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
741525 A. BUILDING __________
B. WING ______________ 		01/30/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
AMERICAN HOME HOSPICE INC 216 W MOORE AVE, 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)
L0500      
35215 Based on interview and record review the agency failed to promote and protect patients' right to be free from abuse, neglect, and exploitation for 2 patients (Patient #1 and #8) in that: The agency did not immediately investigate or take immediate action after receiving an allegation of exploitation (misappropriation of drugs) of Patient #8 by the administrator/RN#55 in accordance with established hospice procedures. RN #55 continued employment until her arrest on 1/21/20. Refer to L 509 The agency did not notify the Texas Health and Human Services within 24 hours after complaints on 06/03/19 the administrator/RN #55 exploited Patient #8. RN #55 was not suspended and continued to work until she was arrested on 01/21/2020. Refer to L 511 The agency did not provide Patient #1 the appropriate/necessary medication to relieve her pain. The administrator/RN #55 exchanged the prescribed hydrocodone with over the counter medications Refer to L 512 The agency did not ensure the rights of Patient #1 were protected from misappropriation of property and neglect by administrator/RN #55. The agency did not initiate an investigation or report to the Texas Health and Human Services and the Department of Family Protective Services after complaints were reported of misappropriation of property and exploitation of Patient #8 by administrator/RN #55 in June of 2019. Refer to L517
L0509      
35215 Based on interview and record review the agency failed to ensure an allegation of exploitation by agency staff was immediately investigated and immediate action was taken to prevent further potential violations in accordance with established procedures for 1 of 13 patients reviewed for patient rights. (Patient #8) The agency did not immediately investigate an allegation of exploitation and take immediate action to prevent further exploitation for 7 months. Administrator/RN#55 called in fraudulent prescriptions for Patient #8. Administrator/RN #55 continued her employment until she was arrested for tampering with narcotics on 1/21/20. This failure could place patients at risk for abuse, neglect and exploitation. Findings included: A POC dated 05/14/19-08/11/19 indicated Patient #8 was a 79-year-old female with diagnoses that included Alzheimer's disease, anxiety disorder and dementia. Patient #8 was admitted to the hospice agency on 05/14/19. Medications listed on the POC included: Morphine oral solution (used to treat moderate to severe pain) 10 mg/5 ml, give 0.25-0.5 ml each hour as needed for pain; Hyoscyamine sublingual tablet 0.125 mg, one tablet every 4 hours as needed for audible congestion; Promethazine tablet 25mg, one tablet every 4 hours as needed for nausea/vomiting; lorazepam tablet 0.5 mg, one tablet every hour as needed for anxiety or restlessness; oxybutynin tablet 5mg: one tablet daily; Niacin ER 1000 mg, one tablet at bedtime; donnepizil 10 mg, one tablet nightly; Tramadol 50 mg., one tablet every 8 hours as needed for pain; and lisinopril 10-12.5 mg, one tablet daily for high blood pressure. An undated Texas Board of Nursing complaint form provided by RN #54 indicated on 05/31/19 RN #54 called Patient #8's caregiver to inform him she and MD #58 would be coming out to do a home visit. Patient #8's caregiver mentioned he received a notice that medications were ready to be picked up from the pharmacy and asked if RN #54 could bring them when she came for the visit. The form indicated RN #54 did not recall any medications being ordered for Patient #8 but told the caregiver she would. The form indicated on 06/03/19, RN #54 called the pharmacy to see who had ordered the medications and discovered administrator/RN #55 ordered medications under Patient #8's name. Administrator/RN #55 went to the pharmacy and picked up the medications she ordered for Patient #8 (2 of the medications did not have a physician order). The form indicated on 06/03/19 RN #54 and MSW #59 went to the pharmacy to investigate the medications that were ordered by administrator/RN #55. The form indicated on 06/03/19 at 10:11 a.m. RN #54 called co-owner #56 and briefed him on what was discovered by the pharmacy staff, and a meeting was set up at 06/03/19 at 1:00 p.m.to discuss the situation. A record of medications dispensed by the local pharmacy dated 05/24/19 thru 05/31/19 indicated alprazolam (used to treat anxiety, panic disorders, and anxiety caused by depression) 1 mg, 60 tablets, and ropinirole (used to treat stiffness, tremors, muscle spasms, and poor muscle control) 1 mg, 30 tablets were dispensed for Patient #8. An untitled form provided by the pharmacy indicated administrator/RN #55 signed for and picked up alprazolam1 mg, 60 tablets, and ropinirole 1 mg, 30 tablets for Patient #8 on 05/31/19 at 11:59 a.m. