investigated. The agency's census was 35. Three condition ievet deficiencies were identi?ed during this complaint investigation and are being cited as part at this statement of deficiencies: -?418.52 Condition oi Participation: Patients rights (L500) -?418.too Condition of Participation Organization - and Administration of Services (L643) ?Piea SQQ a?I'I'acI'r Ed ~?418.108 Condition oi Participation: Short-term inpatient care (L704) 500 418.52 RIGHTS 500 This CONDITION is not met as evidenced by: Based on patient. caregiver and staff interview. review of policy I procedures, review of the agency' 3 complaint tog, and clinical record review, Twin Lakes Hoopice, inc. tailed to promote and protect each patient 5 rights in accordance with this condition of participation when the agency iatied to. ensure the hospice agency promoted and protected each patient 5 rights (L501) -ensure compiete documentation, investigation I and resotution oi complaints (L509) i ensure the patient health information remained confidentiai and safeguarded against unauthorized disclosure SQQ CI) 9 (I oraecrons on (pus 7 creme Zom- bu ear? o? Any de?ciency statement ending with an asterisk tea a de?ciency winch the institution may be omused from cenccting providing It is dotonrunod that tisnts. (See instructions.) Except tor nursing homes. the stated above are disclosahie 90 days other sateguards provide suiftcront protection to the ?own the date cl survey whether or not a plan of correction Is provided For nursing homes. the above ?ndings and plans oi correction are disciosabto 14 15 toi owns the date these docurnents are made availabie to the facility It de?ciencies are cited. an approved pian oi consonants requisite to continued program panicipetron. . FORM. Previous Version: Ohaoiote Event Fm?iry ID.M026I5N It continuation 511ng Page 1 of 31 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED. 06Mf2016 FORM APPROVED OMB N0. 0938-0391 CENTERS FOR MEDICARE MEDICAID SERVICES isrmeuem 0F DEFICIENCIES no) Peovmeaisuemewcm nee) MULTIPLE cotisrnuonon {x31 DATE SURVEY ?to PLAN OF euenws COHPLETED 26t514 8- WING 05i25I2016 was 0? PROVIDER on SUPPLIER STREET sponges. CITY. STATE, ZIP cope P0 sex 502 TWIN LAKES HOSPICE, CLINTON, MO ?735 pa} ID summv STATEMENT OF eenctencres ID Pnowoees PLAN OF connecrion [x5] peer-1x oencreecv musr es eneceoeo av FULL connecrlve Acnon SHOULD es on no REGULATORY on LSC mementos Tito cnoss-eescnenceo TO me APPROPRIATE 0W- DEFICIENCY) . I . (l 500 Continued From page 1 500 \gafbe 3122 a (16ti The cumulative effect of these systemic practices has the potential to reflect alt patients served by the hospice agency. 501 418.52 RIGHTS 501 The patient has the right to be informed 0! his or her rights, and the hospice must protect and promote the exercise oi these rights. This STANDARD is not met as evidenced by: Based on patient, caregiver and staff interview, I review oi policy I procedures, and clinical record I review, Lakes Hospice, Inc. tailed to promote and protect each patient 5 rights, in two (2) of tour (4) cases (RecordsiPatients and when the agency failed to: -Ensure the patients right to informed choice oi hospice care options when a patient transfers semce or revokes hoSpice benelit - (Recorleatient #1 and -Ensure con?dentiality of the patient clinical 5 record and health care information (Record/Patient i This de?cient practice has the potential to eifect all patients served by the hospice. I 1 Findings are: Review of the TLH Transler Policy states Twin Lakes Hospice will provide the necessary paperwork to the receiving iactlity such as nursing assessment. care plan, physician orders, medication list, discharge summary, history and physical and any other documents necessary to care tor the patient 0- FORM Frances Ve-mons (Jessie?s Event Feoiry ID: ii continuation sheet Page 2 at at DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE a MEDICAID SERVICES oerosizots FORM APPROVED OMB N0. 0938*0391 I STATEMENT OF DEFICIENCI ES PROVIDEPJSUPPLIEWCUA PLAN OF CORRECTION 261514 oonsmucnon a BUILDING 8 WING (XS) DATE SURVEY COMPLETED 05i2512016 we eaovtoea on SUPPLIER TWIN LAKES HOSPICE, eraser ADDRESS. orrv. STATE, 2i? cope PO BOX 502 MO 64735 in PREFIX TAG- SUWY STATEIJENT OF DEFICIENCIES (EACH OEFICENCY MUST 8E PRECEDED BY FULL REGULATORY OR L80 IDENTIFYING INFORMATICW) ID PROVIDERS PLAN OF CORRECTION PREFIX CGRHECTNE SHOULD BE m3 10 THE APPROPFI LATE DATE 501 Continued From page 2 . During interviews with the agency . administrator (05125116 at 10:45 AM) and on?cait nurse. RN-A (05l23/16 at 3:00 both veritied per Interview that it was'thetr belief that the patient was transferred to Hospice~i3 during the hours of 05109116. because there was a transiei form on the fax machine in the office the following morning on 05/1 on 6. RN-A stated it was a bad tax copy and the term was barely readable, all you could see was the name of Hospice-B on it. the term was mostly black. TLH administrator con?rmed the term was on the tax machine at the agency the morning of but was unable to prowde a copy of the form, stating the copy was so bad the only thing you could read was the name oi Hospice-B the rest at the term was black so we throw it away. The surveyors were unable to confirm it the term reported to be on the tax machine 05110/18 was a transfer form from Hospice-B, when the agency could not provide a copy or veri?cation of the forms existence The surveyors was also unable to conlirm why TLt-t stall believed the patient had been transferred during the nighttime hours oi when the hospice had not prowded Hospice-B with the necessary clinical intermation related to the patient 8 care to ensure the receiving hospice could satety care for the patient, as stated In TLt?i policy. Clinical record review revealed the patient died during the nighttime hours on 05109/16 with the patient 3 actual time of death documented at 3:10 AM on 05110116. Clinical record review failed to include I any documentation transter of the patient to Hospice-B per patient?s choibe. tum-u During an interview on 05123116 at 3:00 PM. RN-A stated he I she spoke with the staff paracn from Hospice-B sometime during the night of L501 FORM Versions Event Faci?ty to: it continual! on sheet Page 3 at St PRINTED: 0610912016 05/09r?1 6 but was unable to remember the exact time. The RN stated he I she spoke to this staff person Iron} Hospice-B by celi phone, but was unable to remember It the conversation occurred on Twin Lakes Hospice on~call phone or on FIN-A 5 private cell phone. was unabte to remember the name or credentials oi the person he 1 she spoke to from HospicevB. Fievlew at an incident report dated 05110116,reveated documentation that socks with a social worker from Hospice-B. but the RN tailed to document any conversation in the patient 9 clinical record and to remember any health care information that may have been revealed to an unidentified person from Hospice?B. I can?nu- uu? During an interview on 05/24r?16 at 4:06 PM, the patient son con?rmed a family iriend, who was a nurs e. worked tor Hospice-B and the iamily called this person to come help with the patient when the lamiiy was under the impression that TLH was putting out of the patient 5 care. The son stated I got a phone call from them on Monday (came/t 6). they (T LH) said they were done and wouldn be back. I According to the stait person from Hospice 8 requested send a blank transfer form to her and she would handle the rest oi the transfer. stated he {she took a picture 0! the hosptce agency? 5 transler term with the patient's name on the form and sent it by text to the staff person from Hospice B. RN-A tailed to verity the person 9 identity or the set! number the information was texted to, prior to sending patient information. RN-A also failed to ensure the patient inlormation remained contidentiai when the nurse . tailed to ensure the information sent by text was DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8t MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or {x1} 9(2) consrnucrron pro) om: SURVEY *iD new or connecrton NUMBER: A. eurtotno comma-rec 0 251514 8- WING 05i25I2016 NAME or eacwoen on supettert smear nooness. CITY. STATE, zrr:I CODE PO BOX 502 TWIN LAKES iNc CLINTON, MO 64735 on) ID sum srnrensnr or oer-rcusncres to showcase run or cor-rescuer: more: 0591093:th MUST es PHECEDEO BY PREFIX (EACH connecnve narrow SHOULD eE couiu'mn my, HEGUMTORY on Lee monument no caess-aerenencee to the metronome W5 eertcrencv) 501 Continued From page 3 t. 501 FORM OMS-Mtoz-eei Previous Versions Obsolete Event Fedity?.) It continuation sheet Page 4 at at PRINTED: OGJOQIQDIB DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8r MEDICAID SERVICES OMB N0. 093343391 OF DEFICIENCIES (Xi) PROVIDEWSUPPLIEHFCLIA (X2) MULTIPLE DATE SURVEY PLAN OF CORRECTION IDENTIFICATION 3. BUILDING COMPLETED 0 261514 *1 WING osraerzme STREETADUHESS. CITY. 3TATE. ZIP CODE NAME OF PROVIDER OH SUPPLIER TWIN LAKES HOSPICE, INC PO BOX 502 CLINTON, MO 64735 on} ID sunmnv srnrenanr or to pnovrosn-s sun or: conneorron has} pgenx user as eneceoeo av sou. (anon acnorr seems as comm no nacuuronv on L80 roermrverc monument no ceose-nsreneuceo To THE APPROPRIATE WE DEFICIENCY) 501 Continued From page 4 501 According to RNA he she spoke with the staff person from Hosoice 8 multiple times overnight oh 05109/16, but was unable to verity what intonnatlon was discussed or what phone the Information was discussed on. The RN stated he {she had the?on-call phone for TLH, but also used hlsmer personal cell phone at times. FIN-A was unabie to provide any documentation of the content of the actual text messagesstating her phone did not always keep text in memory and the memory from the on-call phone had probably been deleted by new. The agency tailed to promote and protect the pattent 3 right to malntain con?dentiat health information, when the RM texted information to an I unidenti?ed person and unidenti?ed cell phone number. FtesordiPatient 4: Review oi the clinical incident report iorm dated 12125/15 included documentation that the patieni' wile, was unhappy with care provided by TLH and was requesting transier to another hospice agency (Hospice-C). The portion of the Incident repert completed by the administrator stated noti?ed by (Hospice-C) that one of our patients I was seeking admission to their hospice . The administrator also documented talking to the patrent's wire and she reported she was advised to change to another hospice company and she a chess another hoopice company on 12/24415 . i 5 Clinical record review revealed the patient revoked hospice services on when the wife, who was the patient durable power oi attorney for health care, signed the revocation of hospice bene?t by patient choice form on ,a FORM Previous Versions Cheetah: Event tDt?eXtt?t Fedtity re: 1.1021515? rt continuation sheet Page 5 ct at DEPARTMENT OF HEALTH SERVICES 090912018 FORM APPROVED OMB NO. 09380391 CENTERS FOR MEDICARE a MEDICAID SERVICES Ismmem 0F oestcrencres on) eaovroanrsuppuervcm on) MULTIPLE {sz oars sunvev \iD PLAN OF COMECTION NUMBER: A. BUILDING COMPLETED 0 251514 WW0 NAME OF PROWDER OR SUPPLIER STREET ADDRESS. ClT?t'. STATE, .2th TWIN LAKES HOSPICE, INC PO BOX 502 CLINTON, MO 64735 (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEF ICIEHCIES (EACH DEFICIENCY MUST BE FRECEDEC BY FULL REGULATORY OR LSC IDENTIFYDIG WFORIMITION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION DEFICIENCY) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE XS) HON GATE L501 509 Continued From page 5 1224A 5. A progress note completed by FIN-C I dated 12/24r15 with no time documented. stated on soil nurse noti?ed that wife of pt (patient) was wanting to sign pt off TLH services. Wife stated she would like to revoke services as oi today. The clinical record documentation and incident report documentation failed to provide clear evidence that the patient {caregiver were tutly inlormed oi the rights related to revocation and transfer oi services. The agency failed to prowde clear documentation that the patient! caregiver was informed of all options related to their hospice bene?t and was allowed to make a knowledgeable choice to revoke hospice care or transfer hospice care to another provider. EXERCISE OF FOR PROPRTYIPERSON he hospice must] (ti) Immediately Investigate ali alteged violations Involving anyone services on behalt oi the hospice and immediately take action to prevent iurther potential violations while the alleged violation is being verified. Investigations andror documentation of all alleged violations must be conducted in accordance with estabiished procedures; This STANDARD is not met as evidenced by: Based on review of the agency's policy on grievance procedures, review at the events described in the agency complaint log, and Interviews, Lakes Hospice, inc. failed to ensure each grievance would be fully Investigated or documented in. nine (9) cl nine (9) complaints reviewed during this survey. . 501 ?Pineal? 32 Imad FORM Pronotrs Versions Obscicio Event tomsxm Faciity Ii con?rmation sheet Page 6 at 31 DEPARTMENT OF HEALTH AND HUMAN SERVICES 0610932016 FORM APPROVED OMB NO. 0938-0391 CENTERS FOR MEDICARE 8. srnravem OF osmorenctes err} Pnovteenrsuepuenrcm (x2; uumeua consraucrron not care suave-v .. mo PLAN OF connecrton memmtcarrou nausea; summer: commerce 0 261514 e. 05125i2016 srncernooeess. crrY. STATE. ZIP cope NAME OF enovroea on TWIN LAKES HOSPICE, MC PO sex so: CLINTON, MO 54735 This de?cient practice has the potential to affect all patients served by the hospice agency. Findings are. Fievievr oi the agency policy titled Policy Grievance revised date 3-2011. stated: Procedure: 1. A grievance report will be tilled out at the time oi the Incident is reported by the stall member who rs notified at the 2. The grievance report will be turned into the Director of Nursing, the Quality Assurance Coordinator or the Executive Director. The incident will be reviewed by the Ex. Director. the Director oi Nursing, and Quality Assurance. I 3. The Executive Director. Director oi Nursing i and for Quality Assurance Ccoidinator writ contact the patient and I or iamily in an attempt to resolve the incident. preterabiy In person. i 4. liTwrn Lakes Hospice is unabte to resolve the incident to the satisfaction of the patient and! or family the incident will be referred Medical Director. Executive master and I or the team involved in the grievance. 5. The incident will be reviewed to determine ii any policy and I or procedures need Updated. Review of the agency complaint ?le showed multiple incidents with incomplete complaint investigations and resolutions. Review of nine complaints dated tram through 01123115 revealed two separate terms used by agency start. one titled Incident Report and one titted Grievance Report During an interview on 0525/16 at 10:45 AM, the i administrator and director of nursing (DON) were I unable to explain the purpose at the two separate i terms or why some complaints were documented . to SUM STATEUEMF 0F to PROVIDERS Pun OF CORRECTION mam osncretcv near as PHECEDED er FULL ease-er (EACH ACTION secure as con?ne" no nacuuronv on Lee roarvamo er cnossanaranenceo To THE APPROPRIATE ME 509 Continued From page 6 t. 509 PORN Preston: Versions correlate event Fuerryio: ti continuation sheet Page 7 at 31 6 DEPARTMENT OF HEALTH AND HUMAN . FORM APPROVED - CENTERS FOR MEDICARE MEDICAID OMB NO. 0938-0391 [summer as (XI) snoutoemuemenrcua ore) (X3) oars SURVEY we PLAN OF conascrton NUMBER: a. COMPLETED C3 261514 3- WW5 name on on srnseraooness. snare, er coca PO BOX 502 TWIN LAKES HOSPICE. INC CLINTON, MO 64735 . pm to suumv or: to Pnovrosns PLAN or 0e) pgg?x pancrencv MUST as eneceoeo av FULL CORRECTIVE notion SHOULD as comm no REGULATORY on Lee wronrmiorn TAG cnoss-nerenenceo to THE APPROPRIATE WP- 509 Continued From page 7 509 on one term and some on the other. Complaint tit: Review of complaint #1 with a report date of 05/13/16 revealed documentation on the complaint term titled incident Report tailed to include the patient? name or the ctrnicai record associated with the complaint, the name and title oi the stall memberls) involved, and the name oi the patient 5 case manager. Documentation of the complaint investigation failed to include it a resolution was tound and ii the complainant was noti?ed of resolution. Complaint Review at complaint #2 with a report date of 05110/16 revealed documentation on the complaint form titted Critical incident Report failed to include the patient lull name or the clinical record associated with the complaint and any documentation that the patient 3 case manager was contacted or asked to be involved. when the atient 5 family was suddenly requesting transfer to another hospice. Documentation of the complaint investigation failed to include it a resolution was lound and it the complainant was notified of resolution. Complaint Review of complaint #3 with a report date oi 12124I15 revealed documentation on the complaint lorm titled Critical incident Report failed to include the patient '3 lot: name or the ottnicai record associated with the complaint. the name and hits olthe stall member(s) involved, and the name of the patient a case manager. Documentation oi the complaint investigation tailed to include it a resolution was tound and it the complainant was notified oi resolution. The I FORM Preview Versions Octolcto Event Faulty iD 1410261514 It continuation sheet Page a at 3'1 PRINTED: 06lo9i2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOFI MEDICARE 8. MEDICAID SERVICES OMB 0938'0391 I3TATEMENT OF DEFICIENCIES In} MULTIPLE CONSTRUCTION DATE SURVEY IO OF CORRECTION IDENTIFICATION NUMBER. COMPLETED 251514 WING 05125?2016 NAME OF PROVIDER OH SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE PO BOX 502 TWIN LAKES HOSPICE, INC CLINTON, MO 64735 :0 SUMMARY STATEMENT OF OEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X51 PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE CW TAG REGULATORY 08 L33 IDENTIFYING TAG GROSS-REFERENCEO TO THE DATE DEFICIENCY) i. 509 Continued From page 8 i. 509 complaint Involved the family requesting transfer to another hospice and reported being unhappy with clinical cares provided by the hoaptce stall. The complaint investigation failed to document discussion or counseling with stall involved with patient cares. and tailed to document notification or involvement at the patient 3 case manager. The complaint investigation failed to n?u-a include any documentation from the staff involved in the patient a care and tailed to document resolution of complaint including it any education or com petencies were veri?ed with clinical stall involved for a complaint where the complainant reported being unhappy with clinical cares provided to patient. Complaint Fteview oi complaint #4 with a report date of tam-tits revealed documentation on the complaint form titled Grievance Fteport tailed to include the patient 5 full name or clinical record associated with the complaint, the date the incident occurred. the name and title oi the staff memberts) involved, full name of person who lodged complaint and the name oi the patient 5 case manager. Documentation of complaint investigation tailed to include It a resolution was tound and iI the complainant was notified oi resolution. The form includes an area for employee signature and date, director oi nursing signature and date and executive director signature and data, not all of the signatures and dates were included on the completed complaint Investigation form contained only the executive director signature and date. Wes unable to verily if DON and i or emptoyee(s) were involved in complaint investigation 1 resolution. Complaint FORM Previous Versions Obsolete Event iD:NtiXiit Facility EMHOESISH it continuation shoot Page 9 at at DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE d: MEDICAID SERVICES PRINTED: 06109t?2018 FORM APPROVED 0MB NO. 09380391 Emission" or DEFICIENGIES (xi) ro PLAN OF mousse: 261514 MULTIPLE ION A. BUEDING 8 WING no; cars sunvev COMPLETED 05I25i2016 NAME OF PROVIDER OR SUPPLIER TWIN LAKES HOSPICE. INC STREETADDRESS, CITY. STATE. ZIP CODE PO BOX 502 cumon, no 34735 {2:4 to FIX TAG SUMMARY STATEMENT OF DEFICIEHCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY LSC IDENTIFYING INFORMATION) PROVIDERS PLAN OF CORRECTION ID {115) PREFIX (EACH connective some seems as 00th TAG camaeraaencso to THE menopause we OEFIC IENCY) 509 Continued From page 9 Review at complaint #4 with a report date of 09(17115 revealed documentation on the complaint term titled Patient incident Report tailed: to Include it a follow-up Investigation was completed when the hospice aide reported an incident to the social worker and the patient case manager. The complaint investigation tailed to document that the complaint was Investigated and ii a resolution was lound. ?-Odt??hwn Cemplaint Review of complaint #6 with a report date of 08/1215 revealed documentation on the complaint form titled Grievance Report revealed I the patient called and was unhappy with the care and services provided by the hospice. The i complaint investigation documentation tailed to include the name and title of the stall memberis) i involved in the patient 5 care and the name of I the patient 5 case manager. Documentation oi complaint investigation tailed to Include it a resolution was iound and it the complainant was notified of resolution. The term includes an area tor employee signature and date. director oi nursing signature and date and executive director signature and date. Not all oi the signatures and dates were included on the completed complaint investigation. The term included the executive director signature and date. Was unable to verily ii employee(s) were involved in complaint investigation Iresolutlon. Complaint Review of complaint #7 with a report date of 06111115 revealed documentation on the i complaint form titled Grievance Report tailed to I include the name and title of the stait memberis] involved. the full name oi person who iodg ed complaint and the lull name oi the hospice stati L509 FORM Previous Versions Obsolete Event Facility temperate? it continuation sheet Page 10 at at 10 PRINTED: DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID 0M8 NO 0938-0391 STATEMENT or: not PHOVIDEWSUPPLIEWCUA out momma consrnucnon {x31 oars suevav we aim or: connection NUMBER: A Bottom comers!) 