Survey Report for 671751

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	671751	A. BUILDING __________ B. WING ______________	02/04/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
TEXAS BEST HOSPICE SERVICES	100 N CENTRAL EXPY STE 190 ROOM 127, RICHARDSON, TX, 75080
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	Content Of Comprehensive Assessment 418.54(c) Corrected On:
	29909 Based on record review and interview, the hospice failed to conduct and document a patient-specific comprehensive assessment that accurately identified the physical, psychosocial, emotional, and spiritual 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. In one (Patient Record #1) of one discharged patient record reviewed, the skilled nurse failed to conduct and document a Patient-specific comprehensive assessment that identified Patient 1's needs for hospice care and services for a patient living in an assisted living group home. The skilled nurse failed to assess the patient which accurately reflected the patient's health status at the time of the comprehensive assessment and include information to establish and monitor a plan of care as follows: 1. The caregivers' capabilities to care for Patient #1 who required her medications to be given via Gastrostomy tube (PEG). 2. Assess the PEG site and receive orders from the physician on the care and treatment of the site. 3. Assess the patient's nutritional status and clarify with the physician supplement feeding via Gastrostomy tube if required. 4. The caregiver's administration of the medications as ordered by the physician. The failure of the hospice to accurately reflect Patient 1's health status at the time of the comprehensive assessment resulted in Patient #1 being admitted to the hospital for Gastrostomy Tube not working and diagnosed with cellulitis around the insertion site area. Patient #1 did not receive her medications as ordered by the physician which resulted in the patient being oversedated and was malnurished, from possible inadequate amount of PO (by mouth) intake. Findings include: The agency's policy entitled "Care Planning Process" TX.7, revised 030115, read in par:t:..."Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient/family's specific needs and problems...Policy: An Initial Plan of Care (IPOC) will be established prior to the initiation of services. The IDT (Interdisciplinary Team) must develop an individualized written plan of care for each client. The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments...Initial Plan of Care 1.1 Information gathered from the initial assessment must be used by the agency to begin the plan of care and to provide care and services to treat a patient's and patient's family's immediate care and support needs..." The agency's policy entitled "Nutritional Management", TX.25, revised 120108, read in part:..."Purpose: To outline the basic principles for nutritional managment that are needed to provide nutritional services in an interdisciplinary manner and to meet the patient's unique needs...Policy: When the patient is detemined at the initial assessment to be at high nutrition risk and nutrition care planning is more complex, an interdisciplinary approach to nutrition care planning will occur as part of the IDT conference, and may include a consultation with a dietician...Procedure: 1. Intervention not requiring a change in therapeutic diet orders will be initiated by appropriate hospice personnel. 2. Physician ordered diet therapy will be documented in the patient's medical record and communicated to all staff involved in care for the patient. 3. The patient/caregiver will be assessed for willingness and capability to partcipate in the IDT's nutritional plan. 4. The patient/caregiver will be educated regarding the IDT's recommendations for patient's nutritional needs. 5. The Agency will ensure that any nutritional products in the organizational environment are properly maintained...." The agency's policy entitled "Medication Management (Facility Based) TX.29, revised 010107, read in part:..."Purpose: To ensure competent and safe medication administration to patients and maintenance of a current patient medication list..Policy: Agency staff will administer and document medications according to administrative and clinical policies and procedures in accordance with all applicable federal and state laws and regulations. Agency will obtain physician's orders when administering medication...1. Patient-specific information will be made readily available to those involved in the medication management system..." An entrance conference was conducted on 01/30/20 with the Alternate Administrator, Employee B, at 10:50 AM. The surveyor asked Employee B to provide a list of Patients who had recently been admitted to the hospital and patients with a Gastrostomy Tube. Employee B provided a hand written list which revealed that Patient #1 was hospitalized on 01/14/20. A telephone interview was conducted on 01/30/20 with Patient #1's daughter, Identifier G, at 4:55 PM. The surveyor asked Identifier G why Patient #1 was hospitalized. Identifier G told the surveyor that Patient #1 was hospitalized on 01/14/20, due to an infection around the patient's gastrostomy tube site. Identifier G told surveyor that the group home staff were treating Patient #1's gastrostomy tube site by cleansing with hydrogen peroxide and applying a split gauze. Identifier G told the surveyor that the group home staff were changing the dressing 4-5 times each day. Identifier G also told the surveyor that she was concerned that Patient #1 was "always sleepy" due to the facility staff giving Patient #1 Flexeril (Cyclobenzaprine HCL) three times and day and Lorazepam (Ativan) twice a day. Identifier G told the surveyor that Patient #1 was also taking Melatonin for sleep. Identifier G told the surveyor that she felt Patient #1 was being over medicated which caused Patient #1's loosing weight, which poor nutrition caused Patient #1 to develop pressure ulcers. The surveyor requested Identifier G to please e-mail her any information related to Patient #1's hospitalization. Review of the information provided to the surveyor by Identifier G entitled "Internal Medicine Hospitalist Admission History and Plan", dated 01/14/20 and signed by Physician, Identifier J, read in part:..."Chief Complaint: Patient presents with Wound Infection...History of Present Illness...Has a sacral decubitus ulcer, bed-bound and non-ambulatory...Encounter Diagnoses: PEG (gastrostomy tube) Malfunction, Abdominal Wall Cellulitis, Dementia, and Essential Hypertension...All Medication Administration from 01/13/20 to 01/16/20 included on 01/15/20 Clindamycin (Cleocin) premix IVPB (Introvenously Piggy Back) 600 mg..." Patient Record 1: Review of Patient Record 1's discharged record, revealed an order dated 12/18/19 to "Admit patient to Texas Best Hospice with Diagnosis of : End Stage CVA (Cerebral Vascular Accident)", signed by physician (Identifier E). The order also included orders for a Reg (Regular) MS (Mechanical Soft), NAS (No Added Salt) diet. Also included in the order was for the patient to continue current order regimen; and all meds (medications) may be delivered via peg tube (gastrostomy tube). Review of the electronic "RN (Registered Nurse) Initial Assessment" (initial comprehensive nursing assessment), completed by RN/DON (Director of Nurses), Employee D, dated 12/18/19, revealed under "Diagnosis Information at Admission", a primary diagosis of Cerebrovascular Disease. Patient 1 lived at an assisted living home. Patient #1 was admitted to the hospice agency on 12/18/19. It was documented that Patient #1 had no pain at the time of this assessment. Review under the "Wound Care Worksheet" section revealed no wounds. The section "Nutrition adn Fluid Intake Screening" revealed check marks for the following: Difficulty Chewing, Eats alone most of the time. The summary section read in part:..."Admitted to Texas Best Hospice with Cerebrovascular disease, unspecified muscle weakness (generalized) - Dsyphagia following cerebral infarction - Unspecified Dementia without behavioral Essential (primary) hypertension. She is in a group home with different caregivers and is total care requiring a hoyer lift. She exhibits a deficit on the right side as a result of the CVA (Cerebral Vascular Accident). Peg tube placement is verified with 10 ml (milliliters) of air. She is provided feeding by staff and tube is only for meds (medication) unless she is not eating 75% (percent) or more. Pt (patient) is dependent of 6/6 ADLs (activities of daily living)...No wound assessed with skin intact...." The initial comprehensive assessment did not include the following assessments: 1) The patient's weight, which was being determined by MAC (Mid Arm Circumference) and any nutritional concerns, 2) The person assisting the patient with her meals, 3) The assessment of the PEG (gastrostomy site) and if dressing changes to the site were required and 4) The person who was responsible for administering the patient's medications via PEG. And assess the caregiver's ability to perform medication administration via PEG in an assisted living setting. Review of a "Narrative Summary" for the treatment period 12/27/19 - 02/24/20, dated 11/27/19 and signed by NP (Nurse Practioner) Identifer F, read in part:...female with the terminal diagnosis of CVA with right hemiplegia and advanced dementia lives in a group home with 24/7 care...Patient has poor endurance secondary to multiple medical history and recent decline in her condition. Patient needs full assistance with ADLs IDL's (Independent Daily Living). Patient has poor appetitie and