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
671529 A. BUILDING __________
B. WING ______________ 		12/17/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HEART TO HEART HOSPICE OF AUSTIN LTD 4009 BANISTER LANE, SUITE 100, AUSTIN, TX, 78704
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)
L0581      
31946 Based on record review and interview, the agency failed to ensure that hospice aides were instructed on and performing COVID-19 screening of patients prior to performing tasks identified as essential and requiring a face to face visit (in 3 records reviewed where hospice aide services were provided/ Patients #1, #3 and #5). Failure of the agency to ensure that hospice aides have been instructed on and are performing patient screening prior to providing face to face contact has the potential to place agency staff at risk for acquiring and transmitting an infectious disease. The agency currently has 10 hospice aides and 76 patients receiving hospice aide services that potentially could be affected. Findings Include: 1. Review of the agency's policy and procedures for COVID-19 revealed a document entitled "COVID-19 Pandemic Response Plan" revised 5/13/2020. The document read in part: "Policy: Agency will follow recommendation as outlined by the CDC, WHO, State/ Local Government and CHAP. Best efforts will be made to adhere to these policies. Procedure: 10. All patients will receive an initial screen for COVID-19 and will then be screened via mode of assessment." 2. Review of the clinical record for Patient #1 for the period of 9/28/2020 to 11/26/2020 revealed a document entitled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 9/23/2020. The document read in part: "HHA effective 9/28/2020 5wk8, 4wk1." Further review of the clinical record revealed Hospice Aide services were provided 5 times weekly, for a total of forty-four visits, by Hospice Aide (Identifier F). Eleven RN visits were completed during this time. Review of a sample of the hospice aide notes (9/28/20, 9/29/20, 9/30/20, 10/1/20, 10/2/20, 10/5/20 and 10/6/20) did not reveal a screening of the patient for COVID-19 symptoms prior to or at the beginning of the visit. 3. During an interview with the Alternate Supervising Nurse (Identifier B) on 12/17/2020 at 10:30 a.m., the Alternate Supervising Nurse was asked where the hospice aides document the screening of patients prior to visits. The Alternate Supervising Nurse stated the hospice aides are not doing any type of screening on patients. The Supervising Nurse stated the aides get reports from the nurses regarding patients that have been identified as COVID-19 positive. 4. A telephone interview was conducted with Hospice Aide (Identifier F) on 12/17/2020 at 12:40 p.m. Hospice Aide (Identifier F) stated she provides services to patients in facilities and in private residences. Hospice Aide (Identifier F) stated she screens herself daily, but has not screened a patient prior to a visit, and has not been instructed by the agency to do a patient screening. 5. During an interview with the Alternate Supervising Nurse on 12/17/2020, this surveyor requested the name of a patient in a private residence that receives services by Hospice Aide (Identifier F). Patient #3 was identified. 6. Review of the clinical record of Patient #3 for the period of 12/11/2020 to 12/16/2020 revealed Hospice Aide (Identifier F) provided services on 12/14/20 and 12/16/20 The visit notes for aide services were reviewed and did not include a screening of the patient for COVID-19 symptoms prior to the visit. Patient # 3 was seen by a nurse on 12/16/2020, but not on 12/14/2020. 7. Review of the clinical record for Patient #5 for the period of 10/10/2020 to 11/20/2020 revealed a document entitled "Hospice IDG and Plan of Care" dated 10/10/2020. The document read in part: "HHA effective 10/11/2020 5wk12, 4wk1." Further review of the clinical record revealed Hospice Aide (Identifier E) provided services thirty times during this period (Monday through Friday weekly). Nine Registered Nurse visits were completed during this time. Review of a sample of the hospice aide notes (10/13/20, 10/14/20, 10/15/20, 10/16/20, 10/17/20. 10/19/20, 10/20/20, 11/18/20, 11/19/20 and 11/20/20) did not reveal a screening of the patient for COVID-19 symptoms prior to/ or at the beginning of the visit. 8. A telephone interview was conducted with Hospice Aide (Identifier E) on 12/17/2020 at 11:36 a.m. Hospice Aide (Identifier E) stated she provides services to patients in facilities and in private residences. Hospice Aide (Identifier E) states she does not screen the patients prior to the visit, and stated she thinks the facilities screen the patients daily. Hospice Aide (Identifier E) stated the nurses screen the patients in private residences on the days they make a visit and would let them know if anyone had become positive. 9. During an interview with the Administrator (Identifier A) on 12/17/2020 at 3:15 p.m., the Administrator stated the facilities are screening the patients daily, and stated the nurses are screening patients in private residences when they make a visit. The Administrator stated no one is screening the patients in private residences if visits are not made by the nurses.