Every finding on record at Cest La Vie Inc

Based on interview, record review and observation, the hospice failed to maintained compliance with this Condition of Participation - Organization and administration of services, in that: 1) The hospice failed to organize, manage and administer its resources to provide hospice care and services to patients, caregivers, and families necessary for the palliating and management of the patient's terminal illness and related conditions, in that: The hospice failed to maintain Kinnser, the hospice medical record system, functioning so hospice staff; the medical director and physicians could review patient's medical records. This failure prevented the surveyor, patient's physician and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of the patient. As a result the Administrator requested the survey be stopped that was currently in progress. Refer to L0649 2) The Administrator failed to organize and direct the day-to-day operation of the hospice, in that: 1) The administrator failed to maintain Kinnser, the hospice medical record system, functioning so hospice staff; the medical director and physicians could review patient's medical records; and 2) The administrator failed to ensure the agency implemented its policies to ensure inactive patient information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours. These failure prevented the surveyor, patient's physicians and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of each patient. As a result the Administrator requested the survey be stopped that was currently in progress.

Based on record review, interview and observation, the hospice failed to organize, manage and administer its resources to provide hospice care and services to patients, caregivers, and families necessary for the palliating and management of the patient's terminal illness and related conditions, in that: The hospice failed to maintain Kinnser, the hospice medical record system, functioning so hospice staff; the medical director and physicians could review patient's medical records. This failure prevented the surveyor, patient's physician and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of the patient. As a result the Administrator requested the survey be stopped that was currently in progress. Findings include: Surveyor arrived at the hospice's address (Identifier 100) on 12/07/2021 at 9:55 a.m., Surveyor knocked on the door several times, there was no answer to the door. Interview via a phone call was made to the hospice phone number on 12/07/2021 at 10:08 a.m., a female individual answered the call. When requested to speak to the hospice administrator, she said I am just an answering service, the hospice supposed to open at 9:00 a.m., I will transfer your call. The call was transferred to the office manager, and office manager informed the surveyor she will be in office in about 5 minutes. Interview with the hospice administrator via phone call, on 12/07/2021 at 10:28 a.m., the surveyor informed him that she was at the hospice to conduct a recertification, re-licensure and a complaint investigation survey. The administrator said, "the agency has discharged all patients due to problem with Kinnser software, Kinnser have glitch in the system and the agency could not access any patient records. The agency could not appropriately take care of their patients and we discharged all patients. This problem also affected our staff. I had surgery about 3 days ago. If you want me to come in, I will. I live somewhere in Spring." During a follow-up phone interview with the hospice administrator on 12/07/2021 at 10:40 a.m., surveyor asked if the hospice alternate administrator could come in for the survey. The administrator stated, "she is out of town." When asked if the supervising nurse was available to come in, the Administrator stated "I called her, she is not available too, but like I told you if you want me to come in, I can call uber or ask someone to bring me in." Continued interview the surveyor informed the hospice administrator that an administrator must be present in person or over the phone to grant access to patients' records for the survey. The administrator said, "the problem I have is what I have told you about Kinnser glitch." When asked how long the hospice has been having problems with Kinnser and if the hospice had a backup for the client records, the administrator said "About 2 months ago. I will give you access, and you will see what I'm talking about. I will also be heading down to the office. The backup is also affected." An entrance conference was conducted with the hospice administrator and office manager on 12/07/2021 at 11:40 a.m. The hospice representatives were informed the purpose of the visit was to conduct a recertification, re-licensure and a complaint investigation. Surveyor observed the Office manager during the entrance conference ask the Administrator "Did you tell her that all of these people are no longer working." The administrator said "yes." Electronic record review attempted by the Surveyor via Kinnser Software on 12/07/2021 at 1:30 p.m., revealed there were no patients assigned and search options did not reveal any patients. The administrator was informed about the problem, He said "that is what I told you we are facing with Kinnser Software." When asked about the electronic back up or hardcopies of the patient's records, the administrator said "everything is in Kinnser. They are supposed to provide the backup, but everything is affected. The benefit period is all over the place. Kinnser informed us to manually fix the problem. As we tried to fix it, more errors will come up. For example, one patient may have 100 episodes, which is not right. The nurses were concerned by the problem and they stopped working." Surveyor asked if the hospice has an outstanding balance that need to be paid with Kinnser Software. The administrator said, "No, we are up to date with our payment." Copies of email correspondence between Kinnser and the hospice dated 08/09/2021 through 09/22/2021 were provided by the hospice administrator. A client was assigned in Kinnser Software but before surveyor could review the record, the administrator requested to end the survey and a written statement was provided. Record review of the written statement signed and dated by the administrator on 12/07/2021 read as follows: "We are requesting to end today's survey due to complications with our EMR/ Kinnser/Well Sky system and not being able to access patient records." Surveyor give the Memo letters: "Inability to access state and federal records or perform a survey" to the hospice administrator on 12/07/2021 at 3:50 p.m. and left the hospice unable to conduct the complaint investigation, or the re-licensure and re-certification survey. Policy Review of the hospice's policy Revised 09/13/13, page 3 of 4 titled "Safeguarding Medical Record Information" read in part: "In the event that electronic record/ Point of care equipment/ laptop/ PC are unavailable or non-functioning, all medical record entries will be made utilizing appropriate agency paper documents ...." Review of the hospice's policy Revised 09/13/13 page 2 and 3 titled "Medical Record Information Retention and Destruction" read in part: "Inactive client information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours ...."

