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
451765 A. BUILDING __________
B. WING ______________ 		02/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ELARA CARING 12400 NETWORK BLVD., SAN ANTONIO, TX, 78249
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)
L0543      
22360 Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with an individualized plan of care (POC) for one of two discharged hospice patients (Patient #5) whose clinical records were reviewed, in that 1. The SN (Skilled Nurse) failed to conduct visits in accordance with the POC. 2. The SN failed to provide oxygen therapy as ordered in the POC. This failure placed Patient #5 at risk of receiving inadequate care and services. The findings included: A. Review of the agency's policy titled, "Interdisciplinary Team (IDT), Coordination of Care and Services," effective date 06/01/2006, read in part, "...All hospice care and services furnished to patients/families will follow an individualized written POC established by the hospice IDT (Interdisciplinary Team) in collaboration with the attending physician, the patient...and the primary caregiver..." B. Review of Patient #5's closed clinical record revealed a start of care (SOC) date of 06/19/19 with the diagnosis of Chronic Obstructive Pulmonary Disease (Inflammatory Lung Disease) and a revocation (cancellation of services) date 11/25/19. C. Further review Patient #5's closed clinical record included the following: 1. A SN (on-call) note dated 10/16/19 by RN (Registered Nurse)(Staff E) revealed in part, "...Call from [Patient #5's] son...pain and discomfort from shingles...No BM (bowel movement) in 4 days...Requesting nurse visit for assessment...[Ex-Staff H] RN to visit..." 2. A physician order dated 10/16/2019, revealed in part, "...patient with change in status...MD (Physician) contacted...make prn (as needed) visit for symptom management for 10/16/19..." 3. A "Hospice IDG Comprehensive Assessment and Plan of Care Update Report," dated 10/25/19 revealed in part, "...Hospice Physician Order...Problem: Patient with change in status...MD contacted. Ok to make prn visit for symptom management for 10/16/19..." Further review of Patient #5's clinical record revealed no documented evidence of a SN visit on 10/16/19. D. During an interview with the Supervising Nurse/Alternate Administrator on 02/13/19 at 11:20 a.m., she stated that Ex-Staff H was supposed to conduct the visit and she is no longer employed with the agency. The Supervising Nurse/Alternate Administrator stated she was not sure if the visit was conducted on 10/16/19 but that Staff I (LVN - Licensed Vocation Nurse) conducted a visit on 10/17/19. E. During an interview with Staff I on 02/13/19 at 11:51 a.m., she stated that she conducted a visit to Patient #5 on 10/17/19 and that Patient #5 had his medications for shingles and bowel regimen and that Patient #5's son was reluctant to give the pain medications as ordered because he did not like the side effects. F. Further review of Patient #5's clinical record revealed the following: 1. A "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report," dated 10/25/19 revealed in part, "...Changes to Discipline Frequency...SN effective 10/20/2019...5W1 (five times a week)..." 2. SN visit notes for the week of 10/20/19 revealed three SN visits dated 10/20/19, 10/21/19 and 10/22/19. Further review revealed no documented evidence of five SN visits as ordered. During an interview with the Supervising Nurse/Alternate Administrator on 02/13/19 at 11:20 a.m., she stated that she would look for additional documentation. G. Review of Patient #5's clinical record revealed a physician order dated 11/22/2019, which read in part, "...Add nursing visit on 11/22/19..." Further review of the clinical record revealed no documented evidence of a SN visit on 11/22/19. During an interview with the Supervising Nurse/Alternate Administrator on 02/13/19 at 11:20 a.m., she stated that she would look for additional documentation. H. Review of Patient #5's clinical record revealed a physician order dated 09/17/2019 which read in part, "...start oxygen 4 LPM (Liters Per Minute) via nasal cannula continuous..." Review of Patient #5's SN visit notes dated 10/22/19, 10/26/19, 10/30/19, 11/01/19 and 11/07/19 revealed that Patient #5 was receiving supplemental oxygen at "...3 LPM via nasal cannula..." I. During an interview and concurrent record review with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 11:20 a.m., the above findings were reviewed and discussed. The Supervising Nurse stated that the nursing staff that conducted the visits on 10/22/19, 10/26/19, 10/30/19 and 11/01/19 were no longer employed with the agency. The Supervising Nurse further stated she would look for additional documentation. During an interview on 02/12/2020 at 11:05 a.m., with Staff E (RN-Registered Nurse) who conducted the visit on 11/07/19, she stated that she was filling in for another nurse and could not recall specific information. J. During the exit conference on 02/13/2020 at 4:15 p.m., the Administrator/Alternate Supervising Nurse and the Alternate Administrator/Supervising Nurse were informed that the agency had two additional business days to provide additional documentation for review. No additional documentation was provided at the time of exit on 02/13/2020 or within two business days. The Alternate Administrator/Supervising Nurse provided a census of 34 from the active patients on 02/11/2020.