0 261514 a. were 051251201 6 we or enovtosn on SUPPLIER cmr. stars. ZIP PO BOX 502 TWIN LAKES HOSPICE, INC CLINTON, MO 64735 out in susmnv STATEMENT OF to showcase PLAN OF more: must as Pascsoso av FULL PREFIX conascnve ACTION SHOULD as cc non ma aeoumroa?r on IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE care ossicumcn 509 Continued From page 10 t. 509 involved in the complaint. Documentation of the compiaint Investigation tailed to include documentation oi the actual complaint Investigation. the findings related to the investigation. it a resolution was found and it the complainant was noti?ed of resolution. Complaint Review oi complaint #8 revealed it was a two . page type when letter dated 02/17/15 written by - a patient 3 daughter. The daughter was reporting: concerns rotated to stall not responding to the i patient care needs and changes in the patient's condition. when the lamiiy called the I hospice staff and requested help. Although this letter was included in the agency complaint log. provided to the surveyors for review. The agency tailed to document an investigation related to the issues reported by the daughter in i the letter. included in the agency complaint log along with the letter were two progress notes printed from the pattent's clinical record. The first progress note dated mums at, 03:20 AM included documentation by RN-B of a phone conversation with the patient 3 daughter related to a change in the patient condition the nurse gave some advice over the phone but tailed to document it the patient I daughter was satisfied or: if the nurse offered a home visit to see the patient . and assess the change in condition. The second progress note dated tti21115 at 10:05 AM included documentation by HNIDON cl 3 phone conversation with daughter checking on patient s! conditton. The daughter reported the patient had a signi?cant change in condition, and stated the family requested the RNJDON not come see the patient at that time. Abriel handwritten note by the executive director was included on the ?rst progress note, tailed to Include a date and stated FORM cussesrtozest Previous Vernon: Obsctotc ?va Facilylo:m2l?lsm ll continuation sheet Page :1 at 31 11 PRINTED. 0641392018 DEPARTMENT OF HEALTH AND HUMAN SERVICES . FORM APPROVED . CENTERS FOR MEDICARE MEDICAID SERVICES 0MB NO. 0933-0391 envenom- on DEFICIENCIES no) PHOVIDEPJSUPPLEEWCLM no) MULTIPLE consmucnon DATE suavev "to PLAN OF conascmn IDENTIFICATION nuance. A. commerce 0 . 26151 4 a. WJNG 05i25i2016 we or Paovloen on seamen srnsenooness, crrv. ems. ZIP coca PO sex so: TWIN LAKES HOSPICE, INC CLINTON, MO 64735 on} Io summv smeuem on oamcrencres in Paovroees PLAN cs CORRECTION 9L5) mam {anon DEFICIENCY MUST es oneceoso av mu. (EACH connecnve netted SHOULD as comma TAG REGUIATOHY OR L56 IDENTIFYING TAG CROSS-REFERENCED 1'0 THE APPROPRIATE WE - 509 Continued From page 11 509 the executive director had assured her (patient's daughter) this would not occur again and apologized it she Ielt slighted in any way. The agency tailed to follow the agency grievance policy Ior complaint Investigations, i when the agency tailed to document the complaint on a compiaintt?grievance I incident I report term and failed to document any complaint i . I I I Investigation related to the daughter 5 concerns. Complaint Review oi complaint #9 With-a report date oi 01123115 revealed documentation on the complaint form titled Grievance Report failed to . include the full name and title at the hospice staff involved in the complaint and documentation oi the complaint Investigation, including If a resolution was found or If stall were educated related to any changes in policy and procedure lollowing the complaint Investigation. 516 RIGHTS OF THE PATIENT ?lgase Size 1.516 (5) Have a confidential clinical record. Access to or release of patient lolormalton and clinical records is peimitled in accordance with 45 CFR he patient has a right to the lollowing:] i i parts 160 and 164. i i This STANDARD is not met as evidenced by: Based on interviews with clinical staii. administrative staff and patientis) I famliy(s), Twin Lakes i-Ioepice. Inc. failed to ensure the patient? 5 . health information remained confidential and safeguarded against unauthorized disclosure I without speci?c lniormed the RN I texted and dlscussed patient health information i i I I I some awesome-ea) Pmeus Versions Obsolete Eve-ii tD.tiexm Facility ID: it continuation sheet Page 12 at at PRINTED 06109I2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS MEDICARE SERVICES . OMB NO. 0933-0391 0F DEFICIENCIES (Xi) (X2) MULTIPLE DATE SURVEY VD PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 0 251514 FF osrzeizots we 0F PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. 21? CODE PO BOX 502 TWIN LAKES HOSPICE, INC CLINTON, MO was ID SULWY STATEMENT OF ID PROMISES PLAN OF CORRECTION puts} (EACH DEFICIENCY MUST BE PHECEDED BY FULL PREFIX CORRECTME SHOULD BE commuit TAG 08 L30 INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE WW- . oencrenon 516 Continued From page 12 516 with an unidenti?ed celt phone number without verilying the recipient?s identity prior to discussing patient tniormation, in one (1) of tom (4) cases (Patient/Record This deficient practice has the potential to affect all patients served by the hospice agency. I Findings are: RecordfPattent 1: During an interview on osresne at 3.00 PM. RN-A stated he she spoke with the staff person from Hospice 8 sometime during the night of 05109/16 but was unable to rem ember the exact time. The RN stated he I she spoke to this staff person irom Hospice-B by cell phone, but was unabie to remember it the conversation occurred on Twin Lakes Hospice (TLH) on-cail phone or on 3 private cell phone. was unable to remember the name or credentials of the person he I she spoke to item Hospice-B. Review of an incident report dated 0511 0/1 6,reveaied documentation that RN-Aspoke with a social worker from Hospice-B, but the RN tailed to document any conversation In the pattent 3 clinical record and tailed to remember any heaith . care inlermatton that may have been revealed to an unidenti?ed person from Hospice~B. During an interview on 05i24/15 at 4:06 PM. the patient 3 son con?rmed a family lriend, who was a nurse. worked tor Hospice-B and the family called this person to come help with the patient when the family was under the impression that TLH was pulling out oi the patient? 5 care. The son stated i got a phone call from them on Monday (05/09/16). they (TLH) said they were done and wouidn be back. FORM Preston: Versions Obsomu Event to: Helen Faulty lo' 510281514 ?continuation sheet Page t3 cl 31 PRINTED: OSJOQIZOIS DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8- MEDICAID SERVICES OMB NO. 0938?0391 OF DEFICIENCIES {Xi} (X2) MULTIPLE GONSTRUOYION DATE SURVEY ?iD PLAN OF OORREGTION IDENTIFICATION A. Buwme 251514 WING 05125I2016 NAME OF PROVIDER on SUPPLIER STREEI ADDRESS. oIrY. 37MB, ZIP CODE Po Box 502 MM LAKES HOSPICE, INC CLINTON, MO 64735 {In} In SWMARY STATEMENT OF DEFICIENCIES to PROVIDERS PLAN OF CORRECTION PREFIX DEFICIENCY MUST BE PRECEDED BY PREFIX ACTION SHOULD BE TAG LSC IDENTIFYING TAG APPROPRIATE I. 516 Continued From page is 516 According to FIN-A. the stafi person irorn Hospice i requested send a blank transter term to Hospice 8 and they would handie the rest of the transfer. RNA stated he I she took a picture oi the hospice agency 5 transfer form with the patient's name on the term and sent it by text to the stat! person from Hospice 8. RN-A tailed to i verify the person 5 identity or the cell number the i tniormatlon was texted to. prior to sending patient information. FIN-A also tailed to ensure the patient '3 Information remained confidential when the nurse failed to ensure the iniormation sent by text 2 was (protected irom viemng by other persons). According to FIN-A he 1 she spoke the stait person from Hospice multiple times overnight 3 on 05/09}! 6, but was unable to verily what information was discussed or what phone the Iniormation was discussed on. The RN stated he [she had the on?cait phone for TLH, but also used hislher personal cell phone at times. RN-A was unable to provide any documentation oi the content oi the actual text messages stating her phone did not always keep text in memory and the memory irom the on?caii phone had probably been deleted by now. The agency to ensure the patient 5 health ?\?ctse $62 est?Ha chord iniormation remained confidentiai, when the FIN tested Inlormation to an person and unidentified ceit phone number. 343 413.100 ORGANIZATIONAL ENVIRONMENT I ere This CONDITION is not met as eutdenoed by: Based on staff interviews, clinical record review, contract review and policy/procedure review, I I Feats OMS-asertoz-ss} Pmtcus Version-s oosototo Event to-nsxm Feesrytomtozstsu ii continuation sheet Page 14 oi at DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES 06i09i2016 FORM APPROVED OMB NO. 0938-0391 [smeosm or OEFICIENCIES so sum or: (XI) PROWDEWSUPPLIEWCLM IDENTIFICATION 261514 pro) MULTIPLE consrnucnon {Ks} care sunvev can A. BUILDING B. WW6 ETED 05%!2016 were or Peovtoea on TWIN LAKES HOSPICE, iNc STHEHADDHESS. cnv, sure. cans so Box 502 CLINTON, MO 64735 TAG (x4) {0 sum STATEMENT on DEFICIENCIES PREFIX trance oeetomcv MUST as PHECEDED ev FULL neoumronv on Lee 1:450er PREFIX TAG enovtoaes pus OF CORRECTION on) (EACH CORRECTIVE acrtou SHOULD as am TO THE macentnre 04?? priority (L650) (L652) AND FAMILY priority. l. 648 Continued From page 14 Twin Lakes Hospice, inc. tailed to ensure compliance with this condition oi participation when the agency to: -ensure the hospice provided care that optimized the patient comfort and dignity, and was conSIstent with the patient and iarnilv 5 needs and goals. with patient needs and goals as -ensure the governing body assumed toil iegal authority and reaponsibtlity tor the hospice and provisions of all hoSpice services (L651) ensure the administrator is responsible and aware of the day to day operations of the hospice -ensure the hoopice provide short-term inpatient care (respite) when requested by patient I family The cumulative oileci of these systemic practices has the potential to affect all patients served by this hospice agency. 650 ?8.100(3) SERVING THE HOSPICE PATIENT The hospice must provide hospice care that- Optimizes comiort and dignity; and (2) is consistent with patient and iarnily needs and goals, with patient needs and goals as This STANDARD is not met as evidenced by: Based on staff interview, c?nical record review, and policy review, TWiil Lakes Hospice, Inc. tailed to ensure the hospice provided care that . optimized the patient comfort and dignity, and was consistent with the patient and family 5 needs and goals. with patient needs and goals as priority. in one (1) of four (1) ciinicai records F?I?nwmu? .