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
671766 A. BUILDING __________
B. WING ______________ 		12/05/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ALINEA FAMILY HOSPICE CARE LLC 303 E COLLEGE ST SUITE C, TERRELL, TX, 75160
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)
L0545      
35215 Based on record review and interview, the agency failed to ensure updated plans of care (POC) included all services necessary to meet specific patient needs for 1 of 3 patients reviewed for plan of care. (Patient #1) The agency IDG (interdisciplinary Group) did not ensure the plan of care was updated with wound care orders and appropriate supplies in a timely manner for Patient #1.The patient's stage 2 pressure injury deteriorated to an unstageable pressure injury and required debridement. This failure could place patients at risk not receiving care and services to meet their needs. Findings included: A review of Client 1#'s clinical record indicated she was 76 years old female with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, stage 3 kidney failure and gastrostomy tube. Client #1 was admitted to hospice care in August 10, 2019 and developed a pressure ulcer to her right buttock. Client #1's benefit period was 08/10/19 to 11/07/19. During a phone interview on 12/05/19 at 3:40 p.m., Patient #1's daughter (caregiver) said she and her daughter noticed a patch on her mother's (Patient #1) bottom after her hospital stay on 09/07/19 to 09/09/19. The caregiver said the hospital staff did not let her know why it was there and it was not until the caregiver went to clean Patient #1 that she noticed the patch. Patient #1 came home from the hospital on 09/09/19 around 3:00 p.m. RN # 56 made a post hospital visit on 09/09/19 at 5:30 p.m. The caregiver said RN #56 noticed the bandage on Patient #1's bottom but told the caregiver not to remove it for at least 3 days or until it fell off on its own. The caregiver said there were no discharge orders from the hospital at the time of discharge. A patient communication to the physician dated 09/08/19, indicated a message was received by supervising nurse #52, from the routine nurse RN #56 indicating Patient #1 went to the emergency room on 09/07/19. A skilled nursing visit note dated 09/09/19 at 5:30 p.m. indicated RN#56 documented Patient #1's skin was within normal limits, good/elastic. The update to nursing care plan indicated: "There are no problems to display for this section." A skilled nursing noted dated 9/9/19 indicated there was no communication from RN #56 to the discharging hospital or to the nursing supervisor about the (duoderm) patch to Patient #1's bottom. The Plan of Care order for Patient #1 dated 09/10/19 for benefit period 08/10/19 - 11/07/19 indicated the problem for skin was improving. It did not address wound care orders, wound care supplies or signs and symptoms of infection to instruct the family to report to the physician or skilled nurse. The IDT note dated 09/10/19 for Patient #1 indicated a recent hospital stay and did not include any wound care orders or change of frequency for skilled nursing visits to do wound care. The IDT did not include any discussion with family teaching on wound care or family concerns. A skilled nursing note dated 09/12/19 at 3:25 p.m. indicated Patient #1 had a stage 2 pressure ulcer (stage 2 is superficial with pale pink wound bed clear drainage and presents itself with an abrasion or blister or shallow crater, usually over a bony prominence) to her right buttock. RN #56 indicated on the note the wound was worse than when she went into the hospital. The patient communication log dated 09/16/19, untimed indicated for Patient #1: " ... New decubitus on her right buttocks ... skilled nurse to continue to assess wound on her routine visits. The IDT meeting noted dated 10/8/19 for Patient #1 indicated ,"...patient wound is now declining and and has become unstageable. Need to look at alternate wound care for patient. Plan for Nurse Practitioner to visit patient ...". The IDT note did not indicate there was a change in nurse frequency visits for wound care or wound care supplies for family or teaching of wound care. An electronic note dated 10/14/19 at 3:48 p.m. indicated the nurse practitioner #55 did not make a visit to see Patient #1 until the patient's stage 2 pressure injury deteriorated to an unstageable pressure injury. During the visit nurse practitioner #55 was concerned about the worsening sacral wound. His recommendation was to follow with wound care debridement of dead tissue for proper healing. A physician's order dated 10/22/19 for Patient #1 indicated : "May discharge from hospice to seek medical attention for unstageable wound on buttock by admitting to hospital for debridement". The consumer rights and services complaint investigation worksheet dated 11/06/19 at 12:45 p.m. indicated the complainant called the nurse supervisor and explained Patient #1's wound was growing worse and needed to be treated more aggressively and she wasn't getting enough proper supplies to treat the wound for Patient #1. During an interview on 12/04/19 at 9:20 a.m. the administrator said they had just started a new program in July and wasn't acclimated to it yet. The administrator said they did their IDT meetings on paper as well as electronic until they get it worked out. During an interview on 12/05/19 at 11:00 a.m. the administrator said she took full responsibility of nurses not documenting as well as they should. She said the agency had an increase in admits and the nurses were doing more patient care and it was hard for them to keep up with the paper work. A policy titled, "Patient Assessments PE1" dated 09/01/19 indicated t:" ...iii. Plan of Care(POC): An individualized, written POC reflecting interventions based on the problems identified I the initial, comprehensive, and updated comprehensive assessments. Patient and family goals are reflected in the POC ...page 2 of 7..ii. Nursing services must ensure that the nursing needs of the patient are identified in the patient initial assessment, comprehensive assessment, and updated assessments ...E. Pertinent data/information will be communicated within the IDG, as well as to the patient's identified attending physician, verbally and/or in writing ..."
