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
671527 A. BUILDING __________
B. WING ______________ 		12/03/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
FREEDOM HOSPICE 9001 AIRPORT FREEWAY SUITE 570, NORTH RICHLAND HILLS, TX, 76180
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)
L0519      
26268 Based on review of patient records and interview, the agency failed to provide information on the hospice services to be provided and specific limitations on those services. In one (Patient Record #1) of one patient record reviewed, where the usual hospice services had specific limitations, the agency failed to ensure that the patient's legal representative understood that the specific limitations involved providing no direct hospice care due to Covid-19 and the nursing facility's policy of not allowing hospice to enter. Failure of the agency staff to ensure that the patient's legal representative understood the specific limitations on the hospice services to be provided, resulted in a violation of the patient's rights and unnecessary distress for the patient's family during the patient's last stages of death. Findings include: The agency's policy entitled, "Patient Rights and Responsibilities" dated 08/31/16, read in part, "Patient Rights...A patient has the right to be informed in advance about the care to be furnished, the plan of care, expected outcomes, barriers to treatment, and any changes in the care to be furnished. The agency must ensure that written informed consent specifying the type of care and services that may be provided by the agency has been obtained for every patient.... The patient or the legal representative must sign or mark the consent form." The agency's policy entitled, "Facility Patients" dated 01/31/15, read in part, "The hospice must assume responsibility for the professional management of hospice services provided to the resident of a ...SNF...in accordance with the hospice plan of care. ...The hospice will be responsible to provide services at the same level and to the same extent as those services would be provided if the SNF...resident were in his or her own home." Patient Record #1 Review of a discharge list requested and received by the surveyor on 12/02/20, revealed Patient #1's name, start of care date of 10/07/20 and date of death of 10/12/20. Review of Patient Record #1 and a form entitled "Informed Consent and Election of Benefits" (form date, 10/17/17), revealed the patient representative's signature and date of signature (10/07/20), and the reason the patient was unable to sign as "cognitive impairment." The "Informed Consent and Election of Benefits" apprised the patient and patient's family/representative of the following, in part, "I understand all hospice services are administratively supervised by the administrator and clinically supervised by the supervising nurse under the medical direction of the hospice medical director. ...I understand the following hospice services are covered and provided according to my individualized plan of care: Nursing Services...." Review of the "Facility and Hospice Delineation of Duties" for Patient 1 dated 10/07/20, revealed the "Hospice Responsibilities" and the "Facility Responsibilities." Under "Hospice Responsibilities" for Personnel, "IDT Assignment/Frequency (of services) according to POC for the "Skilled Nurse," the frequency was written as two times per week. The "Facility Responsibilities" for Personnel, read "24-hour Room and Board care, meeting the personal care and nursing needs that would have been provided by the caregiver at home at same level of care provided prior to hospice." No documentation was found which stated that the hospice nurse would only be available to the patient by electronic "Facetime." No documentation was found which stated that the facility LVN would be providing hands-on hospice care to the patient. Review of Patient 1's individual "Hospice Plan of Care" with a start of care date of 10/07/20, revealed "This patient is being admitted for hospice services," and listed the terminal "Primary Diagnosis" as "10/03/20 Covid-19." Patient 1's POC under "Additional Services" read "Admit patient to hospice services under routine home care." Under "Interventions" the POC read in part, "IDT: Caregivers and patient screened for s/s COVID prior to entry and PPE utilized for visit per CDC guidelines: SN, MSW, Aide, IDT. IDT: Perform telehealth assessments as needed based on symptoms, facility or family requests or physician guidance." Patient 1's POC was electronically signed by RN (Employee B) and MD (Employee C). No documentation was found on the POC which informed the family the agency would not be providing hands-on hospice care. In an interview with the Administrator (Employee A) on 12/03/20 at approximately 2:00 pm, Employee A was asked the question, when the agency admitted a patient in a SNF which was not allowing the hospice staff entry, what was the family told about how hospice care would be provided? Employee A responded that they were told that the hospice care would be provided in coordination with the facility staff. No mention was made by the Administrator that the hospice staff told the family, the facility was not allowing hospice staff to come into the facility to provide hands-on care to their patient.