L0552      
22360 Based on record review and interview, the agency failed to update the patient's plan of care (POC) for one of two discharged patient's (Patient #5) whose clinical records were reviewed, in that: 1. The POC was not revised to include updated information on the medication regimen with the addition of the following medications: Lactulose, Lidocaine cream and Nystatin oral swish. This deficient practice placed Patient #5 at risk of not having his needs met and could affect the agency's other 34 active hospice patients. The findings included: A. Review of the agency's policy titled, "Care Planning Process," revised 04/08/19, revealed in part, "...in collaboration with the patient's attending physician, will be reviewed and revised...at a minimum of every fifteen (15) calendar days or more often as needed..." B. Review of Patient #5's closed clinical record revealed a start of care (SOC) date of 06/19/19 with the diagnosis of Chronic Obstructive Pulmonary Disease (Inflammatory Lung Disease) and orders for skilled nursing (SN) services once a week for 13 weeks.. Further review of the clinical record revealed that Patient #5 revoked (canceled) hospice services on 11/25/19. C. Review of Patient #5's SN visit notes for the benefit period 09/17/19 to 12/15/19 revealed the following: 1. On 10/15/19 by LVN (Licensed Vocational Nurse)(Ex-Staff K), "...medication refill Lidocaine cream (a local anesthetic (numbing medication)..." 2. On 10/17/19 by RN (Staff E), "...received (call) back from son...gave...dose of Lactulose (a synthetic sugar used to treat constipation) this morning and last night..." 3. On 11/18/19 by RN (Staff G) read in part, "...continues to take Lactulose every 3 days..." 4. On 11/25/19 by RN (Staff G), "...Thrush (fungal infection in the mouth)...use of Nystatin (anti-fungal medication) oral swish..." D. Review of Patient #5's "Hospice IDG Comprehensive Assessment and Plan of Care Updated Reports" dated 09/13/19, 09/27/19, 10/11/19, 10/25/19 and 11/08/19 revealed no documented evidence that Patient #5 POC was updated to include Lactulose, Lidocaine Cream or Nystatin oral swish as part of the treatment regimen. E. During an interview and concurrent record review with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 11:20 a.m., the above findings were reviewed and discussed. The Supervising Nurse stated she would look for additional documentation. F. During the exit conference on 02/13/2020 at 4:15 p.m., the Administrator/Alternate Supervising Nurse and the Alternate Administrator/Supervising Nurse were informed that the agency had two additional business days to provide additional documentation for review. No additional documentation was provided at the time of exit or within two business days. The Alternate Administrator/Supervising Nurse provided a census of 34 from the active patient list on 02/11/2020.
L0671      
22360 Based on record review and interview, the agency failed to ensure clinical records were in accordance with accepted principles of practice for one of two discharged hospice patients (Patient #5) whose clinical records were reviewed in that: 1. Patient #5's clinical record contained an inaccurate Plan of Care (POC) and 2. Patient #'5's clinical record contained inaccurate chaplain visit notes. This failure placed Patient #5 at risk of not receiving accurate care and services and could result in miscommunication between agency staff, patients and families. The agency had a census of 34 active hospice patients. The findings included: A. Review of the agency's policy titled, "Medical Record Content" revised 04/8/19 revealed in part, "...Agency will initiate and maintain an individual and accurate medical record for each patient receiving care in compliance with all federal, state, and local laws and regulations...The patient's records will be complete, promptly and accurately documented..." B. Review of Patient #5's closed clinical record revealed a recertification plan of care (POC) for the benefit period 09/17/19 to 12/15/19 with the primary diagnoses of Chronic Obstructive Pulmonary Disease (Chronic Inflammatory Lung Disease). Further review revealed orders for chaplain (CH) services once a week for one week followed by once every five weeks for five weeks followed by once every four weeks for four weeks. C. Review of Patient #5's closed clinical record revealed CH visit notes once a week for nine weeks on the following dates: 09/19/19, 09/26/19, 10/03/19, 10/10/19, 10/17/19, 10/23/19, 11/01/19, 11/06/19 and 11/13/19. Further review of Patient #5's CH visit notes dated 10/03/19, 10/10/19, 10/17/19, 10/23/19, 11/01/19, 11/10/19 and 11/13/19 revealed in part, "...Visit type: Monthly CH visit..." D. During an interview and concurrent record review with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 11:20 a.m., the above findings were reviewed and discussed. The Supervising Nurse stated that the chaplain (Ex-Staff M) was no longer employed with the agency and that the POC was incorrect. The Supervising Nurse stated that CH visits are usually ordered once a month and that she did not know why the chaplain was visiting once a week and documenting "monthly" visits but that she would look for additional documentation. During the exit conference on 02/13/2020 at 4:15 p.m., the Administrator/Alternate Supervising Nurse and the Alternate Administrator/Supervising Nurse were informed that the agency had two additional business days to provide additional documentation for review. No additional documentation was provided at the time of exit or within two business days. The Alternate Administrator/Supervising Nurse provided a census of 34 from the active patient list on 02/11/2020.