L0554      
35215 Based on interview and record review, the agency failed to maintain responsibility for a communication system which provided effective coordination of care, supervision of care and services in 1 of 3 patients reviewed for coordination of care. (Patient # 1) The hospice did not communicate information of Patient #1's wound to the IDG (Interdisciplinary Group) in a timely manner. The patient's stage 2 pressure injury deteriorated to an unstageable pressure injury and required debridement. This failure could place clients at risk for delays in care and services, poor care and harm. Findings included: A review of Client #1's clinical record with a benefit period of 8/10/19 to 11/07/19 indicated she was admitted to hospice care 8/10/19, was a 76 year old female and had diagnoses including congestive heart failure, chronic obstructive pulmonary disease, stage 3 kidney failure and gastrostomy tube. During a phone interview on 12/05/19 at 3:40 p.m., Patient #1's daughter (caregiver) said she and her daughter noticed a patch on her mother's (Patient #1) bottom after her hospital stay on 09/07/19 to 09/09/19. The caregiver said the hospital staff did not let her know why it was there and it was not until the caregiver went to clean Patient #1 that she noticed the patch. Patient #1 came home from the hospital on 09/09/19 around 3:00 p.m. RN # 56 made a post hospital visit on 09/09/19 at 5:30 p.m. The caregiver said RN #56 noticed the bandage on Patient #1's bottom but told the caregiver not to remove it for at least 3 days or until it fell off on its own. The caregiver said there were no discharge orders from the hospital at the time of discharge. A patient communication note to the physician dated 09/08/19, indicated a message was received by supervising nurse #52, from the routine nurse, that Patient #1 went to the emergency room on 09/07/19 A skilled nursing visit note dated 09/09/19 at 5:30 p.m. indicated RN#56 documented Client #1's skin was within normal limits, good/elastic. The update to nursing care plan indicated: "There are no problems to display for this section." A skilled nursing visit note dated 09/09/19 at 5:30 p.m. indicated RN#56 had written Patient #1's skin was within normal limits, good/elastic. Under update to nursing care plan was written: "There are no problems to display for this section." The hospice aide supervisory visit on 09/11/19 from 8:15 to 9:15 a.m. and on 09/13/19 from 8:15 to 9:15 a.m. indicated the hospice aide was to check pressure areas every visit. There was no communication from Hospice aide #57 to RN #56 in a progress note or a communication note about the (duoderm) patch to Patient #1's right buttock. During an interview on 12/05/19 at 12:00 p.m., nurse supervisor #52 said hospice aides were to report to the case manager any changes in patient status and the case manager was to send a message to the nurse supervisor. Nurse Supervisor #52 said she did not get a message of change in status for Patient #1 during the dates of 09/09/19 and 09/12/19. The plan of care order for Patient #1 dated 09/10/19 for the benefit period 08/10/19 - 11/07/19 indicated the problem for skin was improving. It did not address wound care orders, wound care supplies or signs and symptoms of infection to instruct the family to report to the physician or skilled nurse. The IDT (interdisciplinary team) dated 09/10/19 for Patient #1 indicated a recent hospital visit and did not include any communication with Patient #1's RN case manager for possible wound care orders or change of frequency for skilled nursing visits to do wound care. The IDT did not include any discussion with family or family concerns. An electronic note dated 10/14/19 at 3:48 p.m. indicated nurse practitioner #55 saw Patient #1 and the patient's stage 2 pressure injury had deteriorated to an unstageable pressure injury. The note indicated he was concerned about the worsening sacral wound. His recommendation was to follow-up with wound care debridement of dead tissue for proper healing. A physician's order dated 10/22/19 for Patient #1 indicated: "May discharge from hospice to seek medical attention for unstageable wound on buttock by admitting to hospital for debridement". During an interview on 12/05/19 at 11:00 a.m. the administrator said she took full responsibility of nurses not documenting as well as they should. She said the agency had an increase in admits and the nurses were doing more patient care and it was hard for them to keep up with the paper work. A policy titled, "Coordination of Care PC.22", on page 1 of 2 indicated, " ...I. The agency will provide on-going sharing of information between disciplines providing care and services in all settings ...III. The hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated, coordinated plan of care (POC), achieving unduplicated services and facilitating effective coordination of patient services.