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
451605 A. BUILDING __________
B. WING ______________ 		05/12/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
NURSES IN TOUCH COMMUNITY HOSPICE 1815 TENTH STREET, FLORESVILLE, TX, 78114
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)
L0550      
21939 Based on record reviews and interviews the agency failed to develop a plan of care that included all services necessary for the palliation and management of the terminal illness and related conditions for four of six (#1, #2, #3, #4, and #5's ) patient records reviewed in that: Patient #1, #2, #3, #4, and #5's plan of care did not include medical supplies and appliances necessary to meet the needs of the patient. This failure could place patients at risk for receiving inadequate care and services from agency staff and patients who may need to use the DME's. The findings inlude: Record review of the agency's policy and procedure titled "Comprehensive Assessment" dated 2019, read in part, "The hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care ...the assessment will accurately reflect the patient's status at the time of the comprehensive assessment and include information to establish and monitor a plan of care ..." Record review of the agency's Policy and Procedure titled "The Plan of Care" dated 2014, read in part, "13. The written plan of care will include all services necessary to meet the specific patient and family needs and contain but will not be limited to the following: I. DME and medical supplies necessary to meet patient needs." Record review of Patient #1, #2, #3, #4, and #5's electronic clinical record (ECR) revealed the following: A. Patient #1 had a SOC date of 1/11/2021 and a terminal illness diagnosis of Malignant Neoplasm of the Bladder. Further review revealed an RN assessment was conducted on 1/11/2021 and identified Patient #1 with the following equipment/supplies: oxygen concentrator and scooter. B. Patient #2 had a SOC date of 03/21/2020 and a terminal illness diagnosis of Cardiomyopathy. Further review revealed an RN assessment was conducted on 03/21/2020 and assessed Patient #2 with the following equipment/supplies: hospital bed, over bed table, oxygen concentrator, oxygen cylinder, and wheelchair. C. Patient #3 had a SOC date of 04/30/2021 and a terminal illness diagnosis of Chronic Obstructive Pulmonary Disease. Further review revealed an RN assessment was conducted on 04/30/2021 and assessed Patient #3 with the following equipment/supplies: walker, oxygen concentrator, and oxygen cylinder. D. Patient #4 had a SOC date of 10/22/2020 and a terminal illness diagnosis of Alzheimer's Disease. Further review revealed an RN assessment was conducted on 10/22/2021 and assessed Patient #4 with the following equipment/supplies: over bed table, oxygen concentrator, and wheelchair. E. Patient #5 had a SOC date of 07/08/2020 and a terminal illness diagnosis of Chronic Diastolic Congestive Heart Failure. Further review revealed an RN assessment was conducted on 07/08/2020 and assessed Patient #5 with the following equipment/supplies: bedside commode, grab-bars, handrails, and IV pole. Record review of the Hospice IDG and comprehensive Plan of care update report for Patient #1, (dated 05/6/2021 and 4/22/2021) #2 (dated 4/22/2021 and 05/06/2021), #3 (dated 03/11/2021 and 05/06/2021), #4 (dated 05/06/2021 and 4/22/2021), and #5 (dated 4/8/2021 and 3/11/2021) revealed the POC update reports did not include the medical supplies and equipment necessary to meet the needs of the clients. During an interview on 5/12/2021 at 9:14 a.m. with the Administrator, he acknowledged the equipment/supplies were not on the Hospice IDG and comprehensive Plan of care update reports. Further interview revealed the RN that was updating the POC's had a lack of knowledge to the new ECR system.