- I I I 648 L650 ?ease see a?ihzcheci FORM Preston: Versions Obsolete Event tomato? Faulty l0: ti continuation shoot Page 15 0131 1? 15 DEPARTMENT OF HEALTH AND HUMAN sent/aces CENTERS FOR MEDICARE 8t MEDICAID SERWCES OMB NO. 0933-0391 0F DEFICIENCIES (Xi) 0(2) MULTIPLE DATE SURVEY COMPLETED \n PLAN OF CORRECTION nuueen: BUILDING 261514 5. WING 05i2512016 smear moaess. crrY. sure, ZIP CODE PO Box 502 With LAKES HOSPICE, INC CLINTON, MO 64735 put 10 5mm smrerrem or to Peoytoen-s pow 0F connecnort 1x5} CORRECTNE AOYION SHOULD as cow 1395th DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING TAG :0 THE APPROPRIATE . i NCY) NAME OF PROVIDER OR SUPPLIER 65.0 Continued From page 15 i 650 reviewed (RecordiPetient: 1). deficient practice has the potential to affect aft patients served by the hospice. Findings are: RecordfPatient 1: During an interview on 05123116 at 3:00 PM. FIN-A confirmed he I she was the once? nurse from Monday evening, osreerte at 4:80 PM until Tuesday morning. cartons at 8'00 AM. The RN verified that he I she received a phone cail from . the patient 5 son at approximately 11:00 PM . stating the tamity wanted the patient transferred to another hospice (Hospice-B) and that someone from Hospicepatient home. then stated he I she . ottered to come to the patient 3 home, but the son said to wait untif the person irem Hospice-B i i - "on. mun-mm- arriyed and they would be in contact with FIN-A. During an interview with patient' son on 05124116 at 4.RN-A offered to come to the patient a home dunng the night oi osrosne, the son replied empathicalty No, i clearly remember that, the nurse did not offer to come see my mother . he son also stated that it was the impression of the family that the hospice nurse would not be returning to see the patient. The son stated igot a phone oali irorn them (TLH) on Monday they said they were done and woufdn be back. The son stated his mother 3 condition had continued to deolrne over the weekend. stating his mother was unresponsive and bedridden on 0509/16. The son explained they had a family iriend from the same small town In I which the patient iived, who was a nurse that worked for Hospice-B and the family called to have the triend come see the patient and discuss Event Fadity It continuation sheet Page to oi 31 FORM cans-aserroees) Pro-nous Versions Obsolete DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8r MEDICAID SERVICES PRINTED 061'09r?2016 FORM APPROVED OMB N0. 0938-0391 cs oer-'tcteuctes ctr) Pnovrcearsueetreercm (X2) consrnucrtou (its) DATE SURVEY \Io PLAN OF coanecrton luENl'tFtCA?t'tON Hostess: a summer commerce 0 251514 aware NM 0F PROVIDER OR SUPHJEH STREETADURESS, ct?t?r?. STATE. ZIP CODE PO BOX 502 LAKE osprcE CLINTON, MO 64735 {xi} SUWY STATEMENTOF ID PROVIDERS PLAN OF CORRECTION mam (EACH DEFICIENCY MUST ea Paeceoeo e'r FULL enema: coaaecnvs action snouw es cmamt ran REGULATORY on 1.80 IDENTIFYING womarrom me caoss?aer-?eaencee To THE Manor?s tare DATE DEFICIENCY) L650 Continued From page re i 550 possible trensier, since the iamily had been toid TLH was pulling out due to issues with the tient's daughter, who was the patient pnmary caregiver. According to RN-A he I she spoke with the strait person from Hospice-B several times during the 5 night of 0509116 but was unable to remember I any exact times or com/erections. stated he I she took a picture of TLH transfer lorrn with the patient? name ?lled In and send it by text to the 1 staff person from Hospice-B. A?ccording to RNA he I she spoke with the staff person from Heepice 8 multiple times on 05109? 6, but was unable to verity what information was discussed. I I 1 During the interview on 05/2316 at 3:00 PM. I stated the normal procedure for transierring' a patient to the care of another hospice typically I does not happen in the middle oi the night and I Would be a process which would toiiow agency . policy. Including sending all needed information necessary to Care for the patient and report would . be called from the patient 5 case manager to the receiving hosprces clinical stall. During an interview with TLH administrator on 05f25!16 at 10:45 AM. the administrator stated the normal process tor a patient transfer would toiiow the . agency? 5 transfer policy. I i Review of the TLH Transfer Policy states Twin Lakes Hospice will provide the necessary paperwork to the receiving such as nursing assessment. care plan, physician orders. medication iist, discharge summary, histery and . physicai and any other documents necessary to care for the patlent. I Dunng tntenrrews wath TLH administrator FORM 945455310289) Preview Versions Cinders Event lD.H6X]tl ?0251514 it continuation sheet Page 17 at 31 17 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: SERVICES PRINTED. 0610912016 FORM APPROVED OMB NO. 0938-0391 0F DEFICIENOEES (X1) '10 PLAN OF CORREGTDN NUMBER: 261514 {x2} consrnucneu A. . WING (X3) DATE SURVEY COMPLETED 051232018 route 0F PROVIDER on SUPPLIER TWIN LAKES HOSPICE. INC STREETADDHESS. STATE. CODE PO BOX 502 CLINTON, MO 64735 (X4) i0 PREFIX 7A0 SUMMARY OF OEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDEO BY FULL REGULATORY 08 L36 IDENTIFYING ED PROVIDERS PLAN OF CORRECTION PREFIX CORRECT ACNON SHOULD BE me re THE APPROPR DEFECIENGY) cos DSTE DATE I. 650 Continued From page 17 (05I25I16 at 10:45 AM) and Fill-A (oerzene at 3:00 PM) both verified per interview that it was their beliet that the patient was transferred to Hospice-B dunng the overnight hours of 05/09f16, because there was a transfer form on the fax machine in the office the following morning on 05/10/16. RN-A stated it was a bad fax copy and the term was barely readable, all you could see was the name of HesplceB on it, the term was mostly black. TLH administrator confirmed the form was on the fax machine at the agency the of 05110116, but was unable to provide a copy ol the term, stating the copy was so bad the only thing you could read was the name at Hospice-8 the rest of the term was black so we throw it away. The surveyors were unable to con?rm it the term reported to be on the fax machine 05110116 was a transfer term from Hospice-B. when the agency could not provide a copy or veri?cation of the terms exrstence. The surveyors was also unable to contirm why TLH staff believed the patient had been transferred - during the nighttime hours of 05/09/16, when the hospice had not provided Hospice?B with the necessary clinical information related to the patient a care to ensure the receiving hospice could safely care for the patient, as stated in TLH policy. I i Clinical record review revealed the patient died during the nighttime hours on 05109116 with the I patient 9 actual time of death documented at 3:10 AM on 05/10/16. Clinical record review failed to include any documentation verifying transfer of I ?-umuw?H the patient to Hospice-B. TLH hospice failed to ensure statt provided care that optimized the patient comfort and dignity, when TLH stall stated the patient was transterred 650 FORM massacre-es) Previous Versions (3dech Event roman? FecityiD 9.0261514 ll contimatlen sheet Page 18 et 31 18 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE SERVICES 0630912016 FORM APPROVED OMB NO. 09380391 [emanate or oerrcrancuzs ?ro we: or: connecnon (Xi) PROVIOEWSUPPUEWCUA NUMBER. 261514 MULTIPLE A. BUKOING B. WING no) one suavev COMPLETED 0512SI2016 NAME OF PROVIDER OH SUPPLIER TWIN LAKES HOSPICE, smear appease. cmr. STATE. zip coca 90 Box 502 CLINTON, MO 64735 rx-n to summer srn?renem or: oer-'rcreeries pat-3H): DEFICIENCY MUST ea Paacsoeo av FULL m3 REGULATORY on LSC Lveo erotica} iD PREFIX TAG DEFICIENCY) Pnovrcees as connecnon (EACH coneeonve ACTION snow: as cnoss-nerenenceo TO THE APPROPRIATE DATE ADMINISTRATOR governing body. 650 Continued From page 18 to another hospice during the nighttime hours on 0509/16. and failed to recognize the transier process did not toliow agency policy. The hospice also failed to ensure the patient comfort and dignity were respected at the and of life. when the hospice nurse failed to provide any needed care or home visit at the and of tile. . Clinical record review revealed the patient died at 3:10 AM on 0510/16, RN-A did not make a visit . to the patient a home until 4:19 AM on canon 6. 651 418.100(b) GOVERNING BODY AND Agoverning body (or designated persons so functioning) assumes full legal authority and responsibi?ty for the management 01 the hospice. the provisron of all hospice services. its iiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is tor the day-to-day operation ot the hospice. The administrator must . be a hospice employee and possess education and eXperience required by the hospice's This STANDARD is not met as evidenced by' Based on statt interview, clinical record review. and policy review, Twin Lakes Hospice, inc. governing body and administrator tailed to assumed lull tegai authority and responsibility tor the hospice including proviswns of alt hospice services and tailed to ensure the administrator was and aware of the day to day operations at the hospice agency. This delicient practice has the potential to ailect all patients served by the hospice. i L650 i i u?n- -v - 651 ?Please See Hiachad FORM cms-zserroz-es) Prostate Versions Obsolete Event neon Facility Ii continuation sheet Page 19 at at 19 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED. OSMSIZDI 6 FORM APPROVED OMB NO. 0938-0391 CENTERS FOR MEDICARE a SERVICES entertain or oertctetvcras on} anovioenrsuwuenrcm MULTIPLE cousrnucriott (X3) oars sunvev vo PLAN or connecrrorv NUMBER: a BUILDING COMPLETED 25151:; was 0512512016 NAME OF Pnovroen on SUPPLIER smear ADDRESS. CITY. ewe. ZIP cooe Po BOX 502 . TWIN LAKES INC CLINTON.MO 64735 pm to SUMMARY statement or: oemtencres to Paovtoens PLAN OF connecnort {its} mm war as nnecaoeo ev FULL Peers: (anon connecnve snoum ea (:0qu m3 neeuuronv on Lee tar-'0 minnow TAG to THE APPaoine WE oeatcrervov) 651 Continued From page 19 651 Findings are: The governing body and administrator tailed to ensure complaints were fully investigated and resolutions documented. Review oi the agency compialnt flie showed multiple incidents with incomplete complaint investigations and resotutions. Review oi nine comptarnts dated tram 05(13116 through 01/23/15 revealed two separate tonne used by agency staff, one titted Criticet incident Report" and one titled Grievance Report . During an interview on 05125116 at 10:45 AM, the administrator and director 0! nursing (DON) were unable to explain the purpose oi the two separate forms or why some complaints were documented on one term and some on the other. (Cross reference L509) The governing body and administrator tailed to ensure a patient was provided with short term inpatient respite care when requested by the iamdy on 0510??!3 (Cross reference L852 and The governing body and administrator failed to ensure a patient was transierred per agency policy (Cross reference L501) The governing body and administrator failed to ensure agency staff maintained the con?dentiality of the patient heaith information I clinical record (Cross reterence L5i6) 652 SERVICES (1) A hospice must be primarily engaged in providing the ioliowing care and services and must do so in a manner that is consistent with accepted standards of practice' L652 . Mensa See enriched FORM Prev-Iota Versions omelet: Event ID.H5X1H Faulty to- It continuation sheet Page 20 or 31 20 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 CENTERS eon neotcnne MEDICAID SERVICES Barristers? 