Based on record review, interview and observation, the Administrator failed to organize and direct the day-to-day operation of the hospice, in that: 1) The administrator failed to maintain Kinnser, the hospice medical record system, functioning so hospice staff; the medical director and physicians could review patient's medical records; and 2) The administrator failed to ensure the agency implemented its policies to ensure inactive patient information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours. These failure prevented the surveyor, patient's physicians and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of each patient. As a result the Administrator requested the survey be stopped that was currently in progress. Findings include: Surveyor arrived at the hospice's address (Identifier 100) on 12/07/2021 at 9:55 a.m., Surveyor knocked on the door several times, there was no answer to the door. Interview via a phone call was made to the hospice phone number on 12/07/2021 at 10:08 a.m., a female individual answered the call. When requested to speak to the hospice administrator, she said I am just an answering service, the hospice supposed to open at 9:00 a.m., I will transfer your call. The call was transferred to the office manager, and office manager informed the surveyor she will be in office in about 5 minutes. Interview with the hospice administrator via phone call, on 12/07/2021 at 10:28 a.m., the surveyor informed him that she was at the hospice to conduct a recertification, re-licensure and a complaint investigation survey. The administrator said, "the agency has discharged all patients due to problem with Kinnser software, Kinnser have glitch in the system and the agency could not access any patient records. The agency could not appropriately take care of their patients and we discharged all patients. This problem also affected our staff. I had surgery about 3 days ago. If you want me to come in, I will. I live somewhere in Spring." During a follow-up phone interview with the hospice administrator on 12/07/2021 at 10:40 a.m., surveyor asked if the hospice alternate administrator could come in for the survey. The administrator stated, "she is out of town." When asked if the supervising nurse was available to come in, the Administrator stated "I called her, she is not available too, but like I told you if you want me to come in, I can call uber or ask someone to bring me in." Continued interview the surveyor informed the hospice administrator that an administrator must be present in person or over the phone to grant access to patients' records for the survey. The administrator said, "the problem I have is what I have told you about Kinnser glitch." When asked how long the hospice has been having problems with Kinnser and if the hospice had a backup for the client records, the administrator said "About 2 months ago. I will give you access, and you will see what I'm talking about. I will also be heading down to the office. The backup is also affected." An entrance conference was conducted with the hospice administrator and office manager on 12/07/2021 at 11:40 a.m. The hospice representatives were informed the purpose of the visit was to conduct a recertification, re-licensure and a complaint investigation. Surveyor observed the Office manager during the entrance conference ask the Administrator "Did you tell her that all of these people are no longer working." The administrator said "yes." Electronic record review attempted by the Surveyor via Kinnser Software on 12/07/2021 at 1:30 p.m., revealed there were no patients assigned and search options did not reveal any patients. The administrator was informed about the problem, He said "that is what I told you we are facing with Kinnser Software." When asked about the electronic back up or hardcopies of the patient's records, the administrator said "everything is in Kinnser. They are supposed to provide the backup, but everything is affected. The benefit period is all over the place. Kinnser informed us to manually fix the problem. As we tried to fix it, more errors will come up. For example, one patient may have 100 episodes, which is not right. The nurses were concerned by the problem and they stopped working." Surveyor asked if the hospice has an outstanding balance that need to be paid with Kinnser Software. The administrator said, "No, we are up to date with our payment." Copies of email correspondence between Kinnser and the hospice dated 08/09/2021 through 09/22/2021 were provided by the hospice administrator. A client was assigned in Kinnser Software but before surveyor could review the record, the administrator requested to end the survey and a written statement was provided. Record review of the written statement signed and dated by the administrator on 12/07/2021 read as follows: "We are requesting to end today's survey due to complications with our EMR/ Kinnser/Well Sky system and not being able to access patient records." Surveyor give the Memo letters: "Inability to access state and federal records or perform a survey" to the hospice administrator on 12/07/2021 at 3:50 p.m. and left the hospice unable to conduct the complaint investigation, or the re-licensure and re-certification survey. Policy Review of the agency's policy Revised 09/13/13, page 3 of 4 titled "Safeguarding Medical Record Information" read in part: "In the event that electronic record/ Point of care equipment/ laptop/ PC are unavailable or non-functioning, all medical record entries will be made utilizing appropriate agency paper documents ...." Review of the agency's policy Revised 09/13/13 page 2 and 3 titled "Medical Record Information Retention and Destruction" read in part: "Inactive client information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours ...."