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest on 01/21/20 because she had taken a patient's narcotics for herself and replaced them with over-the-counter medications. During interview on 1/28/2020 at 1:45 p.m., pharmacy technician #57 said the pharmacy had multiple issues with RN #55 calling in fraudulent prescriptions. The technician said she was issued a subpoena on September 18, 2019 on behalf of the BON regarding RN #55. The technician said the agency co-owner/ alternate administrator #50 reached out her about the subpoena on 10/1/19. Pharmacy technician #57 said the co-owner/alternate administrator #50 was aware RN #55 was calling in fraudulent prescriptions. An undated Witness Affidavit statement provided on 1/28/2019 by pharmacy technician #57 indicated administrator/RN#55 called in a prescription of ropinirole and alprazolam for Patient #8 on 05/31/19. At 11:59 a.m. the same day RN #55 picked up and signed for the prescriptions. On 06/03/19 RN #54 and MSW #59 came to the pharmacy and made the staff at the pharmacy aware fraudulent prescriptions were called in by RN #55. On June 11, 2019 RN #55 called in more prescriptions. On 9/25/2019 RN #54 and MD #58 informed the staff at the pharmacy of more suspected fraudulent prescriptions. The statement indicated on 10/1/19 the co-owner/Administrator #50 called and asked if pharmacy technician #57 received a subpoena. The statement indicated during the conversation pharmacy technician #57 asked co-owner/alternate administrator #50 if she was aware of what was happening from the beginning and co-owner/ alternate administrator #50 said, 'yes'. The agency incident report log for June 2019, reviewed on 01/29/20, had no documentation of a nurse calling in fraudulent prescriptions, being reported to the BON, or any other reference related to medication issues. Personnel file for RN #55 indicated a hire date of 05/04/15. There was no documentation of any disciplinary actions against the nurse. During an interview on 1/30/2020 at 11:05 a.m., MD #58 said administrator/RN #55 called in and picked up prescriptions for Patient #8 and administrator/RN #55 had no business picking up the medications. The MD #58 said RN #55 called in medication that was not prescribed for Patient #8 that she picked up and did not deliver to the patient. MD #58 said she talked with the co-owner/alternate administrator #50 the first week of June about administrator /RN #55 calling in fraudulent prescriptions. The MD said co-owner/alternate administrator #50 told MD #58 there was no harm done, so it would not be reported. MD #58 said she suggested co-owner/alternate administrator #50 should drug test all employees, do an evaluation of the patients, get patients new medications and audit them but did not think it was ever done. During a phone interview on 1/30/2020 at 2:55 p.m. RN #54 said co-owner/alternate administrator #50 knew about the medication issues on June 6, 2019. RN #54 said she gave copies from the Board of Nursing report to co-owner #56. RN #54 said the alternate administrator #50 knew about it on June 5, 2019 and she was texted by co-owner/ alternate administrator #50 to call her. RN #54 said on June 6, 2019 the alternate administrator #50 texted wanting copies of what was sent to the Board of Nursing, so she could review it, because more information may need to be added. RN #54 said she did not give alternate administrator #50 the copies because they were given to co-owner #56. During a phone interview on 1/30/2020 at 3:21 p.m., MSW #59 said when she and RN #54 met with owner #56 he said he needed to tell co-owner/ alternate administrator #50 about administrator/RN #55 falsely obtaining the medications. MSW #59 said administrator/ RN #55 was off a few days during this time and when she returned to work, around June 2019 the first thing RN #55 did was call in another prescription. MSW #59 said she found out because the pharmacy had called. MSW# 59 said she could not remember dates of the incidents. MSW #59 said there were staff meetings regarding these issues and that it was kept hush hush, and no one dared to talk about it. During an interview on 1/30/2020 at 2:20 pm the co-owner/alternate administrator #50 kept saying she did not remember an incident in June, and kept repeatedly saying, "I don't know, I don't remember, you tell me." She was visibly shaking and tearful. The co-owner/alternate administrator #50 said that might have been when RN #54 and MSW #59 was in co-owner #56's office, co-owner/alternate administrator #50 said she tried asking what was going on but was told it was private and did not remember if owner #56 told her anything. Co-owner/alternate administrator #50 said RN #54 and MSW #59 didn't say anything to her. The co-owner/alternate administrator #50 indicated she did not investigate and take immediate action to prevent further exploitation to other patients by