DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
451536 A. BUILDING __________
B. WING ______________ 		10/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VITAS HEALTHCARE OF TEXAS L P 3131 EASTSIDE STREET SUITE 200, HOUSTON, TX, 77098
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0509      
32043 Based on record review and interview, the agency failed to immediately investigate and document alleged violation involving anyone furnishing services on behalf of the hospice and immediately act to prevent further potential violations while the alleged violation is being verified in that the agency failed to investigate a complainant from patient #2 that her phone was lost while in their care and someone made an attempt to accessed her accounts. Failure of the agency to make sure that allegation of ANE was properly investigated and corrective actions taken impacted patient #2 due to her concerns not being address. This failed practice may result in the perpetrator continuing to have access to other agency patients. Findings Include: Review of HHS Complaint Intake Worksheet #158183 received on 10/8/19 revealed a complaint in which the complainant reported the following: She was being over medicated and started to hallucinate. On 10/3/19, she started to see dead people and wanted out of the agency. She tried to call a family member while the staff came in and cut the cord of the phone. The complainant then reached for her cellphone and the staff fought with her and broke her cellphone. She put the broken cell phone in her purse. Complainant was transported out by 911 without her purse and EMS had to go back to get her purse. The complainant then notice that the cell phone was no longer in her purse. The company #100 called that someone was trying to access her accounts and the complainant had to change her passwords to her accounts. Complainant's sister called the agency to see what occurred and got the run around and did not know what happened to the cell phone. The agency stated the cellphone might have been lost. Review of agency's complaint and incident log did not show documentation of the above incident. Review of Patient #2's CR revealed SOC on 8/5/19. Patient #2 was transferred to the inpatient unit on 9/3/19 for respite care. Patient #2 was transferred to the hospital on 10/3/19. Further review of the CR showed a note by staff #53/MSW in which patient #2 reported that her online account was accessed at 2:39 a.m., and the patient insinuated that the unauthorized access into her account was from the hospice location. During interview with staff #51/alternate administrator/DON on 10/30/19 at 1:49 p.m., she was asked why the above complaint was not investigated. Staff #51 stated that the complaint was not investigated because patient #2 was no longer in service when she reported the complaint. Staff #51 stated that patient #2 reported that her account was accessed at 2:39 a.m. but staff #51 was unable to provide additional information on the complaint. During telephone interview with staff #53/MSW on 10/30/19 at 2:02 p.m., she stated that she did not obtain additional information from patient #2. Staff #53 was asked if she notified her supervisor. Staff #51 who was present during the interview stated that staff #53 notified her manager and the manager in turn notified her (staff #51). Staff #51 further stated that she consulted with her superiors and they decided not to investigate the complaint because the patient was no longer in service. During interview with staff #50/administrator/General Manager on 10/30/19 at 3:12 p.m., he also stated that the complaint was not investigated because patient #2 was not in their service when the complaint was received. Staff #51 was asked if anyone called the patient to find out when the incident happened, staff #50 stated that they assumed that the incident happened on 10/8/19 when the complaint was received. Review of agency's undated policy titled "(Agency) Management Standard Service Comment Process", read in part: "All complaints and grievances received from a patient, patient's family/guardian or the patient's health care provider regarding treatment, care, or respect for the active, discharged, pending and/or NTUC (Not Taken Under Care) patient's property will be recorded via the Service Comment Electronic System (SCES) and investigated in an expeditious method."
L0543      
32043 Based on record review and interview, the agency failed to make sure that care and services furnished to patients and their families followed an individualized written POC established by the hospice interdisciplinary group for 1 of 2 patients reviewed (patient #1) in that continuous care was not provided to the patient as ordered. Failure of agency to ensure that care was provided as ordered in the POC impacted patient #1's family due to the patient not receiving the required / ordered support that was needed. This failed practice placed the 2 patients and their families at risk for negative outcomes of not receiving necessary care and support. Findings include: Review of agency's Service Comment Form for complaint documentation showed a comment received from family satisfaction survey which read "On July 5th around 10 am, the RN states "Wife was going to die in the next 48 hrs. She gave me pain meds and told me that she was sorry that a 24 hr nurse could not be present, so I watched my wife die without hospice." Entry under action taken also read "The CC case was unable to be staffed due to lack of staff available. The patient had sufficient medications and supplies to ensure the patient was comfortable. EOL care, medication education, and VITAS office and on call number provided to the patient's spouse by the primary RN Case Manager staff #55." Review of patient #1's CR revealed SOC on 7/1/19. Admission orders and Interdisciplinary Care Plan revealed order for continuous care for the management of pain and shortness of breath. Review of Continuous Care Shift Care Note showed that continuous care was provided to the patient by agency nurses from patient #1's arrival home on 7/1/19 at 6:15 p.m. until 7/3/19 at 7:00 p.m. Thereafter continuous care was not provided to the patient until 7/4/19 at 7:45 a.m. Review of the notes showed that patient #1 was on continuous oxygen and the patient was frequently medicated for pain. Comprehensive assessment by staff #55/RN on 7/4/19 showed that patient #1 had tachycardia, arrhythmia, intermittent dyspnea and apnea at rest, no urine output x four days and imminent death, but staff #55 obtained verbal order to discontinue continuous care. Nursing Updated Comprehensive Assessment completed by staff #55/RN on 7/5/19 at 10:30 a.m. showed that patient #1's condition continued to deteriorate. Staff #55 recommended continuous care reinstated and staff #55 notified patient #1's physician. The agency did not provide continuous care to the patient. patient #1 expired at home on 7/6/19 at 3:41 a.m. During interview with staff #51/alternate administrator/DON on 10/30/19 at 11:52 a.m., she was asked why continuous was not provided for patient #1. Staff #51 state that continuous care was not provided for the patient because there was no staff available. Staff #51 also stated that the agency has a backup agreement with another agency, but the backup agency was also unable to provide nurse to cover the shift. Staff #52 stated that the agency was only able to provide continuous care the night of 7/3/19 and CC was discontinued on 7/4/19. When staff were asked why cc was discontinued, staff #51 stated that cc was discontinued because patient #1's condition improved. During follow-up interview with staff #51/alternate administrator and staff #52/Quality Control on 10/30/19 at 12:16 p.m., the staffs were asked why cc was not reinstated on 7/5/19 as indicated in RN assessment. Staff #52 stated that staff #55/RN probably made a mistake and the note was meant for 7/4/19 and not 7/5/19. When surveyor asked to speak with staff #55/RN, staff #51 stated that staff #55 was no longer with the agency. Staff #50/administrator/General Manager who was present during this interview stated that the agency did not necessarily have to provide nurses at the home for continuous care but can utilize the inpatient hospice unit. Staff #50 was asked if the agency offered to transfer patient #1 to the hospice inpatient unit. Staff #50 stated "Well, we don't have any documentation that we did that." Review of agency's undated policy titled "Patient Care Administrator", read in part: "Ensures that hospice care is provided to the ultimate satisfaction of patients and families" "Ensures that the clinical managers are efficiently managing resources to meet patient and family needs."