0F oerrotemies (x1) 1x2} HULTIPLE consrnucrton ore} care sunvev so PLAN or CORRecrIon numeen- a constants 0 261514 3 0512512015 STREET ADDRESS, STATE, ZIP CODE NAME OF pnovroen on suppose TWIN LAKES HOSPICE, INC PO BOX 502 CLINTON. MO 64735 SUP-LHARY STATEMENT OF DEFICIENCIES 4 to grim DEFICIENCY war as eneceoeo av FULL m3 neocuron'ron Icermwmo 652 Continued From page 20 (I) Nursing services. (it) Medical social services. (ill) Physician services. (iv) Counseling services} lnciuding Spiritual counseling, dietary counseling, and bereavement counseling. - Hospice aide, volunteer, and homemaker i services. (vi) Physical therapy, occupational therapy, and speech-language pathology services. (W) Short-term Inpatient care. Medical supplies (Including drugs and biotogicais) and medical appliances. STANDARD is not met as evidenced by: I Based on statt Interviews and clinical record review, Twin Lakes Hospice, inc. felted to ensure - the hospice provided hospice care and services consistent with acceptable standards. when the . hospice tailed to provrde the patient with short-term inpatient care when requested by the patient I family, in one (1) clone applicable cases I). This deficient practice has the potential to allect all patients served by the hooptce Findings are' Recorleaizent t- lssue #1 failure to provide respIte care' A progress note completed by Twin Lakes Hospice (TLH) social worker (SW) dated . 04(28/16 at 09:35 AM stated, ?Received message trom son, son reports that he and his sister got into a physical altercation last night on . 04127116. Son stated they need to start looking at other options because lhe stress of caring for his 5 mother and dealing with his sister is not good on his health. Reported being in ER twice to last I a-n-u ID PROVIDERS PLAN OF PREFIX (EACH CORRECTIVE ACTION SHOULD BE . TAG To THE APPROPRIATE DATE DEFICIENCY) 652 Fsd?ty ID 120251514 it continuation sheet Page 21 0131 some Protects! Versions emote Event tomoxtn 21 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8t MEDICAID SERVICES 22 PRINTED: 0610912016 FORM APPROVED OMB NO. 0938-0391 I5TATEMENT OF DEFICIENCIES '0 PLAN OF CORRECTION IDENTIFICATION NUMBER: 261514 pie) MULTIPLE consreucnon pro: care sunvev ,5 Bum?. commerce NAME OF PROVIDER SUPPLIER TWIN LAKES HOSPICE, INC STREET cm', STATE. 21? 0002 PO 80): M2 CLINTON, MO 64735 in TAG SUMMARY STATEMENY OF DEFICIENGIES (EACH DEFICIENCY MUST BE PHECEDED BY FULL REGULATORY OR LSC IDENTIFYING to pnovroses new or: 0(5) Passer CORRECTIVE SHOULD as COWLEUGH mo TO THE mnoenwe WE 652 Continued From page 21 week related to ulcers. SW explained private caregiver option and prices, son concerned with cost. Son also questions other options. SW explains that the only options the family currently has is family care. hiring caregivers, and nursing home placement. SW also explains that the .- n-ua? - nursing home piacement would be private pay on I the family. Son reports understanding. Son states he will call the caregivers. TLH stall tailed to provide 3 otter other options available to patients and lamllies In crisis as part of the hospice benefit, including options for short-term respite care and I or volunteer services. Review of documentation by FIN-B on the skilled nurse (SN) note dated 05mm 6 at 4:50 AM. revealed the family asked for skilled nursing taciirty (SNF) placement ior respite care at the time of the SN visit. The documented during the SN visit the Son wanted to see it we could get patient In the?nursing home for respite. This nurse checked with (SNF-B) and (SN F-A) both in Clinton. We also checked with SNF-C in (a town approximately 40 miles lrom Clinton. the town where TLH is located). All nursing homes were not able to do this on the weekend. Son and wile will be staying at the house with patient. The tamtly knows to call it they would need anything. Interview with the administrator for Twin Lakes Hospice on 05125I16 at 10:45 AM revealed the hospice on-caii nurse attempted to call tour nursing homes in the Clinton area on 05.!07116. but all reiused to accept the patient and the hospice was unable to tind respite placement for the patient on the weekend ol05r'07116. The administrator stated We have six or seven FORM Pro-nous Versions Obsolete Event lD.N3Xilt Fae-1t? ro- idioms? It continuation sheet Page 22 ct 31 DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 8. MEDICAID SERVICES 064?0912015 FORM APPROVED OMB NO. 0938-0391 ?rmware or {xn ?10 PLAN OF CORRECTION IDENTIFICAHON 261514 MULTIPLE CONSTRUCTION A BUILDING 8 WING oars. surwe?r catamaran 05125i201 6 NAME OF PROVIDER OH. SUPPLIER TWIN LAKES HOSPICE, INC STREET ADDRESS. CITY. STATE. ZIP CODE PO BOX 502 CLINTON, MO 64735 i0 PR FIX TAG SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR [.50 EON) ID PREFIX TAG DEFICIENCY) Pnovioeas PLAN or: 9:5) (EACH connecnve SHOULD or: menu? TO me manoeams We 652 Continued From page 22 respite contracts with nursing homes in the local area. they usually do take admits tor respite. tor . sortie reason they destined that weekend. i 10:20 AM, RN-B stated white at the patient a home for the SN visui on 05107716 the son asked at patient could be pieced in respite care. Late Saturday afternoon i ealied in Ciinton, SNF-A in Clinton and a SNF in Harrisonviile and at] were not a go. When I asked it the SNFs said why they could not accept the patient for respite. the FIN replied they (SNFs) i 1 During an interview with RN-B on cares/ts at said weekend and admits were the issues. During an interview on 05125116 at 10:45 AM, TLH administrator was ask why the patient was not placed in respite care when requested on Saturday. 05/07/16. The administrator stated the hospice has set or seven respite contracts with nursing homes in the local area. they usually do take admits for respite. tor some reason they declined that weekend. We could not verify why I they would not take patient over the weekend, but i believe it had to do with the daughter behaviors. During an interview on 05125116 at 12:to PM, the administrator and director oi nursing ior were ask Ii the SNF had been contacted the weekend of o5i07ito by TLH to request a respite i bed tor a patient. The administrator and director of nursing tor SNF-A con?rmed no one from TLH had contacted the facility requesting an admission tor respite that weekend. The administrator and director at nursing that i the would have been able to admit the i patienton the weekend It needed. stating 'we I 652 FORM Chis?2sertoz?ss) Previous VOW onset-sis Event FwL-yto- timers? Ii continuation sheet Page 23 oi at 23 DEPARTMENT OF HEALTH AND HUMAN PRINTED: 06109li2016 FORM APPROVED - OMB NO. 0938-0391 TWIN LAKES HOSPICE, INC PO BOX 602 CLINT ON. MO 64735 CENTERS FOR MEDICARE a MEDICAID senvrces EATEMENT OF DEFICIENCIES (XI) PEOWOERISUPPLIEPJCLIA CONSTRUCTION (X3) DATE SURVEY \iD PLAN OF NUMBER. A. 0 261514 9 0512512016 W16 OF PROVIDER OR SUPPLIER STREETADDHESS. STATE. ZIP CODE (X4) Io PREFIX TAG SUMW STATEMENY 0?7 DEFICIENCEES DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC DENTIFYING PROVIDERS PLAN OF CORRECTION 0'25} comm? one 652 704 Con?rmed From page 23 have done that before. The director oi nursing and administrator were ask to verify the information once again, the director of nursing verified he I she worked that weekend and no one from TLH contacted the SNF requesting a respite admission. ?nun??n? .- The administrator for SNF-A called back later in 1 the day on 05125116 at 12:55 PM and stated per telephone interview, Our social worker returned and i asked her it she remembered TLH requesting a bed tor respite over the weekend Our sociat worker and the TLH nurse are . slsters-in-law, so I guess she called the social worker directly. The social worker reported speaking to a nurse from TLH over the weekend I that they might have a patient who wanted I placement, but nothing was de?nitely planned. I Administrator for SNF-A stated the social worker lor SNF-A was contacted over the weekend - related to a possible respite admission but I nothing was definite, administrator also stated the SNFA never declined the admission. they never i heard anything more about a respite admission . during the weekend of 05/07/i6. 11H tailed to ensure the patient I family were provided with respite services as part of the patient hospice bene?t when respite care was requested by the family on 05107716. Twin Lakes Hospice, Inc. failed to ensure hospice care and services related to short term Inpatient care was available ior its hospice patients, when the hospice was unable to tied a nursing iacillty to accept a patient ior respite on 05/07i16. 418.108 SHORT-TERM CARE P?gmt CH CORRECTIVE ACTION SHOULD 8E Th0 To THE WOPHIATE 552 i?ciSi?. SQQ attache 704 FORM PIWLB Versions Omoieto EWM IDl?mtt Fao?ltr; to: remote? iicontrnuetton sheet Page 24 ot 31 24 06(0932016 DEPARTMENT OF HEALTH AND HUMAN SERVICES roan APPROVED CENTERS a MEDICAID SERVICES one no. STATEMENT OF (Xi) PROVIDEFUSUPPUENCLM (X3) DATE SURVEY 5ND NAN OF CORRECTED NUMBER: A. BUILDING COMPLETED 251514 B. we osresrzote NAME OF PROVIDER OR SUPPLIER STREEFADDHESS. CITY. STATE. ZIP CODE PO BOX 502 TWIN LAKES HOSPICE, INC CLINTON, MO 6 41,35 (X41 ID - SUMMARY STATEMENT OF iD PROVIDERS PLAN OF pits) paaptx (EACH DEFICIENCY MUST es PRECEDED av FULL nearer (EACH CORRECTIVE acrtott SHOULD ae manor: m3 OR LSD IDENTIFYING TAG GROSS-REFERENCED TO THE 9W osmrevcv; i. 704 Continued From page 24 i. 704 This CONDITION is not met as evidenced by: Based on interviews and ctinicat record review, Twin Lakes Hospice, Inc. tailed to ensure compliance with this condition at participation when the agency tailed to ensure: -short term Inpatient care was available and provided to patients I families when requested for respite purposes (L705) -inpatient respite care was provided In a Medicare! or Medicaid certi?ed iaciltty (L709) I The cumuiative effect of these systemic practices 149.30. 302, had has the potentiai to affect ait patients served by this hospice agency. 