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
671560 A. BUILDING __________
B. WING ______________ 		07/18/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
TEXAS HOME HEALTH HOSPICE 5683 EASTEX FREEWAY, BEAUMONT, TX, 77706
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)
L0524      
44690 Based on record review and interview, the agency failed to conduct and document a patient specific comprehensive assessment that identified the physical needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process for one of five hospice patients (Patient #1) whose clinical records were reviewed in that: The hospice SN failed to include information from the comprehensive assessment to establish and monitor a plan of care to assess Patient #1's Mediport (implanted port with a flexible tube placed into a vein in the chest) and receive orders from the physician on the care and treatment of the site. This failure may have led to the emergency room visit of Patient #1 and placed all patients at risk of unidentified infections resulting in hospitalizations. Findings included: Review of a "Client Coordination Note Report" dated 04/14/22 indicated Patient #1's family member called the agency and reported Patient #1's right chest port (mediport) was red, and patient was complaining of pain at the port. The note indicated Patient #1's family member reported the port had not been flushed since hospice admission. Review of a "Client Coordination Note Report" dated 04/15/22 indicated Patient #1's family member reported Patient #1 was taken to the emergency room on 04/14/22 and patient was being treated for infection of the port (mediport). Review of a hospital emergency room visit note for Patient #1 dated 04/14/22 indicated Patient #1's family member took patient to the emergency room with complaints of erythema (redness of the skin) over right chest port (mediport) site that had been present for two to three days. The note indicated a diagnosis of severe sepsis. Review of a POC dated 08/11/21 - 11/08/21 for Patient #1 indicated a SOC date 08/11/21 and diagnoses including malignant neoplasm (cancerous tumor) of lower lobe, right bronchus or lung, secondary malignant neoplasm of bone, secondary malignant neoplasm of brain, secondary malignant neoplasm of other specified sites, and neoplasm related pain. The POC indicated Patient #1 was to receive SN visits three times a week for one week, twice a week for one week, three times a week for eleven weeks, and one time a week for one week. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care the with physician. The POC indicated goals: A nursing plan of care will be established that meets the patient's needs. The POC did not include orders to assess the patients mediport access site, nor did it address the location, safety measures, or care interventions for the protection of the access site. Review of a SOC comprehensive assessment visit note report for Patient #1 dated 08/11/21 indicated "yes" to "does the patient have an IV access". The note also indicated IV access/flushed under integumentary assessment findings. The note did not address the location or type of access site the patient had. Review of a Hospice Recertification Plan of Care update Order for Patient #1 dated 04/06/22 for certification period 04/08/22 - 06/06/22 indicated Patient #1 was to receive SN once every two weeks for two weeks, then once a week for eight weeks. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care with the physician. The POC did not include orders to assess the patient's mediport access site or care interventions for the protection of the access site. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report for Patient #1 dated 08/26/21, 09/09/21, 09/23/21,10/07/21, 10/21/21, 11/04/21, 11/17/21,12/01/21,12/15/21, 12/29/21, 01/12/22, 01/26/22,02/09/22, 02/23/22,03/09/22, 03/23/22, and 04/06/22 did not indicate the patient had a mediport. Review of SN visits for Patient #1 for the certification period of 02/07/22 - 04/07/22 and 04/08/22 until discharge on 04/21/22 did not reveal documentation of assessment for Patient #1's mediport access site or the location of the site. A SN recertification visit dated 03/21/22 prior to hospitalization did not include an assessment of Patient #1's mediport. During an interview on 07/18/22 at 12:10 a.m., the RN Administrator said the agency did not typically mess with/flush mediports in the hospice environment unless the patient was receiving something through it because of the risk for introducing infection. She said the SN should assess a patient's mediport as part of their skin assessment. During an interview on 07/18/22 at 1:05 p.m., the RN Administrator said she did not know if the nurses were assessing Patient #1's mediport because she was not there. During an interview on 07/18/22 at 1:37 p.m., the RN Administrator, who was part of the IDG/meetings, said she admitted Patient #1 and knew he had a mediport. During an interview on 07/18/22 at 1:56 p.m., the RN Administrator said the nurse of a patient with a mediport was expected to assess the skin/site. She said if the doctor ordered flushes of the port or IV medications the nurse would put an order in for a flush. She said that if a patient's port was subdermal (located or placed beneath the skin) it would be noted on the POC as a wound area to assess. The Administrator said the POC was updated a minimum of every 15 days and with changes. She said a patient's skin was assessed once every 15 days or weekly if the patient had an existing wound. She said a mediport should be documented on subsequent assessments after the SOC and there was no reason for it not to be. The Administrator said the importance of assessing a mediport was problems could be determined at the skin level such as heat and redness (signs of infection). She said by not assessing a mediport a patient could have an infection that may not be caught. The Administrator said Patient #1 went to the hospital on 04/14/22 and was released on 04/20/22. She said the family member reported Patient #1 had sepsis and the patient was treated with IV antibiotics and had the port (mediport) removed. Attempted to call the medical director of the agency for interview on 07/18/22 at 1:50 p.m. and left voicemail but he did not return surveyor's call. Attempted to call RN D, who provided care for Patient #1, for an interview on 07/18/22 at 1:52 p.m. and left voicemail but she did not return surveyor's call. Review of a Comprehensive Assessment policy revised on 02/15/22 indicated "This comprehensive assessment identifies the physical, psychological, emotional, and spiritual needs related to the terminal illness to promote the hospice patients' well-being, comfort, and dignity throughout the dying process ... 