reported or documented. MAC on 10/28/19 - 30 cm (centimeters) and 11/19/19 - 29 cm...Patient has advanced dementia...with comorbidity of CVA with severe functional deficit secondary to impaired respiratory function as evidence by the use of oxygen, unable to care for herself, unable to maintain hydration and calorie intake as evidenced by weight loss along with secondary condition of HTN (Hypertension), severe muscle weaknes makes her appropriate to continue on hospice at this time...." Review of the "Plan of Care Order: 12/1819, for the Benefit Period 12/18/19 - 02/15/20, electronically signed by Phyician, Identifier E, dated 12/27/19, read in part:..."Problems : Dysphagia Description: At risk for Aspiration Goal: Family will verbalize understanting of how to care for Pt with risk of aspiration, Nutrition: Identified 12/18/19 Interventions:...Be positive regarding realistic food intake - Collaborate with physician for any adjustment in consistency of meals to meet Pt needs, prn. Crush pills and put them in soft food such as pudding or ice cream. Some pills should not be crushed. Check with your hospice nurse before crushing any medication...Potential for skin beakdown: Problem - Deficit related to skin/membrane integrity. Goal: Patient will remain free from skin breakdown and pressure ulcers during stay on hospice services. Identified: 12/18/19 Intervention: Assess skin integrity and effectiveness of skin care each visit...Problem: Spritual...." The plan of care also included orders for Skilled Nursing Visits at and visit frequency of 1 time a week and 2 prn (as needed), Medical Social Worker visit 1 time a month and 1 prn, Hospice Aide visits 5 times a week and 2 prn visits, and a Chaplain visit 1 time a month and 1 prn. The Plan of Care did not include PEG tube orders for care and maintenance, orders for weight assessments using MAC measurements to determine nutritional status, clarification of supplemental feeds if intake was less than 75%, and Medication Administration orders for the hospice to assess, review and monitor the medication administration via PEG and patency. Review of the Plan of Care Order dated 12/18/19 signed by RN/ADON (Alternate Director of Nurses), Employee D on 12/18/19, revealed the following list of Medications: Melatonin 5mg (milligram) Dose: 1 tab, Frequency: Take bedtime, Indication: sleep, Instructions: Take bedtimeTake 1mg bedtime by peg tube, Classification: Alternative Medicines Aricept 10mg Dose: 1 tab, Frequency: Twice daily, Indication: Disease, Instructions: Take by pegtube twice daily, Classification: Psychotherapeutic and Neurological Agents Cyclobenzaprine HCL (Hydrochloride) 10mg Dose: 1 tab, Frequency q (every 8 hrs) Indication: Muscle spasm pain, Instructions: take 1 tab via PEG q 8 hrs (hours) prn muscle spasm pain (Flexeril), Classification: Musculoskeletal Therapy Agent Ativan 0.5mg Dose: 1 tab, Frequency: q 8 hrs, Indication: anxiety/agitation, Instructions: 1 tab via PEG q 8 hrs prn anxiety/agitation, Classification: Antianxiety Agent Lactulose Oral Solution 10 GM (gram)/15ml (milligrams) Dose: 30 ml, Frequency: q day, Indication: Constipation, Instructions: 30-45 ml via peg q day prn constipation Metoclopramide HCL 10mg Dose: 1 tab, Frequency Take AM and bedtime, Indication: Gastric, Instructions: Take AM and bedtime by peg tube, Classification: Gastrointestinal Agents Cetirizine HCL 10mg Dose: 1 tab, Frequency: take daily, Indication: allergies, Instructions: Take daily by peg tube, Classification: Antihistamines Aspirin Chewable 81 mg Dose: 1 tab, Frequency: Take daily, Indication: blood thinner, Instructions: Take daily 81mg by peg tube, Classification: Analgesics Amlodipine Besylate 2.5mg Dose: 1 tab, Frequency: Take daily, Indication: HTN (Hypertension), Instructions: Take daily 2.5mg daily, Classification: Calcium Channel Blockers Senna Oral 8.6mg Dose: 1 tab, Frequency: twice daily, Indication: constipation, Instructions: Take twice daily by peg tube 8.6mg/5ml daily by peg tube, Classification: Laxative A second nurse visit was done on 12/19/19, by RN/ADON Nurse, Employee D. Employee D documented that the patient had no pain and that the pain intervention was Ativan. The "Skin" evaluation showed skin WNL (within normal limits), warm with decreased skin turgor. The "Digestive Nurtrition" section revealed a L (left) Arm Circumference of 28. A check mark indicated that meals prepared and administered appropriately, and "Diet: Reg (regular) MS (Mechanical Soft). Under the Comments: section read "Has a pegtube for medications." The Skilled Intervention section revealed that Patient #1 required total care in ADLs (activities of daily living) by staff and staff must feed her and medications are given by staff through the pegtube. The visit note had no evidence that RN, Employee D, had assessed the peg (gastrostomy) tube site and that Patient #1 had a dressing at the insertion site. The third nurse visit was done on 12/23/19, by RN, ADON, Employee D. Patient #1 had no pain during that assessment. The "Digestive Nutrition" section did not include a MAC assessment and there was no evidence that the patient's peg tube had been assessed. The "Skilled Intervention section revealed that the patient's daughter was asking for a feeding if the staff was not able to complete a meal with the patient. Employee D documented that the doctor would be notified and the skilled nurse would followup. Employee D also documented that the patient was eating, skin intact and that the patient had a pegtube, but was using it currently for medications prior to this admission. Employee D documented "she was able eat and continue to eat by staff feeding". There was no evidence in Patient #1's electronic record which indicated that the nurse had contacted a physician regarding the patient's daughter's request for feeding supplements. Review of the IDG (Interdisciplinary Group) Meeting dated 12/23/19, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Under the "Summary/Comment" section revealed that these notes were from and IDG meeting that occurred on 12/13/19. This date was prior to the patient's admission date of 12/18/19. Review of a Plan of Care, dated 12/23/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. No additional comments or changes in medications were identified. Review of a IDG Meeting dated 12/27/19 revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/17/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." Review of the section for "Notes" signed by RN/ADON, Employee D, read in part:...total care in ADLs and personal care. Meds are admin (administered) by her peg tube. Lives in a group home setting. Daughter is requesting her to feed self and this is to keep her right hand active (per the daughter). SN (skilled nurse) reference the daughter to the hand exercised given to group home while she was on home care services, just prior to changing over to hospice... Patient is not safe feeding herself and this will possible cause a faster decline as nutrition will be affected. SN will further assess the nutrition with request home care to write the percent down at meal times and her MAC...." Review of a Plan of Care, dated 12/27/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the 4th nurses visit note dated 12/30/19 and signed by RN/ADON, Employee D, revealed the patient was exhibiting no signs of pain during the visit. The client's Left Arm Circumference was 28. The "skilled intervention" section read in part:..."Her peg tube is intake (intact) and no s/sx (signs or symptoms) of infections. Skin assessment and intact. No feeding requested or needed...." The surveyor was not able to find any orders or interventions documented in the nurses notes that patient #1 had a dressing over her peg site. Review of the 5th nurses note dated 01/08/20 and signed by RN/ADON, Employee D, revealed the client's Left Arm Circumference was 28. The "Skin" section noted "Skin is fragile and there is a old scar on bottom. Lanseptic is to resume as aoppose [spelling] the previous". Review of the "Digestive Nutrition" section of the note had the following comments: "Has a pegtube for medications and followup on possible need to allow feeding by pegtube" Under the "skilled interventions" section, Employee D documented "It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit. SN telephoned the facility and was given the activity of patient sleep at time of the family member but later up (quoted to be 30-45 minutes difference) and she ate, No additional action at this time. Her skin is fragile where there is a history of pressure areas on her bottom. Instructions on risk factors. Family is thinking patient should and would be able to feed herself. Not ready at this time." The nurses note did not include and evidence that Patient's peg had been assessed by Employee D at the time of her visit. Review of the IDG Meeting dated 01/10/20, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/27/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." (This was the same notes which had been previously date from and IDG meeting dated 12/27/19) Review of the "Summary/Comments" section signed by the Supervising Nurse, Employee C, date 01/10/20 read in part:..."MAC is 29...Medication Changes: None noted. Patient remains appropriate for hospice care per Physician, Identifier E. Plan of care reviewed at least every 15 days. Plan of care reviewed with Patient/CG (caregiver). Recertification discussed. Care Coordination with Group Home. Copy of Plan of Care faxed to primary care physician. RN may administer medications. Caregiver may administer medications. Facility staff may administer medications...." Review of the 6th nurses note dated 01/12/20 and signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:..."It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit...1. buttock cleansed with NS (Normal Saline) and patted dry at visit with lanseptic applied and 4x4 to cover. The nurses note also included a "Wound Care Worksheet" which revealed that Patient #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleanse with NS and patted dry at visit with lanseptic applied and 4x4 to cover". This was the first time the surveyor was able to find any evidence in Patient #1's clinical record that the patient had a dressing applied to the peg site. Review of a Physician Order dated 01/12/20, signed by RN/ADON, Employee D, read as follows: "1. burttocks cleaned with NS and pat dry apply laniseptic with each incontinent episode with 4x4 to cover. 