705 413.103 SHORT-TERM INPATIENT CARE 705 Inpatient care must be avaitahle for pain controi, management, and respite purposes. and must be provided In a participating Medicare or Medicaid iecility. This STANDARD is not met as evidenced by. Based on clinical record review and staii interviews. Twin Lakes HOSpice, inc. tailed to ensure each patient received short term inpatient care for respite purposes, when requested by the patient famliy in one (1) at one (1) applicabie cases (FtecordIPatient i This de?cient practice has the potential to attract ail patients served by the hospice agency. Findings are: RecordiPatient Ciinical record review revealed the social worker (SW) documented a progress note of a phone conversation with the patient 5 son on 04(28!16 FORM Pie-violin Versions Obsolete Event Feat)! iD. ii continuation sheet PBQB 25 0i 3! DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 8: MEDICAID SERVICES 6 FORM APPROVED 0MB NO. 0938-0391 op DEFICIENCIES no PLAN OF connection IDENTIFICATION nuneen' 261514 MULTIPLE consrnucnon A. eumnc B. WING ore} oars sUnvEY COMPLETED NAME OF PROVIDER OH SUPPLIER TWIN LAKES HOSPICE, INC srneer ADDRESS. CITY. STATE. 21? cone PO BOX 502 CLINTON, MO 64735 on; ID no SW STATEMENT OF DEFICIENCIES DEFICIENCY MUST 8E PRECEDED BY FULL REGULATORY OR LSC IDEMIFYING ID PROVID PLAN OF CORRECTION can seem connecrtve snouue es ccmerm rAe ceasenaeenenceo to THE APPROPRIATE WE DEFICIENCY) 705 Continued From page 25 at 09:35 AM. The social worker documented Received message lrom son. son reports that he and his sister got into a altercation last night on 04mm 6. Son stated they head to start looking at other options because the stress of caring for his mother and dealing with his sister is not good on his health. Reported being in ER (emergency room) twice In iast week related to ulcers. SW explained private caregiver option and prices, son concerned with cost. Son also questions other options. SW explains that the only options the family currently has is lamily care, hiring caregivers, and nursing home placement SW also explains that the nursing home placement would be private pay on the i family. Son reports understanding. Son states he wilt cell the caregivers. Clinical record review also revealed the patient was upset over the situation, when the Aide Visit Note on 04l28!16 at 10:20 AM stated patient Pi stated things got bad last night betvveen her son a daughter. Pt stated was so nervous and had been vomiting because of II. Aide reported situahon to SW. who elated son had already called about situation, The SW tailed to oller short term inpatient care for respite purposes for a patient 1 family reporting to be in a time crisis! need. During a SN visit on Saturday. 05l07136 at 4.50 AM, documented the family requested respite care for the patient. The FIN documented the Son wanted to see it we could get patient in the nursing home ior respite. This nurse checked with (SNF-B) and (SNF-A) both in Ciinton. We also checked with SNF-C In (a town approximately 40 miles from Clinton where Twin Lakes Hospice is located). All nursing homes were not able to do this on the weekend. 705 FORM OMS-amazes) Pro-nous Versions Obs-stole Event tD-nexm Foosry to. mzetst-t Ii continuation sheet Page 26 at St 26 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED 061091?2015 FORM APPROVED OMB NO. 0938-0391 CENTERS FOR MEDICARE MEDICAID SERVICES OF (x1; Pnovtoewsuwuenrem (x2) CONSTRUCTION eta) DATE sunvav vo sum or: connecnon NUMBER: a BUILDING GOMPLETED 0 261514 8- WING 05i2512016 NAME or PROVIDER on seamen smear menses CITY. ems, PO sex 50: TW LAKES Hos CLINTON, no 54735 0(4) {0 SUMMARY STATEMENT OF OEFICIENCIES ID PROVIDERS PLAN OF CORRECTION mare: {anon oanctancv must as pascacso ev FULL PREFIX (anon connective ACTION SHOULD as some m; aaeuworrv on ?80 toEHTu-?Yeto mo moss-neranencao ro THE APPROPRIATE we 705 Continued From page 26 t. 705 During an interview with FIN-B on OSIQSHS at . 10:20 AM, FIN-B confirmed the son had asked ii I the patient could be place in respite care. stated while at the patient 3 home ior the SN visit on OSJOWIB at 4:50 AM the son asked if patient could be placed in respite care. Late Saturday afternoon (FIN-B) called SNF-B in Clinton, SNF-A in Clinton and a SNF in Harrisonviile and all were not a go. When asked it the SNFs said why they could not accept the patient for respite. the RM replied they (SNFs) said weekend staf?ng and admits were the ISSUES. During an Interview on 05125/16 at 10:45 AM, Twin Lakes Hospice (TLH) administrator was asked why the patient was not placed in respite care when requested on Saturday, 05207116. The administrator stated the hoopice has six or . seven respite contracts with nursing homes in the iooal area. they usually do take admits for respite. for some reason they declined that weekend. We could net verity why they would not take patient over the weekend, but believe it had to do the daughter behaviors. an?u?m The administrator stated the daughter had threatened bodily harm to staii and had stolen medications item the patient. Clinical record review revealed one telephone conversation, with the patient '5 danghter, on OSIOGHS at 11:20 AM documented by FIN-A. The FIN documented the daughter was upset and using multiple protanities and referred to a physicai aitercation her brother and stated the next biack will be your all (referring to the hospice), not mine . Askitled nursing visit dated 05/06/16 at 1035 AM completed by the RNIDON included ?I-It-Ium- .- FORM cus-zaeriez-se} Previous Versions Obsolete Event tomenn Plum it centnumtcn sheet Page 27 at at 27 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED. OBIOQI2016 FORM APPROVED OMB NO. 0938-0391 [armament or serratenoies on) ?to PLAN or oeunsrcarton mousse 261514 MULTIPLE CONSTRUCTION A. BUILDING B. WING pro} oars suavev countereo 0 051252016 time on Pnowoen on TWIN LAKES HOSPICE, INC STREET ADDRESS. CITY. STATE. ZIP CODE no sex 502 cumou, MO 84735 on) to Patient TAG SW STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED FULL REGULATORY OR 1.50 IDENTIFYING WFOHMATION) PROVIDERS PLAN OF CORRECTION PREFIX OOHRECTWE ACTION SHOULD BE TAG cnoss-meneuceo TO THE APPROPR oerrcteucn as: CCWLETIOH we we 705 . and the hospice reported this to the county Continued From page 2? I documentation that the daughter was Upset and yelling loudly. but did not document any physically threatening behavior or physical threats by the patient daiighter dunng the home visit completed by An interdisciplinary note dated 05i09l16 completed by the administrator included documentation that daughter threatened start by phone threatened RN that was at their home. The administrator aiso documented suspicious drug activity was reported to the hospice by the paid caregivers sheriit. The clinical record failed to document any reference to medications being stolen or drug diversion by any family member. The patient had been on service for approximately one month. start of care date 04i06l16, the RNIDON expiained medications were counted on Tuesday and documented on nurse visit notes. Review of all the skiiled nurse visit notes from 04106116 to revealed all medications counts were correct and no medications were missing. During an interview on 05125116 at 12:10 PM. the administrator and director of nursing tor SNF-A were asked it the SNF had been contacted the weekend of (Jerome by TLH to request a respite 2 bed for a patient. The administrator and director of nursing ior skilled nursing (SNF-A) con?rmed no one from TLH had contacted the iacitity requesting a respite placement that weekend. The administrator and director of nursing veri?ed that the iacliity wouid have been abie to admit the patient on the weekend it 1 needed, stating ?we have done that before. . The director oi nursing and administrator were i asked to verify the Information once again. the . director of nursing verified he! she worked that Mumm? ?no. n-m? .- 705 FOPJJ Pre'r?nrs Versions Camden Event Facility it oontinuatio sheet Page 28 ct at 28 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 06i09l2016 FORM APPROVED OMB NO. 0938-0391 I STATEMENT or commences on) ?Io mm on connaorion NUMBER: 261 S14 (X2) prompts consrnucrron no; cars suavsv A. sunsets GOHPLETED NAME OF PROVIDER 0R SUPPLIER TWIN LAKES HOSPICE, INC STREET ADDRESS. CITY. STATE. ZIP CODE PO BOX 502 CLINTON, MO 64?35 pit) to PREFIX m3 SUMMARY STATEMENT OF DEFICIENCIES (PLACE DEFICIENCY MUST BE PRECEDED BY FULL FIEGUUITOFIYOR L50 IDENTIFYING INFORMATION) iD PROVIDERS PLAN OF CORRECTION poi} PREFIX (EACH CORRECTIVE ACTION SHOULD BE (:0me TAG CROSS-REFERENCED TO THE APPROPRIATE 9m DEFICIENCY) 705 709 Commued From page 23 weekend and no one lrom TLH contacted the SNF requesting a respite admission. The administrator for SNF-A called back later in the day on 05/25/16 at 12:55 PM and stated per telephone Interview, Our social worker returned and i asked her if she remembered TLH . requesting a bed for respite over the weekend 05(07218. Our social worker and the TLH nurse i are sisters-in-Iatv. so I guess the TLH nurse i called our social worker directly. The social worker reported speaking to a nurse irom TLH over the weekend that they might have a patient who wanted placement, but nothing was definitely planned. SNF-A administrator confirmed the social worker was contacted related to a possible admission but stated the facility never declined the admission. they never heard anything more about a respite admission the weekend of 05/07/16. TLH failed to provide the patient! family with short term inpatient care for respite purposes when respite was requested by the iamtly on 05107/16 at 4:50 AM. 418 108(b)(1)(ii) INPATIENT CARE FOR RESPITE PURPOSES [inpatient care tor respite purposes must be provided by one of the ioilovring:] (ii) A Medicare or Medicaid-certi?ed nursing {acuity that also meets the standards Speci?ed in s41e.11o v-u-u?uun This STANDARD is not met as evidenced by". Based on clinical record review and stall lntervtew, Twin Lakes Hospice. inc. failed to ensure inpatient care for respite purposes would 705 ??t?ase 3'29 @440. i. 709 roam matrices Versions Obsolete Event Facility touaozstsu It continuation sheet Page 29 ot 31 29 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 3t MEDICAID SERVICES 06m912016 FORM APPROVED OMB NO. 0938-0391 or panoramas on} '0 PLAN OF CORRECTION IDENTIFICATION NUMBER: 251514 0(2) MULTIPLE CONSTRUCTION A. BUILDING B. WING no) oars some? COMPLEI ED 05i25/2016 NAME OF PROVIDER OH TWIN LAKES HOSPICE. INC smear mosses. CITY. STATE. cooe PO BOX 502 CLINTON, MO 64735 .0 summv or: DEFICIENCIES 9-35fo {anon DEFICIENCY MUST ee PHECEDED av FULL m; REGULATORY en IDENTIFYING meoamnom it) pnowoeas PLAN on CORRECTION oer pear-'0: (EACH coaaecrwe sacrum ae comma TAO TO THE APPROPRIATE ME DEFICIENCY) 709 Continued i-?rom page 29 be provided. when requested by the patient! tamily, in one of one cases (RecordJPallent This deiICtent practice has the potential to affect all patients sewed by the hospice agency. Findings are: Recorleatienl 1: Revrew of the clinical record revealed the patient 3 family requested respite placement for the patient during a skilled nursing visit on Saturday. carer/ls at 4:50 AM. urn?- Boring a SN visit on Saturday. 