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
671739 A. BUILDING __________
B. WING ______________ 		02/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SUPERIOR HOSPICE LLC 8000 VANTAGE DRIVE, SAN ANTONIO, TX, 78230
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)
L0549      
27459 Based on record review and interview the agency failed to enforce a written policy that detailed its patient care practices for pressure ulcer (wound) care for one of one discharged patient (Patient #3) whose record was reviewed, in that: the Skilled Nurse (SN) did not perform pressure ulcer wound measurements for Patient #3's right heel (unstaged/deep tissue injury)(pressure-related injury to tissues under intact skin), and coccyx (tailbone) pressure ulcer (Stage 2 - partial thickness skin loss) for two of eight weeks. This deficient practice could place Patient #3 at risk of receiving inadequate care to determine whether wound care therapies were effective and to promote healing. The findings included: 1. Review of the agency's policy titled "Wound Care" (undated) revealed in part "...Wounds will be measured every (q) week and as needed and will be documented on the Skilled Nurse (SN) note and/or coordination note." 2. Review of Patient #3's clinical record revealed a Plan Of Care (POC) with a Start Of Care (SOC) date 12/18/19 and for a certification period from 12/18/19 through 3/16/2020 with a diagnosis of Cirrhosis of the Liver (scarring of the liver) and Diabetes (high blood sugar levels). Further review revealed the Patient had a Stage 2 coccyx wound and a unstageable right heel wound (dead skin tissue) Review of the "Wound Assessment Tool Report" (wound record) of the coccyx dated 12/21/19 through 2/3/2020 revealed there were no measurements performed or documented on Week 3 - 12/29/19 through 1/4/2020 and Week 7 - from 1/27/2020 through 2/1/2020. 3. During an interview on 2/13/2020 at 12:00 p.m., with the Director of Operations/Licensed Vocational Nurse (LVN) A she stated that she will try and find out why the wound measurements were not completed. During an interview on 2/13/2020 at 4:11 p.m., with the Administrator/Supervising Nurse she stated that wound measurements should be performed weekly and documented. No additional evidence was provided at the time of the exit on 2/13/2020 or within two business day. The Compliance Officer provided a census of 46 hospice patients.
L0674      
27459 Based on record review and interviews, the agency failed to keep patient record entries current and accurate for one of two active patients (Patient #2) whose records were reviewed, in that: the Skilled Nurse (SN) did not document pressure ulcer wound measurements for Patient #2's three (3) Stage 4 (skin sore that extends deep and may expose underlying muscle, tendon, cartilage or bone and may have (necrotic) dead tissue) pressure ulcers and two (2) Stage 2 pressure ulcers (skin sore that expands into deeper layers of the skin) for four of eight weeks. This deficient practice could place Patient #2 at risk of receiving inadequate care to determine whether wound care therapies were effective and to promote healing. The findings included: 1. Review of the agency's policy titled "Wound Care" (undated) revealed in part "...Wounds will be measured every (q) week and as needed and will be documented on the SN note and/or coordination note." 2. Review of Patient #2's clinical record revealed a Plan of Care (POC) with a Start of Care (SOC) date of 9/24/19 with a re-certification period from 12/23/19 through 2/20/2020 with a diagnosis of Unspecified Protein Calorie Malnutrition (severe malnutrition), Neurofibromatosis (a genetic disorder (occurs at birth) of the nervous system), and Paraplegia (partial or complete paralysis of the lower half of the body with involvement of both legs that is usually due to injury or disease of the spinal cord). In addition, Patient #2 had Co-morbidities (presence of one or more additional conditions co-occurring at the same time) include Stage 4 pressure ulcers located at: occipital (in the back of the head); scapula (shoulder area); and coccyx (tailbone) and two Stage 2 pressure ulcers located in the right leg and buttocks (bottom). Further review of the POC revealed the SN visit frequency effective 12/23/19 three times a week for eight weeks, two times a week for one week, and three visits when necessary (3wk8, 2w1, and 3 when needed (prn). Review of the patient's "Visit Note Report" (nurses notes) dated 12/23/19 through 2/5/2020 revealed no measurements were performed Week 1 - 12/23/19 through 12/28/19, no documentation of wound measurements; Week 2 - 12/29/19 through 1/4/2020, no documentation of wound measurements; Week 3 - 1/5/2020 through 1/11/2020, no documentation of wound measurements; Week 5 - 1/19/2020 through 1/25/2020, no documentation of wound measurements; 3. During an interview on 2/13/2020 at 2:45 p.m., with the Director of Operations/Licensed Vocational Nurse (LVN #1) she stated that she called Individual #1 and was informed that he did the measurements but did not document it. She added that she would continue to look for the documentation. During a second interview on 2/13/2020 at 4:00 p.m., with the Director of Operations/LVN A she stated that visits were also done by Individual #2 and she would continue to look for the documentation. During an interview on 2/13/2020 at 4:11 p.m., with the Administrator/Supervising Nurse she stated that wound measurements should be documented weekly. Additional evidence was provided 2/15/2020 revealed "Wound Assessment Tool Report" dated from 1/15/2020 through 2/10/2020 read in part that wound assessments were performed on "1/15/2020, 1/31/2020, 2/7/2020, and 2/10/2020 to the following: Cranial Pressure Ulcer (PU) - Stage IV (4), Right scapula - Stage 4, Coccyx - Stage 4, and Right leg - Stage 2, Left Buttock - Stage 2." The Compliance Officer provided a census of 46 hospice patients.