Survey Report for 671733

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	671733	A. BUILDING __________ B. WING ______________	10/19/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
ENCOMPASS HOSPICE OF DFW	901 W ROSEDALE ST SUITE 250, FORT WORTH, TX, 76104
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)
L0557
L0557	30245 Based on record review and interview, the hospice failed to maintain a system of communication with all disciplines providing care and services, in accordance with its policy, that ensured the ongoing sharing of information. In 1 (#1) of 2 discharged patient records reviewed, the registered nurse failed to communicate changes in the patient's status to the Interdisciplinary Group (IDG). The failure of the hospice to maintain a system of communication in accordance with its policy resulted in Patient #1's health status changes were not communicated to the IDG, including the physician involved in Patient #1's plan of care. Patient #1's physician and other team members were unable to review the appropriateness of services and were unable to review whether the Plan of Care required modification. Patient #1 was discharged from services. Finding Include: The agency had a policy titled "Service Delivery Coordination of Services S05." The policy read in part; "1.0 Purpose 1.1 Establish guidelines for communication and liaison between care providers that 1.1.1 Confirm continuity, consistency, efficiency and appropriateness of services delivery...1.2 Confirm that documentation in the clinical record shows coordination of services. 1.3 Assure communication with all physicians involved in the plan of care. 2.1 Definitions 2.1 Coordination of services describes the Agency's methods for cooperation and communication to confirm liaison between team members and physician(s) to support objectives outlined in the plan of care. 3.0 Policy 3.1 Professional staff coordinate services with the physician. Staff...3.1.2 Promptly alert the physician to any changes which suggest a need to modify the plan of care...3.2...every 2 weeks for Hospice...the Case Manager 3.2.1 Reviews the clinical record to determine the adequacy of the plan of care and appropriateness of services...3.2.3 In cooperation with other teams members, care providers, and the physician, makes the decision on updating of the plan of care for hospice...4.0 Procedure 4.1...IDG meetings support coordination of services. 4.1.1 A patient case conference if held at the Agency...every 2 weeks for Hospice to review problem cases and to review plan of care for appropriateness and feasibility of services..." Patient #1 Patient #1's clinical record contained a Plan of Care dated 9/20/2019 to 11/18/2020. The Plan of Care indicated that Patient #1 started on the agency's services on 4/3/2017. Patient #1's clinical record contained a document titled "IDG Summary Report" that was dated 10/1/2019. The IDG Summary Report listed the terminal illness as Multi-System Degeneration of the Autonomic System. Patient #1's clinical record contained documentation of a visit conducted by a nurse practitioner and documentation of skilled nurse visits. Visits were conducted on-site in Patient #1's home. 8/29/2019 - visit conducted by Employee C, a nurse practitioner. Employee C documented that Patient #1 used Bipap at night and oxygen per nasal cannula use during the day. Employee C documented that Patient #1's oxygen saturation was 93% on 4.5 L of oxygen. Employee C documented that Patient #1 had diminished breath sounds.( Employee C did not document that Patient #1 was having issues with edema, dyspnea, or signs of possible silent aspiration). 9/20/2019 - visit conducted by Employee D, a registered nurse. Employee D documented that Patient #1's oxygen level was 96% on 3.5 L of oxygen. Employee D documented that Patient #1 had 1+ edema to bilateral lower extremities, dyspnea with exertion or functional activity, and slight breathlessness at rest. 9/24/2019 - visit conducted by Employee D. Employee D documented that Patient #1's oxygen level was 95% on 3.5 L of oxygen. Employee D documented that there were no cardiac abnormal findings, dyspnea with exertion or functional activity, and very slight breathlessness at rest. 9/27/2019 - visit conducted by Employee E, a registered nurse. Employee E documented that Patient #1's oxygen level was 98% on room air. Employee E documented that there were no cardiac abnormal findings, that Patient #1 had dyspnea with exertion or functional activity, that there were diminished breath sounds to Patient #1's right and left lower lobes, and that Patient #1 did not have breathlessness at rest. -Patient #1's clinical record contained documentation of an IDG meeting that was conducted on 10/1/2019. The documentation was on computerized an agency form titled" Hospice IDG Comprehensive Assessment and Plan of Care Update Report." Employee D documented that Patient #1 was dependent on all activities of daily living, used oxygen at 3.5 L continuous, used nebulizer treatments 2-3 times per day as needed, had a Foley catheter (indwelling tube to drain urine out of the bladder, and used BIPAP as night. Employee D documented that Patient #1 had evidence of disease progression of increased weakness, rigidity, and confusion. Employee D failed to coordinate to the IDG team that Patient #1 had edema to the bilateral lower extremities, had diminished breath sounds, and had slight breathlessness at rest. 10/1/2019 - visit conducted by Employee D. Employee D documented that Patient #1's oxygen level was 97% on 4 L of oxygen. Employee D documented that there were no cardiac