05/07/16 at 4:50 AM. RN-B documented the family requested respite care for the patient. The FIN documented the Son wanted to see it we could get patient in the nursing home for respite. This nursa checked with (SNF-B) and (SNF-A) both in Clinton. We i also checked with SNF-C tn Harrisonvilte (a town i approximately 40 miles from Clinton where Twin . Lakes Hospice is located). All nursing homes were not able to do this on the weekend. the day on careers at t2:55 PM and stated per telephone interview, Our social worker returned and i asked her it she remembered TLH requesting a bed tor respite over the weekend 06107/16. Our social worker and the TLH nurse are ststers-tn-Iaw, so I QUess the TLH nurse called oUr social worker directly. The social worker reported speaking to a nurse from TLH over the weekend that they might have a patient who wanted placement. but nothing was de?nitely I planned. SNF-A administrator confirmed the social worker was contacted related to a possible . admission but stated the facility never declined I the admission. they never heard anything more I I I The administrator for SNF-A called back later in i I 709 FORM Previous Versions Obsolete Event Hey-o1: Fadlty to' trowel-t it continuation shoot Page 30 or at 30 DEPARTMENT OF HEALTH AND HUMAN SERVICES ?@353 Agsegrggiroe'g CENTERS FOR MEDICARE MEDICAID OMB NO. 093843391 I 0F DEFICIENCIES {x13 {x2} MULTIPLE CONSTRUCTION care SURVEY ?to PLAN OF CORRECTION NUMBER A COMPLETED 261514 B. WING 051252015 steers? nooness, ornr. snare, CODE NAME OF PROVIDER on SUPPLIER TWIN LAKES HOSPICE. INC PO BOX 502 CLINTON. MO 64735 about a respite admission the weekend of 05mm 6. During an interview on at 10:45 AM, Twin Lakes Hospice (TLH) administrator was asked why the patient was not placed In respite care when requested on Saturday, 05107716. The administrator stated the hospice has six or seven respite Contracts with nursing homes in the local area, they usuaily do take admits ior respite, I tor some reason they declined that weekend. We could not verity why they woutd not take patient over the weekend, but beiteve it had to do With the daughter behaviors. intendew with the administrator Ior Twin Lakes Hospice on 05/25! 16 at 10.45 AM revealed the hospice on-catl nurse attempted to eat! four nuising homes In the Clinton area on 05(07116. I but all refused to accept the patient and the hospice was unable to ?nd respite placement for the patient on the weekend at 05.!07lts. Twin Lakes Hospice failed to ensure inpatient care was evaitabte for its hospice patients. when the hospice was unable to ?nd a nursing fecriity to accept a patient for respite on 0307/16. i ?piggy; See other chad (X4) ID SUMMARY OF DEFICIENCIES Paovneas FUN OF CORREOTKDN {x53 pagm DEFICIENCY uusr as PRECEDED BY Fuu. PREFIX (EACH CORRECTIVE ACTION SHOULD as me REGULATORY on Lac mo CROSS-REFER EHCED to THE APPROFRIATE W8 I 709 Continued Front page 30 709 FORM Previous Version 00001011) Event romexm Fair; 10? it ccntinuetron sheet Page at of 31 31 ProvrderISupplrer Name' STREET ADDRESS, cmr, ZIP. (X4) ID PREFIX TAG FEDERAL PLAN OF CORRECTION m) TWIN LAKES HOSPICE, Survey Date '87 725 East Ohio Street, Clinton MO 64735 05/25/2016 PROVIDENSUPPUENCUA NUMBER 17- PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS- REFERRENCED TO THE APPROPRJATE 261514 (X5) COMPLETION DATE L500 L501 Twin Lakes Hospice, inc (TLH) will ensure that all patients are informed of his or her rights and the hospice will protect and promote the exercise of these rights. will continue to inform all patients/family members that they have the ability to freely make choices includIng but not limited to transfers to other hOSpices/facilities, the respite bene?t and make every effort possible to protect the patients con?dentiality. We will do this by notifying the patient/family upon admission and periodically during the time we serve the patient that they have the right to choose the respite benefit at any time and if they decide to transfer to another provider or to a facility, we will assist them with that transfer. The Social Worker will discuss these options with the patient/famrly at the time she does then initial admission assessment. TLH will reinforce our policy of providing the necessary paperwork to the receiving facility such as the nursing assessment, care plan, physician orders, medication list, discharge summary, history and physical and any other documents necessary to care for the patient. TLH will reinforce this policy by inservice for all staff on this policy. TLH will also implement a policy is transferring to another hospice due to confidentiality and potential hipaa violations. All employees will be inserviced on this new policy. Also, any communication made to another provider must be made only after the person receiving the information has been identi?ed and measures taken to ensure confidentiality. Our QAPllouality assurance performance improvement) nurse will review all transfers/discharges to ensure full compliance with our policy. that will read "No employee will utilize a cellphone to text messages or forms when a patient 06/27f2016 32 L509 TLH will begin using a new incident report form titled Patient Incident Report" and this form will be used for all complaints/grievances from a patient/family. The new form will include Case Manager or Employee name that is reporting the complaint, the agency name, the patient information and nature of complaint and resolution of complaint. This form will also be signed and reviewed by the Administrator, the Director of Nurses and notification made to the attending physician and Medical Director TLH will continue to inform all patients/families of their right to revocation and transfer upon admission by the social worker and/or RN case manager. TLH will continue to investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. TLH will ensure that all grievances are fully investigated and documented. TLH Administrator/Director of Nurses will reinforce policy on grievances and an Inservice will be done for all staff. .Anyime we have a complaint/grievance. the staff will be educated about that particular concern and how to bring resolution and satisfaction for patient/family. This will ensure that this particular complaint/grievance doesn't occur again in the future. Our QAPliQuality assurance performance improvement) nurse WIN review all complaints and monitor them to ensure full compliance with our grievance policy. 06/27/2016 L516 TLH ensure that the patient rights are honored related to maintaining a con?dential medical record by not utilizing text messages on cell phones to communicate information about a patient transfer or other medical needs. This will be covered in an inservice to all staff and the person that violated this particular policy will receive a counseling session related to this action. 06/27/2016 L648 TLH will ensure that care is provided that optimizes the patient's comfort and dignity and is consistent with the patient's and family?s needs and goals as priority. TLH will also ensure that the governing body assume full legal responsibility for the hospice and provisions of hospice services. TLH will ensure that the Administrator is responsible and aware of the dayvto-day operations of the hospice agency. This will be done by a briefgiven to the governing body two times per year by the QAPI nurse or Director of Nurses regarding any care issues, complaints or transfers/discharges by the agency. Also the Administrator will be noti?ed on a daily and weekly basis at weekly agency meetings regarding any complaint, transfer request or discharge All staff will be educated about this new process and complaints and transfers/discharges will be brought up and discussed at each weekly meeting by the Administrator and/or Director of Nurses. This will also include any short-term inpatient care requests presented to any of the TLH staff members. The Administrator will also review respite contracts to ensure we have contracts suf?cient to meet our patients needs. 06/27/2016 33 L550 TLH will continue to provide hospice care that optimizes comfort and dignity and is consistent with patient and family needs and goals, with patient needs and goals as priority. The QAPI nurse will review all complaints/grievances and transfers/discharges and report to the Administrator and Director of Nurses weekly and to the Governing Body twice per year. ifwe have a complaint/grievance or transfer/discharge that cannot be completed or resolved by the Administrator or Director of Nurses immediately the Medical Director will be noti?ed for assistance in resolving the problem. L651 TLH will ensure that the-governing body assumes full legal responsibility for the management of the hospice, the provision of all hospice services, its ?scal operations and continuous quality improvement. TLH will also ensure that a qualified Administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice. The nurse/Director of Nurses will report issues related to transfers/discharges or Immediately to the Administrator and resolution made. if resolution cannot be made, the Medical Director will be noti?ed and will assist with resolution. The Governing Body will be kept up to date bi-annualiy with a report prepared by the QAPI nurse or Director of Nurses L652 The RN Case Manager or Social Worker will notify the Director of Nurses and the Administrator immediately if a patient/family requests respite care or transfer/discharge. TLH will continue to provide nursing services, medical social services, physician services, counseling services, including spiritual counseling and bereavement counseling, hospice aide, volunteer and homemaker services, physical therapy, occupational therapy, speech-language pathology services, short-term inpatient care, medical supplieslincluding drugs and biologicals) and medical appliances. TLH will ensure that short-term inpatient care is provided when requested by patient/family. TLH will give options to patient/family such as short?term respite care, volunteer services, nursing home placement, and any other service that is available to meet their needs and goals. The social worker and RN case manager will communicate needs to Director of Nurses and Administrator to ensure compliance. Also, the nurse will monitor as part of our Quality assurance and performance improvement plan. L704 TLH will ensure hospice care and services related to short-term inpatient care is available for its hospice patients. The RN Case Manager or Socral Worker will immediately notify the Director of Nurses and Administrator of any patient that wants short-term inpatient care. The TLH staff will be educated about this new policy. Also, if any issues arise with the transfer, the Medical Director will be notified immediately for assistance. The DAM nurse will review all transfers/discharges and report back to the Administrator and Director of Nurses any issues related to the transfer. Also, two times per year, the QAPI nurse will report to the Governing Body any issues related to transfers/discharges. Gift/2772016 34 L705 TLH will ensure that inpatient care will be available for pain control, management, and respite purposes and must be provided in a participating Medicare or Medicaid facility. All staff will be inserviced and educated about the importance of seeking and providing shart- term inpatient care for any patientffamily in a time of need or crisis. The Administrator and Director of Nurses will be immedicateiy noti?ed in the future so that short~term inpatient care can be provided in a timely manner. if problems exist with ?nding short-term inpatient care, the Medical Director will be noti?ed to assist with placement. 