2. buttock cleaned with NS and patted dry at visit with laniseptic each episode apply and 4x4 to cover. 3. Pegtube to be cleaned daily with NS and new splt (split) gauze applied." Review of the 7th nursing visit note date 01/13/20, signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:...No acute changes since yesterday report to SN...Staff feeding her in bed, everything went well. Her pegtube was not freely flushing on previous day, however the meds were allowed but until today the patient was eating and family is wanting to allow bolus, once or twice daily. MD notified and signs of aspirations given in form of instructions to facility. Daughter wanting to allow her daughter to come and fix a meal in am at least on Tuesday and Thursday's (she was informed the facility would need to clear this task) 1. buttock cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover. 2. cleaned with NS and patted dry at visit with lanseptic applied and 4x4 covered. The nurses note also included a "Wound Care Worksheet" which revealed that Client #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleans with NS and patted dry at visit with lanseptic applied and 4x4 to cover." Review of a "Patient Communication" dated 01/13/20, signed by RN/ADON, Employee D, read "Daughter present at visit on today (Monday 13th) with previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval (re-evaluate) at each visit The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/13/20 and signed by RN/ADON, Employee D, read "previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval at each visit. The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/14/20 and signed by RN/ADON, Employee D, read "Discharge patient from hospice services as of 01/14/20 due to patient: revocation from hospice services." An interview was conducted on 01/31/20 with the RN/ADON, Employee D, at 11:30 AM. The surveyor aksed if she could tell the surveyor about Patient #1. Employee D told the surveyor that Patient #1 required transfers via hoyer lift and required total assistance with ADL's which was provided by the assisted living group home facility staff. Employee D told the surveyor that Patient #1 was originally transferred from home health to hospice care in September 2019, but the agency was not able to bill due to another hospice agency had not discharged the patient until December 2019. Employee D told the surveyor that Patient #1 was given all her medications via gastrostomy tube by the facility's owner, Identifier I. The surveyor also asked Employee D if Patient #1 had a dressing at the gastrostomy site. The surveyor explained that she was not able to determine if there was a dressing to Patient #1's site when reviewing Patient #1's record. Employee D told the surveyor that Patient #1 had a dressing and that the facility aides were changing the dressing as follows: Cleansing with NS (Normal Saline) and applying a dry split sponge daily and prn (as needed). The surveyor asked Employee D if Patient #1's gastrostomy site had been draining. Employee D told the surveyor that Patient #1's gastrostomy site had no drainage until 01/12/20. Employee D told the surveyor that the facility's owner, Identifier I had told her that the patient's daughter, Identifier H, had tried to give a bolus feed, and it was leaking around the tube site. Employee D said that Patient #1's gastrostomy tube site looked red on 01/13/20, but there were no sign or symptoms of infection. Employee D told the surveyor that Identifier H had notified her on 01/14/20 that she was going to have Patient #1 transported to the hospital to have Patient #1's pressure ulcers and gastrostomy tube evaluated. Employee D said that was when the agency discharged Patient #1 from hospice services for revocation due to hospitalization. A telephone interview was conducted on 01/31/20 with Patient #1's daughter, Identifier H, at 2:42 PM. Identifier H, was Patient #1's primary POA (Power of Attorney). The surveyor asked Identifer H, if she had requested the bolus feedings on 12/23/20, as revealed in Patient #1's nurses note. Identifier H said "Yes". Identifier H told the surveyor that the facility owner, Identifier I, had given Patient #1 Jevity via gastrostomy tube one time before. Identifier H said that she was first notified that Patient #1 had a pressure sore to her buttocks on 01/13/20. Identifier H told the surveyor that she made a visit with the RN/ADON, Employee D, and Identifier I, on 01/13/20. Identifier H said that Employee D had trouble flushing the gastrostomy tube. When Employee D removed the dressing to the gastrostomy tube site. Identifier H said that "it was red and had a odor". Identifier H asked Employee D if the site was infected if they would be able to treat it. Employee D told her that she would have to discuss it with the DON (Director of Nurses), Employee C, because the agency didn't do "preventative treatment". A telephone interview was conducted on 01/31/20 with the assisted living, facility owner, Identifier I, at 4:00 PM. The surveyor asked Identifier I what services the facility was providing for Patient #1. Identifier I told the surveyor that the facility staff were feeding her by mouth her meals and Identifier I said she was administering all Patient #1's medications via gastrostomy tube. The surveyor asked Identifier I if she was a nurse. Identifier I said "No", and said she was a CNA (certified nursing assistant). The surveyor asked Identifier I, if the facility had a RN on staff or under contract. Identifier I said "No", just the agency's RN. The surveyor asked who changes Patient #1's gastrostomy tube site dressing and how often was it changed. Identifier I told the surveyor that the CNA's change Patient #1's gastrostomy tube site dressing 5 - 6 times daily, due to leakage. I asked Identifier I how long this had been occuring. She said for approximately 6 months. The surveyor asked Identifier I what was the dressing treatment that the CNA's were doing. She said at first the CNA's were cleansing with a wound cleanser and applying a gauze. She then told the surveyor that in approximately October or Novermber the CNA's started cleansing the site with hydrogen peroxide. The surveyor asked Identifier I to please fax or email the surveyor the MAR (Medication Administration Record) for December 2019 and January 2020. Identifier I had problem with her fax machine and on 02/04/20, emailed Patient #1's MAR's for December 2019 and January 2020 to the Alternate Administrator, Employee B. Employee B provided a copy to the surveyor. Review of Patient #1's MAR revealed many discrepancies from the list of medications that were ordere
	d by the physician on the Plan of Care. There were 3 medications that Identifier I was administering to Patient #1 which were not listed on the Plan of Care Orders as follows: Escitalopram 10mg in am, Docusate Sodium 100 mg twice a day and Donepezil 10mg twice a day. Identifier I was administering Cyclobenzaprine HCL (Flexeril) 10 mg twice a day. The Plan of Care had orders for this medication to be given every 8 hours prn (as needed). Identifier I was also administering Ativan 0.5mg twice a day when the Plan of Care had orders for this medication to be given every 8 hours prn for anxiety. An interview was conducted on 02/04/20 with the Alternate Administrator, Employee B, the DON, Employee C and the ADON, Employee D at 1:40 PM. The surveyor discussed that above findings with Employee B, C and D. The surveyor asked Employee D if she was able to explain the discrepancies on why Patient #1 was receiving all the above medications that were not listed on the plan of care and why Flexeril and Ativan were given twice daily instead of prn as ordered by the physician. The surveyor also asked Employee D if she was aware that the facility staff were changing Patient #1's gastrostomy tube site dressing 5-6 times daily due to drainage. Employee D was not able to answer the surveyor. Employee D said that she thought the medications were given that way by Patient #1's daughters request. Employee D told the surveyor that she never reviewed the MAR with the facility staff and did not know the medications were on the MAR and the dosages given for Flexeril and Ativan. Employee D told the surveyor that the Plan of Care did not include orders to manage the gastrostomy tube site, due to an oversite error because the patient was on service prior to this new admission dated 12/18/19. Employee D provided the surveyor with a copy of an order dated 12/13/19 and signed by RN/ADON as follows: "Hydrogen peroxide maybe used for peg tube cleaning at site daily and prn." The hospice failed to conduct and document a patient-specific comprehensive assessment that accurately identified the physical, psychosocial, emotional, and spiritual 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.