4. During the comprehensive patient assessment, all baseline data, and other relevant information shall be documented in the patient's clinical record, including at least the following information and assessments, as relevant ... F. A physical assessment ... I. Complications and risk factors that affect care planning ... 5. The comprehensive assessment shall determine: A. Patient problems and needs related to the terminal illness ..." Review of an Ongoing Nursing Assessment policy revised on 02/15/22 indicated " ...Elements assessed and documented shall include: G. Skin integrity ... 3. Based on assessments, the care plan- including problems, needs, goals, and outcomes shall be reviewed and updated by the interdisciplinary group members responsible for the case ..." Review of a Hospice Nursing Care policy revised on 02/15/22 indicated " ...3. A hospice registered nurse shall be assigned as the case manager for each patient and family/caregiver, and their duties shall be enumerated in a job description. Duties shall include ... B. Coordination of care and fostering communication between the patient and the interdisciplinary group. C. Participating in developing and implementing the plan of care ... G. Recommending revisions or changes in the plan of care as necessary ..." Review of a Plan of Care policy revised on 02/15/22 indicated " ...1. A written individualized plan of care will be established and maintained for each individual admitted to the hospice program ... 5. The Case Manager (or admitting registered nurse) will notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, identifying patient needs and the recommended services to meet those needs. The plan of care will be reviewed before care is delivered ... 16. The written plan of care will contain, but will not be limited to, the following ... B. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling ... F. Safety measures to protect against abuse, injury, infection, or infectious disease, as appropriate ... Q. drugs and treatments ..." Review of About Your Implanted Port dated 05/10/21 and accessed at https://www.mskcc.org/cancer-care/patient-education/your-implanted-port indicated "...Your implanted port will need to be flushed by a nurse every 4 weeks when it's not being used. This is done to make sure the catheter doesn't become blocked. If it becomes blocked, it may not work anymore and it may have to be removed ...Call Your Interventional Radiologist if You: have new or increased pain at the site of your port, have swelling or a growing bruise at the site of your port, Have pus or fluid coming from your incision(s), notice your incision(s) are hot, tender, red, or irritated ..."
L0538      
44690 Based on record review and interview, the IDG failed to ensure patient-specific needs were identified and assessed in during the updated comprehensive assessments and documented on the updated IDG POCs for one of five patients (Patient #1). This failure may have led to the emergency room visit of Patient #1 and placed all clients at risk of unidentified infections resulting in hospitalizations. Findings included: Review of a "Client Coordination Note Report" dated 04/14/22 indicated Patient #1's family member called the agency and reported Patient #1's right chest port (mediport) was red, and patient was complaining of pain at the port. The note indicated Patient #1's family member reported the port had not been flushed since hospice admission. Review of a "Client Coordination Note Report" dated 04/15/22 indicated Patient #1's family member reported Patient #1 was taken to the emergency room on 04/14/22 and patient was being treated for infection of the port (mediport). Review of a hospital emergency room visit note for Patient #1 dated 04/14/22 indicated Patient #1's family member took patient to the emergency room with complaints of erythema (redness of the skin) over right chest port (mediport) site that had been present for two to three days. The note indicated a diagnosis of severe sepsis. Review of a POC dated 08/11/21 - 11/08/21 for Patient #1 indicated a SOC date 08/11/21 and diagnoses including malignant neoplasm (cancerous tumor) of lower lobe, right bronchus or lung, secondary malignant neoplasm of bone, secondary malignant neoplasm of brain, secondary malignant neoplasm of other specified sites, and neoplasm related pain. The POC indicated Patient #1 was to receive SN visits three times a week for one week, twice a week for one week, three times a week for eleven weeks, and one time a week for one week. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care the with physician. The POC indicated goals: A nursing plan of care will be established that meets the patient's needs. The POC did not include orders to assess the patient's mediport access site, nor did it address the location, safety measures, or care interventions for the protection of the access site. Review of a SOC comprehensive assessment visit note report for Patient #1 dated 08/11/21 indicated "yes" to "does the patient have an IV access". The note also indicated IV access/flushed under integumentary assessment findings. The note did not address the location or type of access site the patient had. Review of a Hospice Recertification Plan of Care update Order for Patient #1 dated 04/06/22 for certification period 04/08/22 - 06/06/22 indicated Patient #1 was to receive SN once every two weeks for two weeks, then once a week for eight weeks. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care with the physician. The POC did not include orders to assess the patient's mediport access site or care interventions for the protection of the access site. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report for Patient #1 dated 08/26/21, 09/09/21, 09/23/21,10/07/21, 10/21/21, 11/04/21, 11/17/21,12/01/21,12/15/21, 12/29/21, 01/12/22, 01/26/22,02/09/22, 02/23/22,03/09/22, 03/23/22, and 04/06/22 did not indicate the patient had a mediport. Review of SN visits for Patient #1 for the certification period of 02/07/22 - 04/07/22 and 04/08/22 until discharge on 04/21/22 did not reveal documentation of assessment for Patient #1's mediport access site or the location of the site. A SN recertification visit dated 03/21/22 prior to hospitalization did not include an assessment of Patient #1's mediport. During an interview on 07/18/22 at 12:10 a.m., the RN Administrator said the agency did not typically mess with/flush mediports in the hospice environment unless the patient was receiving something through it because of the risk for introducing infection. She said the SN should assess a patient's mediport as part of their skin assessment. During an interview on 07/18/22 at 1:05 p.m., the RN Administrator said she did not know if the nurses were assessing Patient #1's mediport because she was not there. During an interview on 07/18/22 at 1:37 p.m., the RN Administrator, who was part of the IDG/meetings, said she admitted Patient #1 and knew he had a mediport. During an interview on 07/18/22 at 1:56 p.m., the RN Administrator said the nurse of a patient with a mediport was expected to assess the skin/site. She said if the doctor ordered flushes of the mediport or IV medications the nurse would put an order in for a flush. She said that if a patient's mediport was subdermal (located or placed beneath the skin) it would be noted on the POC as a wound area to assess. The Administrator said a POC was updated a minimum of every 15 days and with changes. She said a patient's skin was assessed once every 15 days or weekly if the patient had an existing wound. The Administrator said Patient #1's mediport was not mentioned during IDG meetings until the agency was made aware of the infection. She said that it was normal not to mention a mediport during IDG meetings unless a change had occurred. She said a mediport should be documented on subsequent assessments after the SOC and there was no reason for it not to be. The Administrator said the importance of assessing a mediport was problems could be determined at the skin level such as heat and redness. She said by not assessing a mediport a patient could have an infection that may not be caught. The Administrator said Patient #1 went to the hospital on 04/14/22 and was released on 04/20/22. She said the family member reported Patient #1 had sepsis and the patient was treated with IV antibiotics and had the mediport removed. Attempted to call the medical director of the agency for interview on 07/18/22 at 1:50 p.m. and left voicemail but he did not return surveyor's call. Attempted to call RN D, who provided care for Patient #1, for an interview on 07/18/22 at 1:52 p.m. and left voicemail but she did not return surveyor's call. Review of a Comprehensive Assessment policy revised on 02/15/22 indicated "This comprehensive assessment identifies the physical, psychological, emotional, and spiritual needs related to the terminal illness to promote the hospice patients' well-being, comfort, and dignity throughout the dying process ... 4. During the comprehensive patient assessment, all baseline data, and other relevant information shall be documented in the patient's clinical record, including at least the following information and assessments, as relevant ... F. A physical assessment ... I. Complications and risk factors that affect care planning ... 5. The comprehensive assessment shall determine: A. Patient problems and needs related to the terminal illness ..." Review of an Ongoing Nursing Assessment policy revised on 02/15/22 indicated " ...Elements assessed and documented shall include: G. Skin integrity ... 3. Based on assessments, the care plan- including problems, needs, goals, and outcomes shall be reviewed and updated by the interdisciplinary group members responsible for the case ..." Review of a Hospice Nursing Care policy revised on 02/15/22 indicated " ...3. A hospice registered nurse shall be assigned as the case manager for each patient and family/caregiver, and their duties shall be enumerated in a job description. Duties shall include ... B. Coordination of care and fostering communication between the patient and the interdisciplinary group. C. Participating in developing and implementing the plan of care ... G. Recommending revisions or changes in the plan of care as necessary ..." Review of a Plan of Care policy revised on 02/15/22 indicated " ...1. A written individualized plan of care will be established and maintained for each individual admitted to the hospice program ... 5. The Case Manager (or admitting registered nurse) will notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, identifying patient needs and the recommended services to meet those needs. The plan of care will be reviewed before care is delivered ... 16. The written plan of care will contain, but will not be limited to, the following ... B. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling ... F. Safety measures to protect against abuse, injury, infection, or infectious disease, as appropriate ... Q. drugs and treatments ..." Review of About Your Implanted Port dated 05/10/21 and accessed at https://www.mskcc.org/cancer-care/patient-education/your-implanted-port indicated "...Your implanted port will need to be flushed by a nurse every 4 weeks when it's not being used. This is done to make sure the catheter doesn't become blocked. If it becomes blocked, it may not work anymore and it may have to be removed ...Call Your Interventional Radiologist if You: have new or increased pain at the site of your port, have swelling or a growing bruise at the site of your port, Have pus or fluid coming from your incision(s), notice your incision(s) are hot, tender, red, or irritated ..."