Based on interview, record review and observation, the hospice failed to maintained compliance with this Condition of Participation - Clinical Records, in that: The hospice failed to maintain a clinical record containing past and current findings for each hospice patient that was available to the patient's attending physician and hospice staff, in that; The clinical records for each discharged patient was not available to the patient's attending physician, hospice staff or to a HHSC survey representative. This failure prevented the surveyor, patient's physicians and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of each patient. As a result the Administrator requested the survey be stopped that was currently in progress. Refer to L0671

Based on record review, interview and observation, the hospice failed to maintain a clinical record containing past and current findings for each hospice patient that was available to the patient's attending physician and hospice staff, in that; The clinical records for each discharged patient was not available to the patient's attending physician, hospice staff or to a HHSC survey representative. This failure prevented the surveyor, patient's physicians and hospice staff from reviewing the patient's medical records to ensure each patient's discharge was coordinated and facilitated the medical needs of each patient. As a result the Administrator requested the survey be stopped that was currently in progress. Findings include: Surveyor arrived at the hospice's address (Identifier 100) on 12/07/2021 at 9:55 a.m., Surveyor knocked on the door several times, there was no answer to the door. Interview via a phone call was made to the hospice phone number on 12/07/2021 at 10:08 a.m., a female individual answered the call. When requested to speak to the hospice administrator, she said I am just an answering service, the hospice supposed to open at 9:00 a.m., I will transfer your call. The call was transferred to the office manager, and office manager informed the surveyor she will be in office in about 5 minutes. Interview with the hospice administrator via phone call, on 12/07/2021 at 10:28 a.m., the surveyor informed him that she was at the hospice to conduct a recertification, re-licensure and a complaint investigation survey. The administrator said, "the agency has discharged all patients due to problem with Kinnser software, Kinnser have glitch in the system and the agency could not access any patient records. The agency could not appropriately take care of their patients and we discharged all patients. This problem also affected our staff. I had surgery about 3 days ago. If you want me to come in, I will. I live somewhere in Spring." During a follow-up phone interview with the hospice administrator on 12/07/2021 at 10:40 a.m., surveyor asked if the hospice alternate administrator could come in for the survey. The administrator stated, "she is out of town." When asked if the supervising nurse was available to come in, the Administrator stated "I called her, she is not available too, but like I told you if you want me to come in, I can call uber or ask someone to bring me in." Continued interview the surveyor informed the hospice administrator that an administrator must be present in person or over the phone to grant access to patients' records for the survey. The administrator said, "the problem I have is what I have told you about Kinnser glitch." When asked how long the hospice has been having problems with Kinnser and if the hospice had a backup for the client records, the administrator said "About 2 months ago. I will give you access, and you will see what I'm talking about. I will also be heading down to the office. The backup is also affected." An entrance conference was conducted with the hospice administrator and office manager on 12/07/2021 at 11:40 a.m. The hospice representatives were informed the purpose of the visit was to conduct a recertification, re-licensure and a complaint investigation. Surveyor observed the Office manager during the entrance conference ask the Administrator "Did you tell her that all of these people are no longer working." The administrator said "yes." Electronic record review attempted by the Surveyor via Kinnser Software on 12/07/2021 at 1:30 p.m., revealed there were no patients assigned and search options did not reveal any patients. The administrator was informed about the problem, He said "that is what I told you we are facing with Kinnser Software." When asked about the electronic back up or hardcopies of the patient's records, the administrator said "everything is in Kinnser. They are supposed to provide the backup, but everything is affected. The benefit period is all over the place. Kinnser informed us to manually fix the problem. As we tried to fix it, more errors will come up. For example, one patient may have 100 episodes, which is not right. The nurses were concerned by the problem and they stopped working." Surveyor asked if the hospice has an outstanding balance that need to be paid with Kinnser Software. The administrator said, "No, we are up to date with our payment." Copies of email correspondence between Kinnser and the hospice dated 08/09/2021 through 09/22/2021 were provided by the hospice administrator. A client was assigned in Kinnser Software but before surveyor could review the record, the administrator requested to end the survey and a written statement was provided. Record review of the written statement signed and dated by the administrator on 12/07/2021 read as follows: "We are requesting to end today's survey due to complications with our EMR/ Kinnser/Well Sky system and not being able to access patient records." Surveyor give the Memo letters: "Inability to access state and federal records or perform a survey" to the hospice administrator on 12/07/2021 at 3:50 p.m. and left the hospice unable to conduct the complaint investigation, or the re-licensure and re-certification survey. Policy Review of the agency's policy Revised 09/13/13, page 3 of 4 titled "Safeguarding Medical Record Information" read in part: "In the event that electronic record/ Point of care equipment/ laptop/ PC are unavailable or non-functioning, all medical record entries will be made utilizing appropriate agency paper documents ...." Review of the agency's policy Revised 09/13/13 page 2 and 3 titled "Medical Record Information Retention and Destruction" read in part: "Inactive client information stored in a computer data system will be protected from accidental deletion and remain accessible to identified staff during normal working hours ...."