L0549	Content Of Plan Of Care 418.56(c)(4) Corrected On:
	29909 Based on record review and an interview, the hospice failed to ensure the plans of care included drugs, treatments and interventions necessary for the palliation and management of the patients terminal illness and related conditions for 1 discharged patient (#1) of 1 whose record was reviewed. 1. Patient #1's Plan of Care failed to include an accurate list of medications Patient #1 was being administered by the assisted living facilty where the patient resided. This failure resulted in lack of coordination of services which resulted in Patient #1 being overmedicated which caused the patient to be sleepy. This placed Patient #1 at risk for poor nutrition. Patient #1 developed pressure ulcers to her buttocks. 2. Patient #1's Plan of Care failed to include dressing change orders for Patient #1's gastrostomy site. This failure resulted in lack of coordination of services which resulted in Patient #1's hospitalization due to cellulitis around the gastrostomy tube site. 3. Patient #1's Plan of Care failed to include assessments of the patient's weight, which was being determined by MAC (Mid Arm Circumference) and any nutritional concerns. This failure resulted in the agency's failure to identify the patient's weight loss, which placed Patient #1 a risk for poor nutrition. Patient #1 developed pressure ulcers to her buttocks. The findings included: The agency's policy entitled "Care Planning Process" TX.7, revised 030115, read in par:t:..."Purpose: To ensure that care provided is appropriately planned in a timely manner to meet the patient/family's specific needs and problems...Policy: An Initial Plan of Care (IPOC) will be established prior to the initiation of services. The IDT (Interdisciplinary Team) must develop an individualized written plan of care for each client. The plan of care must reflect client and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments...Initial Plan of Care 1.1 Information gathered from the initial assessment must be used by the agency to begin the plan of care and to provide cre and services to treat a patient's and patient's family's immediate care and support needs..." The agency's policy entitled "Implementing Care and Treatment", TX.8, revised 080115, read in part:..."Purpose: To ensure patient care and treatment are provided as identified in the care planning process...Policy: The Agency staff providing patient care and treatment will be competent to the level of care/treatment needed. The Agency designates a qualified registered nurse, who is a member of the IDT, who will oversee the following when coordinating the assignments of patient care: The continuous assessment of each patient's/family's needs, The implementation of the IDT POC for each patient/family, The principles of the care to be provided, The staff qualifications and proficiency levels....VI, When the provision of care/treatment cannot be implemented as established on the care planning document(s), the patient's physician will be notified. the appropriate documentation will be completed and submitted by discipline/Patient/Care Manager.... The agency's policy entitled "Medication Management (Facility Based) TX.29, revised 010107, read in part:..."Purpose: To ensure competent and safe medication administration to patients and maintenance of a current patient medication list..Policy: Agency staff will administer and document medications according to administrative and clinical policies and procedures in accordance with all applicable federal and state laws and regulations. Agency will obtain physician's orders when administering medication...1. Patient-specific information will be made readily available to those involved in the medication management system..." An entrance conference was conducted on 01/30/20 with the Alternate Administrator, Employee B, at 10:50 AM. The surveyor asked Employee B to provide a list of Patients who had recently been admitted to the hospital and patients with a Gastrostomy Tube. Employee B provided a hand written list which revealed that Patient #1 was hospitalized on 01/14/20. A telephone interview was conducted on 01/30/20 with Patient #1's daughter, Identifier G, at 4:55 PM. The surveyor asked Identifier G why Patient #1 was hospitalized. Identifier G told the surveyor that Patient #1 was hospitalized on 01/14/20, due to an infection around the patient's gastrostomy tube site. Identifier G told surveyor that the group home staff were treating Patient #1's gastrostomy tube site by cleansing with hydrogen peroxide and applying a split gauze. Identifier G told the surveyor that the group home staff were changing the dressing 4-5 times each day. Identifier G also told the surveyor that she was concerned that Patient #1 was "always sleepy" due to the facility staff giving Patient #1 Flexeril (Cyclobenzaprine HCL) three times and day and Lorazepam (Ativan) twice a day. Identifier G told the surveyor that Patient #1 was also taking Melatonin for sleep. Identifier G told the surveyor that she felt Patient #1 was being over medicated which caused Patient #1's loosing weight, which poor nutrition caused Patient #1 to develop pressure ulcers. The surveyor requested Identifier G to please e-mail her any information related to Patient #1's hospitalization. Review of the information provided to the surveyor by Identifier G, entitled "Internal Medicine Hospitalist Admission History and Plan", dated 01/14/20 and signed by Physician, Identifier J, read in part:..."Chief Complaint: Patient presents with Wound Infection...History of Present Illness...Has a sacral decubitus ulcer, bed-bound and non-ambulatory...Encounter Diagnoses: PEG (gastrostomy tube) Malfunction, Abdominal Wall Cellulitis, Dementia, and Essential Hypertension...All Medication Administration from 01/13/20 to 01/16/20 included on 01/15/20 Clindamycin (Cleocin) premix IVPB (Introvenously Piggy Back) 600 mg...." Patient Record 1: Review of Patient Record 1's discharged record, revealed an order dated 12/18/19 to "Admit patient to Texas Best Hospice with Diagnosis of : End Stage CVA (Cerebral Vascular Accident)", signed by physician (Identifier E). The order also included orders for a Reg (Regular) MS (Mechanical Soft), NAS (No Added Salt) diet. Also included in the order was for the client to continue current order regimen; and all meds (medications) may be delivered via peg tube (gastrostomy tube). Review of the electronic "RN (Registered Nurse) Initial Assessment" (initial comprehensive nursing assessment), completed by RN/ADON (Alternate Director of Nurses), Employee D, dated 12/18/19, revealed under "Diagnosis Information at Admission", a primary diagosis of Cerebrovascular Disease. Patient 1 lived at an assisted living home. Patient #1 was admitted to the hospice agency on 12/18/19. It was documented that Patient #1 had no pain at the time of this assessment. Review under the "Wound Care Worksheet" section revealed no wounds. The section "Nutrition and Fluid Intake Screening" revealed check marks for the following: Difficulty Chewing, Eats alone most of the time. The summary section read in part:..."Admitted to Texas Best Hospice with Cerebrovascular disease, unspecified muscle weakness (generalized) - Dsyphagia following cerebral infarction - Unspecified Dementia without behavioral Essential (primary) hypertension. She is in a group home with different caregivers and is total care requiring a hoyer lift. She exhibits a deficit on the right side as a result of the CVA (Cerebral Vascular Accident). Peg tube placement is verfied with 10 ml (milliliters) of air. She is provided feeding by staff and tube is only for meds (medication) unless she is not eating 75% (percent) or more. Pt (patient) is dependent of 6/6 ADLs (activities of daily living)...No wound assessed with skin intact...." The initial comprehensive assessment did not include the following assessments: 1) The patient's weight, which was being determined by MAC (Mid Arm Circumference) and any nutritional concerns, 2) The person assisting the patient with her meals, 3) The assessment of the PEG (gastrostomy site) and if dressing changes to the site were required and 4) The person who was responsible for administering the patient's medications via PEG. And assess the caregiver's ability to perform medication administration via PEG in an assisted living facility. Review of a "Narrative Summary" for the treatment period 12/27/19 - 02/24/20, dated 11/27/19 and signed by NP (Nurse Practioner) Identifer F, read in part:...female with the terminal diagnosis of CVA with right hemiplegia and advanced dementia lives in a group home with 24/7 care...Patient has poor endurance secondary to multiple medical history and recent decline in her condition. Patient needs full assistance with ADLs IDL's (Independent Daily Living). Patient has poor appetitie and reported or documented. MAC on 10/28/19 - 30 cm (centimeters) and 11/19/19 - 29 cm...Patient has advanced dementia...with comorbidity of CVA with severe functional deficit secondary to impaired respiratory function as evidence by the use of oxygen, unable to care for herself, unable to maintain hydration and calorie intake as evidenced by weight loss along with secondary condition of HTN (Hypertension), severe muscle weaknes makes her appropriate to continue on hospice at this time...." Review of the "Plan of Care Order: 12/1819, for the Benefit Period 12/18/19 - 02/15/20, electronically signed by Phyician, Identifier E, dated 12/27/19, read in part:..."Problems : Dysphagia Description: At risk for Aspiration Goal: Family will verbalize understanting of how to care for Pt with risk of aspiration, Nutrition: Identified 12/18/19 Interventions:...Be positive regarding realistic food intake - Collaborate with physician for any adjustment in consistency of meals to meet Pt needs, prn. Crush pills and put them in soft food such as pudding or ice cream. Some pills should not be crushed. Check with your hospice nurse before crushing any medication...Potential for skin beakdown: Problem - Deficit related to skin/membrane integrity. Goal: Patient will remain free from skin breakdown and pressure ulcers during stay on hospice services. Identified: 12/18/19 Intervention: Assess skin integrity and effectiveness of skin care each visit...Problem: Spritual...." The plan of care also included orders for Skilled Nursing Visits at and visit frequency of 1 time a week and 2 prn (as needed), Medical Social Worker visit 1 time a month and 1 prn, Hospice Aide visits 5 times a week and 2 prn visits, and a Chaplain visit 1 time a month and 1 prn. The Plan of Care did not include PEG tube orders for care and maintenance, orders for weight assessments using MAC measurements to determine nutritional status, clarification of supplemental feeds if intake was less than 75%, and Medication Administration orders for the hospice to assess, review and monitor the medication administration via PEG and patency. Review of the Plan of Care Order dated 12/18/19 signed by RN/ADON, Employee D on 12/18/19, revealed