06/27l2016 L709 TLi-i will ensure that short-term inpatient care is provided in a Medicare or Medicaid certi?ed facility for reSpite care when requested by the patient/family. The RN Case Manager or Social Worker will immediately notify the Director of Nurses and the Administrator regarding any request for short-term inpatient care. The Medical Director will also be notified if any issue arise if immediate placement is not possible. The QAPI nurse will add this to our plan to help us monitor for ongoing compliance and report to the Administrator, Director of Nurses and the Governing Body any ?ndings related to short-term inpatient care. The TLH staff will he inserviced regarding the importance of responding immediately to ?any requests by patient/family for short?term inpatient care and our new policy. 06/27/2015 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. 35 PRINTED: 063152016 FORM APPROVED Missouri Department ci Health and Senior Services STATEMENT OF 1x2} MULTIPLE CONSTRUCTION (XS) DATE sunve?r use PLAN or: NUMBER: A BUILDING covetETso M0261514 *1 WM . 0512512016 NAME or: woman on sueeLten - STREET menses. crrY. STATE. ZIP cone PO BOX 502 TWIN LAKES HOSPICE. CLINTON, MO 64735 rm} to SUMMARY STATEMENT OF to PLAN OF CORRECTION passer CH MUST BE eY FULL PREFIX oonnecme ACTION SHOULD BE comma Tate REGULATORY on LSC IDENTIFYING mmrtom m; caoss-neranmceo To THE APPROPRIATE one 000 30-35 Initial Comments 000 A complaint investigation was completed on 05/25/16 at Twin Lakes Hospice, inc. Four clinics! records were reviewed and intervrews were conducted. The agency's complaint log and policies were reviewed. The "?ags? complaint is substantiated. One or more at the ?a 6/ allegations reported were veri?ed and 593 Ct Lid de?ciencies are cited related to the allegations being investigated. The agency's census was 35. 110 General Provisions 110 A hospice shalt be primarily engaged In providing the care and services described in 19 CSR 3035.010 and in 19 088 30- 35.020 of this rule, and shall: Provide 24-hour nursing coverage for telephone consultation and visits as needed; Timsa 3241 ?Ha CW4 This regulation is not met as evidenced by: REFER TO FEDERAL TAG L652 116 Patient Flights L113 Patient Flights. The hospice shall have a written statement oi patient rights which sheil inciude, but need not be limited to. those speci?ed herein. This regulation is not met as evidenced by: REFER TO FEDERAL TAG L500 19W am glad 127 Patient Rights 12? The right to con?dentiality of the clinical records maintained by the hospice and to be informed of the hospice's policy ior disclosure of ciinicai records; Wesson Department at Health and Senior Services meorwom? on Pnowoenrsueeusn srermuas s/ TITLE (9 on) (a V1 'Ii . use FORM N8Xl1i . [reorientation sheet tor: Missouri Department oi Heaith and Senior Services PRINTED: OEHSJZOI 6 FORM APPROVED STAYEMENT OF DEFICIENCIES PLAN OF CORRECT NUMBER M0261514 A. BUILDING B. WING MULHPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 0 082512016 NAME OF PROVIDER OR SUPPLIER TWIN LAKES HOSPICE, ??10 PO BOX 502 CLINTON. MO 64?35 srne'er menses. cm. STATE. ZIP cone (x4) 10 PREFIX me Sl?iiMAH?r? SYATEMENT 0F (EACH DEFICIENCY MUST BE PRECEOED BY FULL REGULATORY OR LSC IDENTIFYING PHEFK (EACH TAG TO THE APPROPRIATE enowoens run or connection (x5, oonnecrwe xenon secure as we Damiano-n L127 L144 Li47 Continued From page 1 This regulation is not met as evidenced by: REFER TO FEDERAL TAG L516 Governing Body Administration. Governing Body. Ahospice shaii have a governing body that assumes tuil legal for the hospice's total operation. This regulation is not met as evidenced by: REFER TO FEDERAL TAG L651 Administrator Provisions Administrator Provisions. The administrator organizes and directs the agency?s ongoing functions; maintains ongoing liaison among the governing body, the interdisciplinary group(s) and the stair: employs quali?ed psrsonnei: implements an effective budgeting and accounting system; and eniorces written policies and procedures. This reguiation Is not met as evidenced by: REFER TO FEDERAL TAG L651 L127 L144 L147 ?Plant? 520 din-?U! age {He Misswn Department at Heaitn and Senior Services STATE FORM {leer-W on sheet 2 ci2 37 Provrder/Supplier Name: STATE PLAN OF CORRECTION ED TWIN LAKES HOSPICE, Survey Date 5mm ADDRESS, (man? :9 725 East Ohio Street Clinton MO 64735 05/25/2016 In} mnemmcmon NUMBER 17- =9 261514 PLAN OF CORRECTION (EACH (XS) (X4) ID PREFIX SHOULD BE CROSS- COMPLETION TAG REFERRENCED TO THE APPROPRIATE DEFICIENCY) DATE Twin Lakes Hospicel'i?LH) will continue to prowde 24 hour nursing coverage for telephone L110 consultation and visits as needed. Refer to Federal Tag 652 06/27/2016 TLH will continue to provide a statement of patient rights which shall include, but need not be L116 limited to, those speci?ed herein. Refer to Federal Tag L500 and L501 06/27/2016 TLH will continue to provide the patient's con?dentiality of the clinical records maintained by the hospice and to be informed ofthe hospice?s policy for disclosure of clinical records. Refer L127 to Federal Tag L516 06/27/2016 TLH wlli continue to have a governing body that assumes full legal responsibility for the L144 hospice?s total operation. Refer to Federal Tag L651 06/27/2016 TLH will continue to provide an Administrator that organizes and directs the agency?s ongoing functions; maintains ongoing liaison among the governing body, the interdisciplinary group(s) and the staff; employs quali?ed personnel; implements an effective budgeting and accounting L147 system; and enforces written poiicies and procedures. Refer to Federal Tag L651 06/27/2016 38 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. 39 DEPARTMENT OF HEALTH HUMAN SERVICES CENTERS FOR MEDICARE a MEDICAID SERVICES - OMB NO. 0933-0391 STATEMENT OF DEFICIENCIES 041} PROVIDERJSUPPUERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING R-C 261514 WING 0710612018 STREET Aconess. CITY. STATE. ZIP CODE PO BOX 502 TWIN LAKES HOSPICE. INC CLINTON. MO 64735 NAME OF PROVIDER OR SUPPLIER (X4) OF DEFICIEHCIES ID PROVIDERS PLAN OF CORRECTION {x5} PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY 0R LSC IDENTIFYMG INFORMATION) TAG TO THE APPROPRIATE 000} INITIAL COMMENTS 000} A complaint investigation was completed on 05!25l16 at Twin Lakes Hospice, Inc. Four clinicat records were reviewed and interviews were conducted. The agency's complalnt log and poiicies were reviewed. The . complaint is substantiated One or more of the allegations reported were veri?ed and de?ciencies are cited related to the allegations being investigated. The agency's census was 35. Three condition level de?ciencres were idenh?ed dunng this compIaInt investigation and are being cited aS part of this statement of de?CIeriCIes. {3418.52 Condition of Particrpatron. Patient?s rights (L500) -?418 100 Condition of PartICIpation: Organization and Administration of Services (L648) -?418.108 Condition of PartICIpatIon: Short-term inpatient care (L704) taitilcFouow_up Suweyotioatc: A follow-up survey to the survey of 0512516 was completed on Three clinical records were revise?warm. Inservice information and sign-In Sheets were revrewed Interviews were conducted with staff and one patient's iamIIy Dunng the survey it was determined de?ciencies L705 and L709 with conditIons of participation. Patient rights. Organization and administration of servrces. and Short?term MBORATORY OR PROVIDERISUPPLIER REPRESENTATIVES SIGNATURE NTLE DATE Any de?ciency statement endIng an aslensk denotes a de?aency which the may be excused from correcting providing It is determined that other safeguards provide su?icrent protection to the patients. {See Instruotions Except for nursing homes. the ?ndings stated above are 90 days fellovnng the date of survey whether or not a plan at is provided Eor nursing homes. the above ?ndings and pians of correction are disclosablp 14 days following the date these documents are made available to the fatality Ii de?cienmes ere cried. an approved plan ?of correction is reqursne to continued program partICIpatIon FORM Previous Veryons Obsolete Event FaulttyiD. If contmuatron sheet Page 1 of 2 40 DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 07I18I2016 FORM APPROVED OMB NO. 0938~0391 . CENTERS FOR MEDICARE STATEMENT OF DEFICIENCIES PROWDERJSUPPUERICLIA (X2) MULTIPLE CONSTRUCTION 0(3) DATE SURVEY AND PW OF CORRECTION NUMBER A. BUILDING COMPLETED R-c 261514 0710612016 NAME OF PROVIDER CIR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE TWIN LAKES HOSPICE, INC PO BOX 502 CLINTON, MO 64735 Inpatient are corrected. During the survey it was determined Twin Lakes Hospice, Inc. is in compliance with the requirements of 42 CFR 418.52. 418.100 and 418 108 of the focused survey on) if.) . SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) mam (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE cowwnon TAG REGULATORY 0R LSC IDENTIFYING TAG To THE APPROPRIATE DATE 000} Continued From page 1 000} cmezseuozeo) Previous Versions Ohsotate Event ID Faanrylo. if continuation sheet Page 2 of 2 41 Missouri Department of Heailh and Senior Servrces PRINTED: oinsraore FORM APPROVED STATEMENT OF OEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERJSUPPUERICUA - IDENTIFICATION NUMBER M0261514 WING MULTIPLE CONSTRUCTION A BUILDING DATE SURVEY . COMPLETED R-C 0710612016 NAME OF PROWDER OR SUPPLIER TWIN LAKES HOSPICE, INC PO BOX 502 CLINTON. MO 64735 STREET ADDRESS. CITY. STATE. ZIP CODE (X4) ID PRE FIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION 1x5) (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) COMPLETE 000} 30-35 Initial Comments A complaint investigatron till/[000115053 was completed on 05I25l16 at Twin Lakes Hospice. inc Four cirnicai records were reviewed and Interviews were conducted. The agency's complaint log and petioles were reviewed. The complaint is substantiated. One or more of the allegations reported were ven?ed and de?ciencies are cited related to the allegations being Investigated. The agency's census was 35. ?"mFollow?up Surveym?m? A follow-up survey to the survey of 05/25116 was completed on 07/06/16. Three ciinicai records were reviewed. lnservice Information and sign-in sheets were reviewed Interviews conducted with staff and one patient?s family.. During the survey it was determined de?ciencies L110. L116, L127, L144, and L147 are corrected. During the survey it was determaned Twin Lakes Hospice. Inc. is compliance with the requuremenis of Section 197250497280. and the reguiations promulgated thereunder (L 000} Mrssoun Department of Heaith and Senior Services LABORATORY 0R PROVIDERJSUPPLIER REPRESENTATIVES SIGNATURE STATE FORM 0-899 TITLE (X81 DATE It oontrnuabon sheet 1 of 1 42