abnormal findings, that Patient #1 had dyspnea with exertion or functional activity, and Patient #1 had very slight breathlessness at rest. 10/4/2019 - visit conducted by Employee D. Employee D documented that Patient #1's oxygen level was 97% on 3.5 L of oxygen. Employee D documented that that there were no cardiac abnormal findings, that the pulmonary assessment revealed no abnormal findings of the pulmonary system, and Patient #1 had very slight breathlessness at rest. 10/8/2019 - visit conducted by Employee D. Employee D documented that Patient #1's oxygen level was 98% on 3.5 L of oxygen. Employee D documented that Patient #1 had 1+ edema to the bilateral lower extremities, dyspnea with exertion or functional activity, and Patient #1 had very slight breathlessness at rest. -Patient #1's clinical record contained documentation by Employee G, a registered nurse, of an IDG meeting that was conducted on 10/15/2019. Employee G documented for nursing services the age and gender of Patient #1 and the hospice diagnosis. Employee B, a registered nurse, documented the same information as Employee G. Employee G and Employee B failed to coordinate with the IDG that Patient #1 had edema to the bilateral lower extremities and slight breathlessness at rest. 10/15/2019 - visit conducted by Employee F, a registered nurse. Employee F documented that Patient #1's oxygen level was 96% on 4.5 L of oxygen. Employee F documented that there were no cardiac abnormal findings, that Patient #1 had diminished breath sounds in the right upper, middle, and lower lobes, and diminished breath sounds in the left upper and lower lobes, dyspnea at rest, and that Patient #1 had moderate breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. 10/17/2019 - visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 96% on 4.5 L of oxygen. Employee F documented that Patient #1 had 1+ pitting edema to the bilateral lower extremities, had diminished breath sounds to all pulmonary lobes, and Patient #1 had moderate breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. 10/21/2019 - visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 96% on 4.5 L of oxygen. Employee F documented that Patient #1 had 1+ pitting edema to the bilateral lower extremities, had crackles present in the right upper, middle, and lower pulmonary lobes and crackles in the left upper and lower lobes, and Patient #1 did not have any breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. 10/28/2019 - visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 96% on 4.5 L of oxygen. Employee F documented that there were no cardiac abnormal findings, that Patient #1 had diminished breath sounds in the right upper and middle lobes and the left upper lobe, Patient #1 had crackles in the right and left lower lobes, and Patient #1 had slight breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. -Patient #1's clinical record contained documentation, by Employee F, of a IDG meeting conducted on 10/29/2019. Employee F documented that (physician) agreed to be Patient #1's attending physician, discussed decreasing skilled nurse visits to once a week due to no signs/symptoms of decline. Employee F documented no evidence of disease progression. Employee F failed to coordinate with the IDG that Patient #1 had 1+ edema to the bilateral lower extremities, had crackles to all lung fields, had moderate breathlessness at rest, and had signs of possible silent aspiration. 10/31/2019 - visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 97% on 5 L of oxygen. Employee F documented that there were no cardiac abnormal findings, that Patient #1 had diminished breath sound in all pulmonary lobes, and Patient #1 had slight breathlessness at rest. 11/7/2019 - visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 96% on 5 L of oxygen. Employee F documented that there were no cardiac abnormal findings, that Patient #1 had dyspnea with exertion or functional activity, Patient #1 had diminished breath sounds in all pulmonary lobes, and Patient #1 had moderate breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. -Patient #1's clinical record contained documentation, by Employee F, of a IDG meeting conducted on 11/12/2019. Employee F documented that skilled nurse visits were being decreased to once a week due to no signs/symptoms of decline and no changes in condition or evidence of disease progression. Employee F failed to coordinate with the IDG that Patient #1 that Patient #1 had diminished breath sounds in all pulmonary lobes, had moderate breathlessness at rest, and had signs of possible silent aspiration. 11/12/2019- visit conducted by Employee F. Employee F documented that Patient #1's oxygen level was 98% on 4 L of oxygen. Employee F documented that there were no cardiac abnormal findings, that Patient #1 had diminished breath sounds to the right and left lower lobes, and Patient #1 had very, very, slight breathlessness at rest. Employee F documented that Patient #1 had signs of possible silent aspiration. During an interview with on 10/19/2020 at approximately 10:35 a.m. with Employee B, the Alternate Director of Nursing, the surveyor discussed the record of Patient #1. Employee B reviewed the record in the computer. The surveyor discussed that the registered nurses had documented in the skilled nurse notes that Patient #1 had episodes of edema, moderate breathlessness at rest, crackles in all lung fields, and signs of possible silent aspiration. The surveyor discussed that the IDG meetings did not indicate that this information was discussed in the IDG. Employee B stated, "I didn't see it in the IDGs."