the following list of Medications: Melatonin 5mg (milligram) Dose: 1 tab, Frequency: Take bedtime, Indication: sleep, Instructions: Take bedtimeTake 1mg bedtime by peg tube, Classification: Alternative Medicines Aricept 10mg Dose: 1 tab, Frequency: Twice daily, Indication: Disease, Instructions: Take by pegtube twice daily, Classification: Psychotherapeutic and Neurological Agents Cyclobenzaprine HCL (Hydrochloride) 10mg Dose: 1 tab, Frequency q (every 8 hrs) Indication: Muscle spasm pain, Instructions: take 1 tab via PEG q 8 hrs (hours) prn muscle spasm pain (Flexeril), Classification: Musculoskeletal Therapy Agent Ativan 0.5mg Dose: 1 tab, Frequency: q 8 hrs, Indication: anxiety/agitation, Instructions: 1 tab via PEG q 8 hrs prn anxiety/agitation, Classification: Antianxiety Agent Lactulose Oral Solution 10 GM (gram)/15ml (milligrams) Dose: 30 ml, Frequency: q day, Indication: Constipation, Instructions: 30-45 ml via peg q day prn constipation Metoclopramide HCL 10mg Dose: 1 tab, Frequency Take AM and bedtime, Indication: Gastric, Instructions: Take AM and bedtime by peg tube, Classification: Gastrointestinal Agents Cetirizine HCL 10mg Dose: 1 tab, Frequency: take daily, Indication: allergies, Instructions: Take daily by peg tube, Classification: Antihistamines Aspirin Chewable 81 mg Dose: 1 tab, Frequency: Take daily, Indication: blood thinner, Instructions: Take daily 81mg by peg tube, Classification: Analgesics Amlodipine Besylate 2.5mg Dose: 1 tab, Frequency: Take daily, Indication: HTN (Hypertension), Instructions: Take daily 2.5mg daily, Classification: Calcium Channel Blockers Senna Oral 8.6mg Dose: 1 tab, Frequency: twice daily, Indication: constipation, Instructions: Take twice daily by peg tube 8.6mg/5ml daily by peg tube, Classification: Laxative A second nurse visit was done on 12/19/19, by RN/ADON, Employee D. Employee D documented that the patient had no pain and that the pain intervention was Ativan. The "Skin" evaluation showed skin WNL (within normal limits), warm with decreased skin turgor. The "Digestive Nurtrition" section revealed a L (left) Arm Circumference of 28. A check mark indicated that meals prepared and administered appropriately, and "Diet: Reg (regular) MS (Mechanical Soft). Under the Comments: section read "Has a pegtube for medications." The Skilled Intervention section revealed that Client #1 required total care in ADLs (activities of daily living) by staff and staff must feed her and medications are given by staff through the pegtube. The visit note had no evidence that RN, Employee D, had assessed the peg (gastrostomy) tube site and that patient #1 had a dressing on at the insertion site. The third nurse visit was done on 12/23/19, by RN, ADON, Employee D. Patient #1 had no pain during that assessment. The "Digestive Nutrition" section did not include a MAC assessment and there was no evidence that the patient's peg tube had been assessed. The "Skilled Intervention section revealed that the patient's daughter was asking for a feeding if the staff was not able to complete a meal with the patient. Employee D documented that the doctor would be notified and the skilled nurse would followup. Employee D also documented that the patient was eating, skin intact and that the patient had a pegtube, but was using it currently for medications prior to this admission. Employee D documented "she was able eat and continue to eat by staff feeding". There was no evidence in Patient #1's electronic record which indicated that the nurse had contacted a physician regarding the Patient's daughter's request for feeding supplements. Review of the IDG (Interdisciplinary Group) Meeting dated 12/23/19, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Under the "Summary/Comment" section revealed that these notes were from and IDG meeting that occurred on 12/13/19. This date was prior to the patient's admission date of 12/18/19. Review of a Plan of Care, dated 12/23/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. No additional comments or changes in medications were identified. Review of a IDG Meeting dated 12/27/19 revealed the same "Probems" and interventions as identified ont the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/17/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." Review of the section for "Notes" signed by RN/Alternate Supervising Nurse, Employee D, read in part:...total care in ADLs and personal care. Meds are admin (administered) by her peg tube. Live in a group home setting. Daughter is requesting her to feed self and this is to keep her right hand active (per the daughter). SN (skilled nurse) reference the daughter to the hand exercised given to group home while she was on home care services, just prior to changing over to hospice... Patient is not safe feeding herself and this will possible cause a faster decline as nutrition will be affected. SN will further assess the nutrition with request home care to write the percent down at meal times and her MAC...." Review of a Plan of Care, dated 12/27/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the 4th nurses visit note dated 12/30/19 and signed by RN/ADON, Employee D, revealed the patient was exhibiting no signs of pain during the visit. The patient's Left Arm Circumference was 28. The "skilled intervention" section read in part:..."Her peg tube is intake (intact) and no s/sx (signs or symptoms) of infections. Skin assessment and intact. No feeding requested or needed...." The surveyor was not able to find any orders or interventions documented in the nurses notes that Patient #1 had a dressing over her peg site. Review of the 5th nurses note dated 01/08/20 and signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. The "Skin" section noted "Skin is fragile and there is a old scar on bottom. Lanseptic is to resume as aoppose [spelling] the previous". Review of the "Digestive Nutrition" section of the note had the following comments: "Has a pegtube for medications and followup on possible need to allow feeding by pegtube" Under the "skilled interventions" section, Employee D documented "It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit. SN telephoned the facility and was given the activity of patient sleep at time of the family member but later up (quoted to be 30-45 minutes difference) and she ate, No additional action at this time. Her skin is fragile where there is a history of pressure areas on her bottom. Instructions on risk factors. Family is thinking patient should and would be able to feed herself. Not ready at this time." The nurses note did not include and evidence that Patient's peg had been assessed by Employee D at the time of her visit. Review of the IDG Meeting dated 01/10/20, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/27/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." (This was the same notes which had been previously date from and IDG meeting dated 12/27/19) Review of the "Summary/Comments" section signed by the Supervising Nurse, Employee C, date 01/10/20 read in part:..."MAC is 29...Medication Changes: None noted. Patient remains appropriate for hospice care per Physician, Identifier E. Plan of care reviewed at least every 15 days. Plan of care reviewed with Patient/CG (caregiver). Recertification discussed. Care Coordination with Group Home. Copy of Plan of Care faxed to primary care physician. RN may administer medications. Caregiver may administer medications. Facility staff may administer medications...." Review of the 6th nurses note dated 01/12/20 and signed by RN/ADON, Employee D, revealed the client's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:..."It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit...1. buttock cleansed with NS (Normal Saline) and patted dry at visit with lanseptic applied and 4x4 to cover. The nurses note also included a "Wound Care Worksheet" which revealed that Patient #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with ND and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleanse with NS and patted dry at visit with lanseptic applied and 4x4 to cover". This was the first time the surveyor was able to find any evidence in Patient #1's clinical record that the patient had a dressing applied to the peg site. Review of a Physician Order dated 01/12/20, signed by RN/ADON, Employee D, read as follows: "1. burttocks cleaned with NS and pat dry apply laniseptic with each incontinent episode with 4x4 to cover. 2. buttock cleaned with NS and patted dry at visit with laniseptic each episode apply and 4x4 to cover. 3. Pegtube to be cleaned daily with NS and new splt (split) gauze applied." Review of the 7th nursing visit note date 01/13/20, signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:...No acute changes since yesterday report to SN...Staff feeding her in bed, everything went well. Her pegtube was not freely flushing on previous day, however the meds were allowed but until today the patient was eating and family is wanting to allow bolus, once or twice daily. MD notified and signs of aspirations given in form of instructions to facility. Daughter wanting to allow her daughter to come and fix a meal in am at least on Tuesday and Thursday's (she was informed the facility would need to clear this task) 1. buttock cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover. 2. cleaned with NS and patted dry at visit with lanseptic applied and 4x4 covered. The nurses note also included a "Wound Care Worksheet" which revealed that Client #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleans with NS and patted dry at visit with lanseptic applied and 4x4 to cover." Review of a "Patient Communication" dated 01/13/20, signed by RN/ADON, Employee D, read "Daughter present at visit on today (Monday 13th) with previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval (re-evaluate) at each visit The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/13/20 and signed by RN/ADON, Employee D, read "previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval at each visit. The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/14/20 and signed by RN/ADON, Employee D, read "Discharge patient from hospice services as of 01/14/20 due to patient: revocation from hospice services." An interview was conducted on 01/31/20 with the RN/ADON, Employee D, at 11:30 AM. The surveyor aksed if she could tell the surveyor about Patient #1. Employee D told the surveyor that Patient #1 required transfers via hoyer lift and required total assistance with ADL's which was provided by the assisted living group home facility staff. Employee D told the surveyor that Patient #1 was originally transferred from home health to hospice care in September 2019, but the agency was not able to bill due to another hospice agency had not discharged the patient until December 2019. Employee D told the surveyor that Patient #1 was given all her medications via gastrostomy tube by the facility's owner, Identifier I. The surveyor also asked Employee D if Patient #1 had a dressing at the gastrostomy site. The surveyor explained that she