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
451547 A. BUILDING __________
B. WING ______________ 		10/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HOSPICE BRAZOS VALLEY INC 502 W 26TH STREET, BRYAN, TX, 77803
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)
L0558      
34717 Based on agency policy review, record review, and interview, the hospice agency failed to maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to provide for an ongoing sharing of information with hospice and other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions in 1 of 5 active patient's (Patient #1) whose clinical records were reviewed. The failure of the hospice to maintain an ongoing sharing of information has the potential to cause harm to Patient #1 in that providers may be unaware of changes in condition causing delays in care and services or services not being provided to patients who are receiving hospice care while residing in a skilled nursing facility. Findings Included: Review of the agency's Policy and Procedure Manual revealed a policy entitled "Policy and Procedure 300, Coordination of Services Policy, Approved: 9/28/12", which read in part "All personnel providing services will actively participate in planning and coordinating patient care to assure that their efforts effectively complement one another and support the objectives outlined in the plan of care as ordered by the physician and under the direction of the R.N. Case Manager. All personnel providing services will ensure the ongoing sharing of information between all disciplines. This includes services provided by the Hospice personnel and other non-hospice healthcare providers that may furnish services unrelated to the terminal illness and related conditions." Review of the clinical record for Patient #1 revealed a start of care date of: 04/17/2019 with a diagnosis of Senile Degeneration of the Brain and Dementia. Date of discharge was 05/13/2019 due to death. Review of the clinical record for the time period 04/17/2019 - 05/13/2019 revealed documentation of physician's orders dated 04/17/2019 which read: Treatments- SN (Skilled Nurse) 04-17-19 1-3 X week X 1 week, 04-17-19 5 PRN (as needed), 04-21-19 1-2 X week X 13 weeks. MD/DO NOTIFICATION: Physician notified of admission/recert (recertification)/current status and needs." Review of the clinical record for Patient #1 for the time period 04/17/2019 - 05/13/2019 documentation of a SN visit note dated 05/01/2019 signed by RN (Identifier E) which read in part "Received message from LVN (Identifier F) stated facility staff reported Patient #1 has DTI (deep tissue injury) to both great toes, and shear left upper/mid buttocks, covered with foam dressing. Skin prep on toes." The record did not contain documentation that the hospice Supervising Nurse and the physician were notified of the reported skin breakdown. Review of the clinical record for Patient #1 revealed documentation of a SN visit note dated 05/06/2019, signed by RN (Identifier E) which read in part "5) SKIN- bilateral great toes with DTIs- foot cradle in place; rt/lt buttock DTIs- WC (wound care) per facility WC nurse." The record did not contain documentation that RN (Identifier E) assessed the wounds to the patient's toes and buttocks and coordinated care with the facility wound care nurse regarding wound care orders, frequency of wound care or an update of the effectiveness of treatment. A Telephone Interview was conducted on 10/16/2019 with RN (Identifier E) at 8:30 a.m. SN visit notes dated 05/01/2019 and 05/06/2019 were reviewed. Surveyor asked where in the record documentation of coordination of care with the Supervising Nurse, Physician and skilled nursing facility staff would be located. RN stated "We rely on the facility to provide wound care." Surveyor asked if the agency received a documentation of wound assessments and wound care orders from the facility. RN stated "No." An Interview was conducted on 10/16/2019 with Supervising Nurse (Identifier C) at 10:10 a.m. The clinical record for Patient #1 was reviewed and the Surveyor requested documentation of coordination of care between the hospice agency and skilled nursing facility regarding assessment of wounds, wound care orders and the effectiveness of treatment for the time period 05/01/2019 - 05/13/2019. The Supervising Nurse acknowledged the record did not contain acceptable documentation of coordination of care.