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
671633 A. BUILDING __________
B. WING ______________ 		11/20/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
COMFORT HOSPICE 4545 FULLER DRIVE, SUITE #330, IRVING, TX, 75038
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)
L0513      
26268 Based on record review and interview, the hospice agency failed to advise the patient's family of a change in the patient's plan of care when the patient had a change of condition. In one (Patient Record #2) of one patient record reviewed, where the patient had a sudden change in condition, the family was not notified of the patient's change of condition or of a change in the plan of care. Failure of the agency to consult with Patient #2's family/POA in advance of any change in the plan of care of the patient, resulted in the patient's pain medications being changed and the family/POA not being involved in the change of the patient's plan of care. Findings include: A current census of 76 patients in the parent office and 38 patients in the alternate delivery site, was verified by the census report provided by the Administrator (Employee A) on 11/19/19 at approximately 11:30 am. Patient Record #2 Review of the electronic initial comprehensive nursing assessment dated 07/11/2019, revealed Patient #2 had a start of care date of 07/11/19 and a terminal diagnosis of "Cerebral Infarction" with a comorbidity of "Dysphagia." The assessment also noted that Patient #2 had a right hip fracture on 07/09/19 and that the Cerebral Infarction occurred in 2011. Further review of the initial comprehensive nursing assessment for Patient #2 dated 07/11/19, revealed documentation in part, "Pt...lives alone. Pt does have 24 hr (hour) (private) caregivers [PCGs] who have been taking care of the patient for 10 years. Pt has a daughter who is her POA. The Comprehensive Plan of Care for Patient #2 dated 07/11/19, noted under "Pain/Altered Comfort" the measurable goal of "Patient/Caregiver will verbalize/demonstrate understanding of pain management measures." On the "Hospice IDG (Interdisciplinary Group) Plan of Care Update Report" dated 07/18/19, the LMSW (Licensed Masters Social Worker) noted the caregiver's [POA's] reluctance to provide pain medication." Review of a "[Agency] Nursing Assessment" (form dated "Jul 2013") note of Patient #2, signed and dated 08/24/19 by RN (Employee E), showed a nursing visit made between "0100 am" and "0130" am. Documentation of the visit note indicated the "CG" called the oncall nurse. The CG who called the hospice agency about Patient #2 was a private caregiver [Identifier J]. The "Nursing Assessment" read in part, "Pain intensity (0-10)- 9" on a numeric scale. Also a FLACC score was written as 9. "Current regimen: Morphine liquid prn. Pt unable to swallow Norco this (unable to read). Satisfied with pain control, Y" was circled for yes. Under "Teaching- educated CG on pain medication administration with liquid Morphine q (every) hour as needed. On the second page of the"Nursing Assessment", dated 08/24/19, documentation read in part, "Collaboration regarding: medication administration; With, Physician/Nurse: RN E; Additional comments: CG educated on administering liquid Morphine and liquid Lorazepam from comfort kit. SN (skilled nurse) administered 0.5 (unable to read) of liquid Lorazepam with 1 cc (20 mg) liquid Morphine during SNV (skilled nurse visit) FLACC decreased from 9 to 2." The oncall nursing assessment note dated 08/24/19, documented in part, that the "CG was educated on administering ...." and "Teaching: educated CG on pain medication administration...." The after-hours call was from one of Patient #2's private caregivers, [Identifier J]. Review of Patient #2's record, revealed no documentation that the oncall nurse, RN E, notified the POA or any other family member about Patient 2's change in condition on 08/24/19. No documentation was found from the RN case manager, notifying the family the next day, 08/25/19, of the change in the plan of care. On 08/26/19, a nursing visit note reported that Patient #2 expired and was pronounced at 11:00 am. In an interview with the Administrator, Employee A, on 11/20/19 at approximately 10:30 am, the surveyor explained she would like to speak with RN E, the oncall nurse. Employee A stated that the oncall nurse, RN E, as well as the RN case manager, [Employee D] no longer worked for the hospice agency. On 09/03/19, the hospice agency received a call from Patient #2's daughter/POA, who stated her concerns about her mother's care in the final days of her life. She stated that the (private) caregiver called Nurse [RN E] about pt not doing well and she was instructed to give Morphine and Lorazepam. The POA stated that she was concerned with the amount of meds (medications) given and that she had been doing well on Hydrocodone. In an interview with Employee A on 11/20/19 at approximately 12:30 pm, the surveyor asked why the oncall nurse had not notified the POA about Patient #2's change of condition. Employee A stated that she did not know why.