was not able to determine if there was a dressing to Patient #1's site when reviewing Patient #1's record. Employee D told the surveyor that Patient #1 had a dressing and that the facility aides were changing the dressing as follows: Cleansing with NS (Normal Saline) and applying a dry split sponge daily and prn (as needed). The surveyor asked Employee D if Patient #1's gastrostomy site had been draining. Employee D told the surveyor that Patient #1's gastrostomy site had no drainage until 01/12/20. Employee D told the surveyor that the facility's owner, Identifier I had told her that the patient's daughter, Identifier H, had tried to give a bolus feed, and it was leaking around the tube site. Employee D said that Patient #1's gastrostomy tube site looked red on 01/13/20, but there were no sign or symptoms of infection. Employee D told the surveyor that Identifier H had notified her on 01/14/20 that she was going to have Patient #1 transported to the hospital to have Patient #1's pressure ulcers and gastrostomy tube evaluated. Employee D said that was when the agency discharged Patient #1 from hospice services for revocation due to hospitalization. A telephone interview was conducted on 01/31/20 with Patient #1's daughter, Identifier H, at 2:42 PM. Identifier H, was Patient #1's primary POA (Power of Attorney). The surveyor asked Identifer H, if she had requested the bolus feedings on 12/23/20, as revealed in Patient #1's nurses note. Identifier H said "Yes". Identifier H told the surveyor that the facility owner, Identifier I, had given Patient #1 Jevity via gastrostomy tube one time before. Identifier H said that she was first notified that Patient #1 had a pressure sore to her buttocks on 01/13/20. Identifier H told the surveyor that she made a visit with the RN/ADON, Employee D, and Identifier I, on 01/13/20. Identifier H said that Employee D had trouble flushing the gastrostomy tube. When Employee D removed the dressing to the gastrostomy tube site. Identifier H said that "it was red and had an odor". Identifier H asked Employee D if the site was infected if they would be able to treat it. Employee D told her that she would have to discuss it with the DON (Director of Nurses), Employee C, because the agency didn't do "preventative treatment". A telephone interview was conducted on 01/31/20 with the assisted living, facility owner, Identifier I, at 4:00 PM. The surveyor asked Identifier I what services the facility was providing for Patient #1. Identifier I told the surveyor that the facility staff were feeding her by mouth her meals and Identifier I said she was administering all Patient #1's medications via gastrostomy tube. The surveyor asked Identifier I if she was a nurse. Identifier I said "No", and said she was a CNA (certified nursing assistant). The surveyor asked Identifier I, if the facility had a RN on staff or under contract. Identifier I said "No", just the agency's RN. The surveyor asked who changes Patient #1's gastrostomy tube site dressing and how often was it changed. Identifier I told the surveyor that the CNA's change Patient #1's gastrostomy tube site dressing 5 - 6 times daily, due to leakage. The surveyor asked Identifier I how long this had been occuring. She said for approximately 6 months. The surveyor asked Identifier I what was the dressing treatment that the CNA's were doing. She said at first the CNA's were cleansing with a wound cleanser and applying a gauze. She then told the surveyor that in approximately October or Novermber the CNA's started cleansing the site with hydrogen peroxide. The surveyor asked Identifier I to please fax or email the surveyor the MAR (Medication Administration Record) for December 2019 and January 2020. Identifier I had problem with her fax machine and on 02/04/20, emailed Patient #1's MAR's for December 2019 and January 2020 to the Alternate Administrator, Employee B. Employee B provided a copy to the surveyor. Review of Patient #1's MAR revealed many discrepancies from the list of medications that were ordered by the physician on the Plan of Care. There were 3 medications that Identifier I was administering to Patient #1 which were not listed on the Plan of Care Orders as follows: Escitalopram 10mg in am, Docusate Sodium 100 mg twice a day and Donepezil 10mg twice a day. Identifier I was administering Cyclobenzaprine HCL (Flexeril) 10 mg twice a day. The Plan of Care had orders for this medication to be given every 8 hours prn (as needed). Identifier I was also administering Ativan 0.5mg twice a day when the Plan of Care had orders for this medication to be given every 8 hours prn for anxiety. An interview was conducted on 02/04/20 with the Alternat
	e Administrator, Employee B, the DON, Employee C and the ADON, Employee D at 1:40 PM. The surveyor discussed that above findings with Employee B, C and D. The surveyor asked Employee D if she was able to explain the discrepancies and why Patient #1 was receiving all the above medications that were not listed on the plan of care. The surveyor also asked Employee D why Flexeril and Ativan were given twice daily instead of prn as ordered by the physician. The surveyor also asked Employee D if she was aware that the facility staff were changing Patient #1's gastrostomy tube site dressing 5-6 times daily due to drainage. Employee D was not able to answer the surveyor. Employee D said that she thought the medications were given that way by Patient #1's daughter's request. Employee D told the surveyor she never reviewed the MAR with the facility staff and did not know the medications that were on the MAR and the dosages given. Employee D told the surveyor that the Plan of Care did not include orders to manage the gastrostomy tube site, due to an oversite error because the patient was on service prior to this new admission dated 12/18/19. Employee D provided the surveyor with a copy of an order dated 12/13/19 and signed by RN/ADON as follows: "Hydrogen peroxide maybe used for peg tube cleaning at site daily and prn." The hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions. The Plan of Care failed to include all the drugs and treatments necessary to meet the needs of the patient.
L0558
L0558	29909 Based on record review and interview, the hospice agency failed to enforce its written policy to ensure that the interdisciplinary team (IDT) maintains responsibility for coordinating and supervising the care and services for 1 (#1) of 1 discharged patient who had a gastrostomy tube which was used for administration of medications and required dressing changes at least daily. The interdisciplinary team failed to coordinate Patient #1's care regarding the administration of medications and dressing changes requirement with all staff providing care. Patient #1 required total care and lived in an assisted living group home. This failure to coordinate services between the assisted living staff resulted in Patient #1 not receiving adequate care or interventions which lead to Patient #1's hospitalization. Patient #1 was admitted to the hospital for a Malfunctioning gastrostomy tube and cellulitis around the tube site. The failure of the agency to coordinate with the assisted living facility staff regarding the accurate list of medications and dosages resulted in Patient #1 being overmedicated. Patient #1 exhibited signs weight loss which placed Patient #1 at risk for poor nutrition. Patient #1 developed pressure ulcers to her buttocks. Findings include: Record review of the agency's policy manual included an agency policy titled "INTERDISCIPLINARY TEAM COORDINATION OF CARE and SERVICES" TX.9, revised 110108, read in part:..."Purpose: To describe the process by which the Interdisciplinary Team (IDT) ensures the monitoring and coordination of the patient/family's specific needs and problems...The IDT will prepare a written plan of care for each patient/family which specifies the care and services necessary to meet the patient/family-specific needs identified in the comprehensive assessment, as those needs related to the terminal illness and related conditions...3. Coordination of Services: 3.2 Develop, coordinate, supervise, and evaluate the care and services provided to patients and families, regardless of their treatment setting. Ensure that the care and services are provided in accordance with the POC (Plan of Care). Ensure that the care and services provided are based on all assessments of the patient/family needs...3.4 Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether care and services are provided directly or under arrangement...3.5 Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions...." Patient Record 1: Review of Patient Record 1's discharged record, revealed an order dated 12/18/19 to "Admit patient to Texas Best Hospice with Diagnosis of : End Stage CVA (Cerebral Vascular Accident)", signed by physician (Identifier E). The order also included orders for a Reg (Regular) MS (Mechanical Soft), NAS (No Added Salt) diet. Also included in the order was for the client to continue current order regimen; and all meds (medications) may be delivered via peg tube (gastrostomy tube). Review of a "Narrative Summary" for the treatment period 12/27/19 - 02/24/20, dated 11/27/19 and signed by NP (Nurse Practioner) Identifer F, read in part:...female with the terminal diagnosis of CVA with right hemiplegia and advanced dementia lives in a group home with 24/7 care...Patient has poor endurance secondary to multiple medical history and recent decline in her condition. Patient needs full assistance with ADLs IDL's (Independent Daily Living). Patient has poor appetitie and reported or documented. MAC on 10/28/19 - 30 cm (centimeters) and 11/19/19 - 29 cm...Patient has advanced dementia...with comorbidity of CVA with severe functional deficit secondary to impaired respiratory function as evidence by the use of oxygen, unable to care for herself, unable to maintain hydration and calorie intake as evidenced by weight loss along with secondary condition of HTN (Hypertension), severe muscle weaknes makes her appropriate to continue on hospice at this time...." Review of the electronic "RN (Registered Nurse) Initial Assessment" (initial comprehensive nursing assessment), completed by RN/ADON (Alternate Director of Nurses), Employee D, dated 12/18/19, revealed under "Diagnosis Information at Admission", a primary diagosis of Cerebrovascular Disease. Patient 1 lived at an assisted living home. Patient #1 was admitted to the hospice agency on 12/18/19. It was documented that Patient #1 had no pain at the time of this assessment. Review under the "Wound Care Worksheet" section revealed no wounds. The section "Nutrition and Fluid Intake Screening" revealed check marks for the following: Difficulty Chewing, Eats alone most of the time. The summary section read in part:..."Admitted to Texas Best Hospice with Cerebrovascular disease, unspecified muscle weakness (generalized) - Dsyphagia following cerebral infarction - Unspecified Dementia without behavioral Essential (primary) hypertension. She is in a group home with different