Survey Report for 671544

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
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	671544	A. BUILDING __________ B. WING ______________	02/03/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
BLUEBONNET HOSPICE OF EAST TEXAS INC	1101 RIDGE ROAD SUITE 203, ROCKWALL, TX, 75087
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)
L0629
L0629	38797 Based on clinical record review and interview, the agency failed to ensure that a Registered Nurse (RN) made an on-site visit every 14 days to assess the quality of care and services provided by the hospice aide, in 1 of 2 clinical record reviewed (Patient#1), which supervisory visits were due. Failure of the agency Registered Nurse to conduct an onsite supervisory visit at least every 14 days, had the potential of patients receiving hospice aide services not having their needs met and problems not reported. Findings Include: Patient #1: Patient 1's clinical record for the treatment period of 09/24/2019 to 11/13/2019 included hospice aide visits three to four times a week. Patient 1's clinical record included aide visits dated 9/25/19; 9/26/19; 9/27/19; 9/30/19; 10/1/19; 10/2/191 10/4/19; 10/7/19; 10/8/19; 10/11/19; 10/14/19; 10/15/19; 10/16/19; 10/18/19; 10/21/19; 10/22/19; 10/23/19; 10/25/19; 10/28/19; 10/29/19; 10/30/19; 11/1/19; 11/4/19; 11/5/19; 11/6/19; 11/8/19; 11/11/18; 11/12/18; and 11/13/19. Patient 1's clinical record included 1 aide supervisory visits signed by RN, Employee C dated 10/24/19. The first supervisory visit was due by 10/9/19. Patient 2's clinical record did not include any aide supervisory visits after 10/24/19. The next supervisory visit was due by 11/7/19. In an interview with the Alternate Administrator, Employee A at approximately 11:12 AM on 02/03/19, the surveyor asked why there were not any aide supervisory visits prior to or after 10/24/19. Employee A stated, "I'm not sure." The surveyor asked if RN, Employee C could be asked. Employee A responded that Employee C was no longer employed with the agency, but the surveyor could speak with the Director of Nursing. In an interview with the Director of Nursing, Employee B at approximately 11:40AM 02/03/19, the surveyor asked why there were not any aide supervisory visits prior to or after 10/24/19. Employee B said, "I don't know what happened. I don't know the nurse did not perform the supervisory visits." The agency did not dispute the findings and did not provide any additional evidence to explain or correct the findings.