L0678      
22360 Based on record review and interview, the agency failed to enforce its policy on receipt of physician orders for one of two discharged hospice patients (Patient #5), in that: 1. The nursing staff failed to write down and sign the supplemental verbal orders within 24 hours of receiving the orders for medication and treatment changes. Failure to ensure that the agency's policy on receipt of physician orders was followed placed Patient #5 at risk for errors in administering care and treatment. The findings included: A. Review of the agency's policy titled, "Orders for Care," revised 04/08/19, read in part: "...Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders...The verbal orders may be signed by an RN (Registered Nurse), LVN (Licensed Vocational Nurse)/LPN (Licensed Practical Nurse, with co-signature by the RN..." B. Review of Patient #5's closed clinical record revealed a recertification plan of care (POC) for the benefit period 09/17/19 to 12/15/19 with the primary diagnoses of Chronic Obstructive Pulmonary Disease (Chronic Inflammatory Lung Disease) and orders for skilled nursing (SN) services once a week for 13 weeks. C. Review of a SN visit note dated 10/02/19 revealed that Hospice RN (Ex-Staff J) conducted an assessment on Patient #5 and noted, "...small raised dry pustules with erythema (redness)...radiating to lateral side of abdomen...possibly shingles...informed patient...physician...would be notified for treatment plan..." Review of a SN visit note dated 10/17/19 by Hospice LVN (Staff I), revealed in part, "...completed a prescription for Acyclovir antiviral medication from previous order...dated 10/03/19..." Further review of Patient #5's clinical record revealed no documented evidence that the supplemental verbal order for Acyclovir was written down and signed by the nurse within 24 hours of obtaining the order. D. During an interview with Staff I on 02/13/2020 at 11:51 a.m., she stated that Patient #5 had completed his prescription for Acyclovir for the treatment of his shingles and that she did not take the order and only saw the empty prescription bottle dated 10/03/2020. E. During an interview and concurrent record review with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 11:20 a.m., the above findings were reviewed and discussed. The Supervising Nurse stated that Ex-Staff J was no longer employed with the agency but that she would look for additional documentation. During a second interview with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 2:20 p.m., she stated that the hospice physician (Ex-Staff C) who gave the orders no longer worked for the agency and that she did not find additional documentation. F. Review of Patient #5's clinical record revealed a physician order, which read in part, "...verbal date 10/12/19...start Gabapentin (medication to treat nerve pain) 300 mg (milligrams) by mouth 3 times a day...start Norco (opioid analgesic) 5/325 mg 1 - 2 tabs (tablets) every 6 hrs (hours) as needed..." and signed by Staff F on 10/15/19, three days after receiving the order. G. During an interview with RN (Staff F) on 02/12/2020 at 10:46 a.m., she stated she did not recall any information specific to Patient #5 because "it was a long time ago." H. During an interview and concurrent record review with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 11:20 a.m., the above findings were reviewed and discussed. The Supervising Nurse stated she would look for additional documentation. During a second interview with the Supervising Nurse/Alternate Administrator on 02/13/2020 at 2:20 p.m., she stated that the hospice physician (Ex-Staff C) who gave the orders was no longer working for the agency and that she did not find additional documentation. During the exit conference on 02/13/2020 at 4:15 p.m., the Administrator/Alternate Supervising Nurse and the Alternate Administrator/Supervising Nurse were informed that the agency had two additional business days to provide additional documentation for review. No additional documentation was provided at the time of exit or within two business days. The Alternate Administrator/Supervising Nurse provided a census of 34 from the active patient list on 02/11/2020.