caregivers and is total care requiring a hoyer lift. She exhibits a deficit on the right side as a result of the CVA (Cerebral Vascular Accident). Peg tube placement is verfied with 10 ml (milliliters) of air. She is provided feeding by staff and tube is only for meds (medication) unless she is not eating 75% (percent) or more. Pt (patient) is dependent of 6/6 ADLs (activities of daily living)...No wound assessed with skin intact...." The record contained no documentation that coordination of care had occurred between the hospice agency and the assisted living facility staff to 1) identifying the persons assisting the patient with her meals, 2) the assessment of the PEG (gastrostomy tube site) and the person who was responsible for administering the patient's medications via PEG, and if the staff were administering the proper medications and dosages, 3) if the staff were licensed to provide the care and 4) who the assisted living staff were who provided PEG dressing changes and if they provided the care as ordered by the physician. Review of the "Plan of Care Order: 12/1819, for the Benefit Period 12/18/19 - 02/15/20, electronically signed by Phyician, Identifier E, dated 12/27/19, read in part:..."Problems : Dysphagia Description: At risk for Aspiration Goal: Family will verbalize understanting of how to care for Pt with risk of aspiration, Nutrition: Identified 12/18/19 Interventions:...Be positive regarding realistic food intake - Collaborate with physician for any adjustment in consistency of meals to meet Pt needs, prn. Crush pills and put them in soft food such as pudding or ice cream. Some pills should not be crushed. Check with your hospice nurse before crushing any medication...Potential for skin beakdown: Problem - Deficit related to skin/membrane integrity. Goal: Patient will remain free from skin breakdown and pressure ulcers during stay on hospice services. Identified: 12/18/19 Intervention: Assess skin integrity and effectiveness of skin care each visit...Problem: Spritual...." The plan of care also included orders for Skilled Nursing Vists at and visit frequency of 1 time a week and 2 prn (as needed), Medical Social Worker visit 1 time a month and 1 prn, Hospice Aide visits 5 times a week and 2 prn visits, and a Chaplain visit 1 time a month and 1 prn. Review of the Plan of Care Order dated 12/18/19 signed by RN/ADON, Employee D on 12/18/19, revealed the following list of Medications: Melatonin 5mg (milligram) Dose: 1 tab, Frequency: Take bedtime, Indication: sleep, Instructions: Take bedtimeTake 1mg bedtime by peg tube, Classification: Alternative Medicines Aricept 10mg Dose: 1 tab, Frequency: Twice daily, Indication: Disease, Instructions: Take by pegtube twice daily, Classification: Psychotherapeutic and Neurological Agents Cyclobenzaprine HCL (Hydrochloride) 10mg Dose: 1 tab, Frequency q (every 8 hrs) Indication: Muscle spasm pain, Instructions: take 1 tab via PEG q 8 hrs (hours) prn muscle spasm pain (Flexeril), Classification: Musculoskeletal Therapy Agent Ativan 0.5mg Dose: 1 tab, Frequency: q 8 hrs, Indication: anxiety/agitation, Instructions: 1 tab via PEG q 8 hrs prn anxiety/agitation, Classification: Antianxiety Agent Lactulose Oral Solution 10 GM (gram)/15ml (milligrams) Dose: 30 ml, Frequency: q day, Indication: Constipation, Instructions: 30-45 ml via peg q day prn constipation Metoclopramide HCL 10mg Dose: 1 tab, Frequency Take AM and bedtime, Indication: Gastric, Instructions: Take AM and bedtime by peg tube, Classification: Gastrointestinal Agents Cetirizine HCL 10mg Dose: 1 tab, Frequency: take daily, Indication: allergies, Instructions: Take daily by peg tube, Classification: Antihistamines Aspirin Chewable 81 mg Dose: 1 tab, Frequency: Take daily, Indication: blood thinner, Instructions: Take daily 81mg by peg tube, Classification: Analgesics Amlodipine Besylate 2.5mg Dose: 1 tab, Frequency: Take daily, Indication: HTN (Hypertension), Instructions: Take daily 2.5mg daily, Classification: Calcium Channel Blockers Senna Oral 8.6mg Dose: 1 tab, Frequency: twice daily, Indication: constipation, Instructions: Take twice daily by peg tube 8.6mg/5ml daily by peg tube, Classification: Laxative A second nurse visit was done on 12/19/19, by RN/ADON, Employee D. Employee D documented that the patient had no pain and that the pain intervention was Ativan. The "Skin" evaluation showed skin WNL (within normal limits), warm with decreased skin turgor. The "Digestive Nurtrition" section revealed a L (left) Arm Circumference of 28. A check mark indicated that meals prepared and administered appropriately, and "Diet: Reg (regular) MS (Mechanical Soft). Under the Comments: section read "Has a pegtube for medications." The Skilled Intervention section revealed that Patient #1 required total care in ADLs (activities of daily living) by staff and staff must feed her and medications are given by staff through the pegtube. The visit note had no evidence that RN, Employee D, had assessed the peg (gastrostomy) tube site and that patient #1 had a dressing on at the insertion site. The third nurse visit was done on 12/23/19, by RN, ADON, Employee D. Patient #1 had no pain during that assessment. The "Digestive Nutrition" section did not include a MAC assessment and there was no evidence that the patient's peg tube had been assessed. The "Skilled Intervention section revealed that the patient's daughter was asking for a feeding if the staff was not able to complete a meal with the patient. Employee D documented that the doctor would be notified and the skilled nurse would followup. Employee D also documented that the patient was eating, skin intact and that the patient had a pegtube, but was using it currently for medications prior to this admission. Employee D documented "she was able eat and coninue to eat by staff feeding". There was no evidence in Patient #1's electronic record which indicated that the nurse had contacted a physician regarding the patient's daughter's request for feeding supplements. Review of the IDG (Interdisciplinary Group) Meeting dated 12/23/19, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Under the "Summary/Comment" section revealed that these notes were from and IDG meeting that occurred on 12/13/19. This date was prior to the patient's admission date of 12/18/19. Review of a Plan of Care, dated 12/23/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. No additional comments or changes in medications were identified. Review of a IDG Meeting dated 12/27/19 revealed the same "Problems" and interventions as identified ont the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/17/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." Review of the section for "Notes" signed by RN/Alternate Supervising Nurse, Employee D, read in part:...total care in ADLs and personal care. Meds are admin (administered) by her peg tube. Live in a group home setting. Daughter is requesting her to feed self and this is to keep her right hand active (per the daughter). SN (skilled nurse) reference the daughter to the hand exercised given to group home while she was on home care services, just prior to changing over to hospice... Patient is not safe feeding herself and this will possible cause a faster decline as nutrition will be affected. SN will further assess the nutrition with request home care to write the percent down at meal times and her MAC...." Review of a Plan of Care, dated 12/27/19, and signed by RN/ADON, Employee D, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the 4th nurses visit note dated 12/30/19 and signed by RN/ADON, Employee D, revealed the patient was exhibiting no signs of pain during the visit. The patient's Left Arm Circumference was 28. The "skilled intervention" section read in part:..."Her peg tube is intake (intact) and no s/sx (signs or symptoms) of infections. Skin assessment and intact. No feeding requested or needed...." The surveyor was not able to find any orders or interventions documented in the nurses notes that Patient #1 had a dressing over her peg site. Review of the record contained no evidence that coordination of services had occurred between the hospice agency and the assisted living facility staff related to care for the patient's gastrostomy tube site and medication being properly administered throught the patient's gastrostomy tube. Review of the 5th nurses note dated 01/08/20 and signed by RN/DON, Employee D, revealed the patient's Left Arm Circumference was 28. The "Skin" section noted "Skin is fragile and there is a old scar on bottom. Lanseptic is to resume as aoppose [spelling] the previous". Review of the "Digestive Nutrition" section of the note had the following comments: "Has a pegtube for medications and followup on possible need to allow feeding by pegtube" Under the "skilled interventions" section, Employee D documented "It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit. SN telephoned the facility and was given the activity of patient sleep at time of the family member but later up (quoted to be 30-45 minutes difference) and she ate, No additional action at this time. Her skin is fragile where there is a history of pressure areas on her bottom. Instructions on risk factors. Family is thinking patient should and would be able to feed herself. Not ready at this time." The nurses note did not include and evidence that Patient's peg had been assessed by Employee D at the time of her visit. Review of the IDG Meeting dated 01/10/20, revealed the same "Problems" and interventions as identified on the Plan of Care dated 12/18/19. Review of the section for "Notes" signed by physician, Identifier E, dated 12/27/19 read in part:...Total care including feeding. Has peg tube for meds. Dtr (daughter) recently asking pt (patient) to be bolused twice daily, even though she eats and has not lost weight...." (This was the same notes which had been previously date from and IDG meeting dated 12/27/19) Review of the "Summary/Comments" section signed by the Supervising Nurse, Employee C, date 01/10/20 read in part:..."MAC is 29...Medication Changes: None noted. Patient remains appropriate for hospice care per Physician, Identifier E. Plan of care reviewed at least every 15 days. Plan of care reviewed with Patient/CG (caregiver). Recertification discussed. Care Coordination with Group Home. Copy of Plan of Care faxed to primary care physician. RN may administer medications. Caregiver may administer medications. Facility staff may administer medications...." Review of the 6th nurses note dated 01/12/20 and signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:..."It was a concern of the daughter if her mother will need to start receiving feeding in her pegtube after a family member made a visit...1. buttock cleansed with NS (Normal Saline) and patted dry at visit with lanseptic applied and 4x4 to cover. The nurses note also included a "Wound Care Worksheet" which revealed that Client #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with ND and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleanse with NS and patted dry at visit with lanseptic applied and 4x4 to cover". This was the first time the surveyor was able to find any evidence in Patient #1's clinical record that the patient had a dressing applied to the peg site. Review of a Physician Order dated 01/12/20, signed by RN/ADON, Employee D, read as follows: "1. burttocks cleaned with NS and pat dry apply laniseptic with each incontinent episode with 4x4 to cover. 