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
741503 A. BUILDING __________
B. WING ______________ 		10/04/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
GUIDING LIGHT HOSPICE 3218 NACOGDOCHES RD, SAN ANTONIO, TX, 78217
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)
L0523      
22360 Based on record reviews and interviews, the interdisciplinary team (IDT) failed to complete the initial comprehensive assessment within five days after the election of hospice care for one of three active patients (Patient #3) and one of three discharged patients (Patient #4) whose record was reviewed, in that, the spiritual assessments were conducted more than 5 days after the start of care (election of hospice). This deficient practice placed Patient #3 and #4 at risk of not having their individualized spiritual needs met during the dying process and could result in miscommunication between patients, staff and agency employees. This deficient practice has the potential of affecting the agency's other 88 active hospice patients. The findings included: A. Review of the policy titled, "Initial Patient Assessment/Patient Admission," revised date 04/01/15, read in part, "...The initial comprehensive assessment, with input from appropriate IDT members...will be completed within 5 calendar days and will include...Spiritual orientation and needs..." B. Review of Patient #3's clinical record revealed a start of care (SOC) date of 04/05/19 and an initial spiritual assessment conducted on 04/30/19, 25 calendar days after the start of care. C. Review of Patient #4's closed clinical record revealed a SOC date of 07/01/19 and an initial spiritual assessment conducted on 07/09/19, 8 days after the start of care. D. During an interview with the Supervising Nurse/Alternate Administrator on 10/03/19 from 1:35 p.m. to 2:40 p.m., the above findings were reviewed and discussed. The Supervising Nurse/Alternate Administrator stated "yes" the spiritual assessments were late and he did not know but that he would look for additional documentation. E. During the exit conference on 10/04/19 at 12:22 p.m., the Administrator and Alternate Administrator were informed that the agency had two additional business days to provide additional documentation for review. No additional documentation was provided by the time of exit or within two business days after the exit. The Alternate Administrator provided a census of 89 hospice patients from the active patient list on 10/02/19.
L0543      
22360 Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with an individualized plan of care (POC) for one of three discharged hospice patients (Patient #6) whose records were reviewed, in that the nurse provided a service (pill box set up and refills) that was not on the plan of care. This failure could place the agency's 89 active hospice patients at risk of receiving inadequate care from an interdisciplinary team that did not have up-to-date information on the patients. The findings included: A. Review of the agency's policy titled "Responsibilities of the Supervising Nurse," revised date 01/01/18 revealed in part, "...The responsibilities of the Supervising Nurse include, but are not limited to...ensuring that a patient's plan of care is executed as written..." Review of the agency's policy titled, "Plan of Care Process," revised date 05/01/19 revealed in part, "...The POC will include all services necessary for the palliation and management of the terminal illness and related conditions..." B. During an interview with Registered Nurse (RN) Staff D on 10/04/19 at 9:00 a.m., he stated he was Patient #6's case manager and explained that during the skilled nurse visits he would periodically set up and refill Patient #6's medication box for the caregivers at the personal care home. C. During an interview with Patient #6's daughter on 10/01/19 at 2:45 p.m., she stated that Staff D would periodically set up and refill Patient #6's medication box. D. Review of Patient #6's "Combined Disciplinary Plan of Care," dated 07/11/19 revealed a nurse frequency of "1 visit per week..." Further review revealed no documented evidence that interventions included set up and refill of the medication box. E. During an interview on 10/04/19 at 12:00 p.m., the findings above were reviewed and discussed with the Supervising Nurse/Alternate Administrator and the Administrator. The Supervising Nurse/Alternate Administrator stated "okay" and that he would look for additional documentation. F. During the exit conference on 10/04/19 at 12:22 p.m., the Administrator and Alternate Administrator were informed that the agency has two additional business days to provide additional documentation for review. No additional documentation was provided by the time of exit or within two business days. The Alternate Administrator provided a census of 89 from the active patient list on 10/02/19.
L0678      
22360 Based on interview and record review, the agency failed to include physician orders in the clinical record for one of three discharged hospice patients (Patient #6) whose clinical records were reviewed. This deficient practice placed Patient #6 at risk of harm and could result in care and treatment errors. This failure could also affect the agency's 89 active hospice patients. The findings included: A. Review of the agency's policy titled, "Orders for Care," revised date 10/01/15, revealed in part, "... Supplemental verbal orders may be obtained before care is provided and are written within 24 hours of receiving the orders..." B. Review of Patient #6's nursing note dated 07/29/19 revealed in part, "...Encouraged giving pt (patient) dose of morphine (narcotic used to relieve moderate to severe pain) due to pts (patient's) respiratory rate and moaning..." C. During an interview with RN (Registered Nurse) Staff D on 10/03/19 at 3:11 p.m., she stated that she conducted the visit on 07/29/19 and that Client #6 had the morphine available at the personal care home. D. Review of Patient #6's clinical record revealed no documented evidence of a physician order for morphine for pain management. E. During an interview with the Supervising Nurse/Alternate Administrator on 10/03/19 from 1:35 p.m. to 2:40 p.m., he stated that the morphine order was filled by the pharmacy back in 07/22/19 and that he could not find the written order in the clinical record. The Supervising Nurse/Alternate Administrator stated that the nurse who took the verbal order probably did not document it in the clinical record but that he would continue to look for additional documentation. During the exit conference on 10/04/19 at 12:22 p.m., the Administrator and Alternate Administrator were informed that the agency had two additional business days to provide additional documentation for review. No additional information was provided by the time of exit or within two business days. The Alternate Administrator/Supervising Nurse provided a census of 89 from the active patient list on 10/02/19.