2. buttock cleaned with NS and patted dry at visit with laniseptic each episode apply and 4x4 to cover. 3. Pegtube to be cleaned daily with NS and new splt (split) gauze applied." Review of the 7th nursing visit note date 01/13/20, signed by RN/ADON, Employee D, revealed the patient's Left Arm Circumference was 28. Review of the "Digestive Nutrition" under the comment sections read "Has a pegtube for medications and followup on possible need to allow feeding by pegtube. Review of the "skilled intervention " section read in part:...No acute changes since yesterday report to SN...Staff feeding her in bed, everything went well. Her pegtube was not freely flushing on previous day, however the meds were allowed but until today the patient was eating and family is wanting to allow bolus, once or twice daily. MD notified and signs of aspirations given in form of instructions to facility. Daughter wanting to allow her daughter to come and fix a meal in am at least on Tuesday and Thursday's (she was informed the facility would need to clear this task) 1. buttock cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover. 2. cleaned with NS and patted dry at visit with lanseptic applied and 4x4 covered. The nurses note also included a "Wound Care Worksheet" which revealed thatPatient #1 had Left buttock wound measuring 1/2cm (centimeter) x 2cm x 0 depth and a Right buttock wound measuring 1cm x 1/2cm x0 depth. Under the "Comments" sections read "pegtube with drainage and MD notified, no smell with area cleaned and new dressing applied and secured. 1. buttocks cleaned with NS and pat dry apply lanseptic with each incontinent episode with 4x4 to cover 2. buttocks cleans with NS and patted dry at visit with lanseptic applied and 4x4 to cover." Review of a "Patient Communication" dated 01/13/20, signed by RN/ADON, Employee D, read "Daughter present at visit on today (Monday 13th) with previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval (re-evaluate) at each visit The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/13/20 and signed by RN/ADON, Employee D, read "previous wound care supplies before patient admission to Agency and offered Medihoney (information supplied to her about pending treatment) After calling MD we will use the current treatment request as approved. Family and facility may apply treatment between visits with each wound #2 and #3 Calcium Alginate dressing (cut to fit) followed by Duoderm. Report and [any] changes. Reval at each visit. The Medihoney is to be used at a later date if not with good progress." Review of a "Physician Order" dated 01/14/20 and signed by RN/ADON, Employee D, read "Discharge patient from hospice services as of 01/14/20 due to patient: revocation from hospice services." An interview was conducted on 01/31/20 with the RN/ADON, Employee D, at 11:30 AM. The surveyor aksed if she could tell the surveyor about Patient #1. Employee D told the surveyor that Patient #1 required transfers via hoyer lift and required total assistance with ADL's which was provided by the assisted living group home facility staff. Employee D told the surveyor that Patient #1 was originally transferred from home health to hospice care in September 2019, but the agency was not able to bill due to another hospice agency had not discharged the patient until December 2019. Employee D told the surveyor that Patient #1 was given all her medications via gastrostomy tube by the facility's owner, Identifier I. The surveyor also asked Employee D if Patient #1 had a dressing at the gastrostomy site. The surveyor explained that she was not able to determine if there was a dressing to Patient #1's site when reviewing Patient #1's record. Employee D told the surveyor that Patient #1 had a dressing and that the facility aides were changing the dressing as follows: Cleansing with NS (Normal Saline) and applying a dry split sponge daily and prn (as needed). The surveyor asked Employee D if Patient #1's gastrostomy site had been draining. Employee D told the surveyor that Patient #1's gastrostomy site had no drainage until 01/12/20. Employee D told the surveyor that the facility's owner, Identifier I had told her that the patient's daughter, Identifier H, had tried to give a bolus feed, and it was leaking around the tube site. Employee D said that Patient #1's gastrostomy tube site looked red on 01/13/20, but there were no sign or symptoms of infection. Employee D told the surveyor that Identifier H had notified her on 01/14/20 that she was going to have Patient #1 transported to the hospital to have Patient #1's pressure ulcers and gastrostomy tube evaluated. Employee D said that was when the agency discharged Patient #1 from hospice services for revocation due to hospitalization. A telephone interview was conducted on 01/31/20 with Patient #1's daughter, Identifier H, at 2:42 PM. Identifier H, was Patient #1's primary POA (Power of Attorney). The surveyor asked Identifer H, if she had requested the bolus feedings on 12/23/20, as revealed in Patient #1's nurses note. Identifier H said "Yes". Identifier H told the surveyor that the facility owner, Identifier I, had given Patient #1 Jevity via gastrostomy tube one time before. Identifier H said that she was first notified that Patient #1 had a pressure sore to her buttocks on 01/13/20. Identifier H told the surveyor that she made a visit with the RN/ADON, Employee D, and Identifier I, on 01/13/20. Identifier H said that Employee D had trouble flushing the gastrostomy tube. When Employee D removed the dressing to the gastrostomy tube site. Identifier H said that "it was red and had an odor". Identifier H asked Employee D if the site was infected if they would be able to treat it. Employee D told her that she would have to discuss it with the DON (Director of Nurses), Employee C, because the agency didn't do "preventative treatment". A telephone interview was conducted on 01/31/20 with the assisted living, facility owner, Identifier I, at 4:00 PM. The surveyor asked Identifier I what services the facility was providing for Patient #1. Identifier I told the surveyor that the facility staff were feeding her by mouth her meals and Identifier I said she was administering all Patient #1's medications via gastrostomy tube. The surveyor asked Identifier I if she was a nurse. Identifier I said "No", and said she was a CNA (certified nursing assistant). The surveyor asked Identifier I, if the facility had a RN on staff or under contract. Identifier I said "No", just the agency's RN. The surveyor asked who changes Patient #1's gastrostomy tube site dressing and how often was it changed. Identifier I told the surveyor that the CNA's change Patient #1's gastrostomy tube site dressing 5 - 6 times daily, due to leakage. The surveyor asked Identifier I how long this had been occuring. She said for approximately 6 months. The surveyor asked Identifier I what was the dressing treatment that the CNA's were doing. She said at first the CNA's were cleansing with a wound cleanser and applying a gauze. She then told the surveyor that in approximately October or Novermber the CNA's started cleansing the site with hydrogen peroxide. The surveyor asked Identifier I to please fax or email the surveyor the MAR (Medication Administration Record) for December 2019 and January 2020. Identifier I had problem with her fax machine and on 02/04/20, emailed Patient #1's MAR's for December 2019 and January 2020 to the Alternate Administrator, Employee B. Employee B provided a copy to the surveyor. Review of Patient #1's MAR revealed many discrepancies from the list of medications that were ordered by the physician on the Plan of Care. There were 3 medications that Identifier I was administering to Patient #1 which were not listed on the Plan of Care Orders as follows: Escitalopram 10mg in am, Docusate Sodium 100 mg twice a day and Donepezil 10mg twice a day. Identifier I was administering Cyclobenzaprine HCL (Flexeril) 10 mg twice a day. The Plan of Care had orders for this medication to be given every 8 hours prn (as needed). Identifier I was also administering Ativan 0.5mg twice a day when the Plan of Care had orders for this medication to be given every 8 hours prn for anxiety. The record contained no documentation that coordination of care had occurred between the hospice agency and the assisted living facility staff to 1) identifying the persons assisting the client with her meals, 2) the assessment of the PEG (gastrostomy tube site) and the person who was responsible for administering the client's medications via PEG, and if the staff were administering the proper medications and dosages, 3) if the staff were licensed to provide the care and 4) who the assisted living staff were providing PEG dressing changes and if they provided the care as ordered by the physician. An interview was conducted on 02/04/20 with the Alternate Administrator, Employee B, the DON, Employee C and the ADON, Employee D at 1:40 PM. The surveyor discussed that above findings with Employee B, C and D. The surveyor asked Employee D if she was able to explain the discrepancies and why Patient #1 was receiving all the above medications that were not listed on the plan of care. The surveyor also asked Employee D why Flexeril and Ativan were given twice daily instead of prn as ordered by the physician. The surveyor also asked Employee D if she was aware that the facility staff were changing Patient #1's gastrostomy tube site dressing 5-6 times daily due to drainage. Employee D told the surveyor that she never reviewed the MAR with the facility staff and did not know the medications were on the MAR and the dosages given for Flexeril and Ativan. The surveyor explained that she was not able to determine if the hospice agency had coordinated services with the assisted living facility staff . Employee D did not dispute the surveyors findings and could not explain why the assisted living staff were not communicating what treatments they were doing and what medication changes and dosages had occured. Employee D said she thought the PEG dressing changes and medications were given that way per Patient #1's daughter's requests. Employee D provided the surveyor with a copy of an order dated 12/13/19 and signed by RN/ADON as follows: "Hydrogen peroxide maybe used for peg tube cleaning at site daily and prn." The hospice agency failed to enforce its written policy to ensure that the interdisciplinary team (IDT) maintains responsibility for coordinating and supervising the care and services for 1 (#1) of 1 discharged patient who had a gastrostomy tube which was used for administration of medications and required dressing changes at least daily.