administrator/RN #55. A text message, with a screen shot of an email dated June 5, 2019 at 1:56 p.m. indicated co-owner/alternate administrator #50 texted RN #54 initiating a discussion regarding what was sent to the Board of Nursing. During an interview on 1/30/2020 at 4:22 p.m., co-owner #56 said he honestly was not sure if RN #54 and MSW #59 had told co-owner/alternate administrator #50. Co-owner #56 said he told RN #54 to hold off on reporting to the Board of Nursing until the agency investigation was done. Co-owner #56 said RN #54 said was already been reported to the Board of Nursing. Co-owner #56 said he thought he remembered alternate administrator #50 telling him to let her talk to RN #54 first. Co-owner #56 said RN #54 had a printout of papers of patients she gave him that didn't get medications that were ordered. Owner #56 said he doesn't remember what happened to the copies. Co-owner #56 said MD #58 talked with him about that incident and about administrator/RN #55 but did not remember exactly what was said. The co-owner/alternate administrator #56 indicated she did not investigate and take immediate action to prevent further exploitation to other patients by administrator/RN #55. An abuse, neglect and exploitation procedure dated 8/1/2019 indicated: Purpose: To identify suspected or alleged victims of abuse, neglect, or exploitation (ANE) of a patient or individual, or misappropriation of property. To establish appropriate protocols ... Procedure: II. Agency management will: A. Immediately investigate all alleged violations ... B. Address any allegations of or evidence of abuse to determine if immediate care is needed ...C. Report if there is cause to believe abuse, neglect or exploitation ...within 24hours to ...Texas Health and Human services ...1-800-458-9858 ...E. Report if there is cause to believe ...misappropriation of patient property has occurred by a staff member ...F. Immediately suspend any agency employee ...H. The agency will send a written report, using the Provider investigation form, of the investigation to the TX HHS Consumer Rights and Services no later than the tenth day after reporting the act ...III. All reports of suspected abuse or neglect of a patient or individual, or misappropriation of property will be documented by the agency ... The agency did not provide additional information at the time of exit on 01/30/20 at 5:00 p.m.
L0511      
35215 Based on interview and record review the agency failed to ensure a verified violation was reported to the state survey agency within 5 working days of becoming aware of the exploitation for 1 of 13 patients reviewed for exploitation. (Patient #8) The agency did not report administrator/RN #55 after she exploited Patient #8 for three months. Administrator/RN#55 called in fraudulent prescriptions for Patient #8. Administrator/RN #55 continued her employment until she was arrested for tampering with narcotics on 1/21/20. This failure could place patients at risk for abuse, neglect and exploitation. Findings included: A POC dated 05/14/19-08/11/19 indicated Patient #8 was a 79-year-old female with diagnoses that included Alzheimer's disease, anxiety disorder and dementia. Patient #8 was admitted to the hospice agency on 05/14/19. Medications listed on the POC included: Morphine oral solution (used to treat moderate to severe pain) 10 mg/5 ml, give 0.25-0.5 ml each hour as needed for pain; Hyoscyamine sublingual tablet 0.125 mg, one tablet every 4 hours as needed for audible congestion; Promethazine tablet 25mg, one tablet every 4 hours as needed for nausea/vomiting; lorazepam tablet 0.5 mg, one tablet every hour as needed for anxiety or restlessness; oxybutynin tablet 5mg: one tablet daily; Niacin ER 1000 mg, one tablet at bedtime; donnepizil 10 mg, one tablet nightly; Tramadol 50 mg., one tablet every 8 hours as needed for pain; and lisinopril 10-12.5 mg, one tablet daily for high blood pressure. An undated Texas Board of Nursing complaint form provided by RN #54 indicated on 05/31/19 RN #54 called Patient #8's caregiver to inform him she and MD #58 would be coming out to do a home visit. Patient #8's caregiver mentioned he received a notice that medications were ready to be picked up from the pharmacy and asked if RN #54 could bring them when she came for the visit. The form indicated RN #54 did not recall any medications being ordered for Patient #8 but told the caregiver she would. The form indicated on 06/03/19, RN #54 called the pharmacy to see who had ordered the medications and discovered administrator/RN #55 ordered medications under Patient #8's name. Administrator/RN #55 went to the pharmacy and picked up the medications she ordered for Patient #8 (2 of the medications did not have a physician order). The form indicated on 06/03/19 RN #54 and MSW #59 went to the pharmacy to investigate the medications that were ordered by administrator/RN #55. The form indicated on 06/03/19 at 10:11 a.m. RN #54 called co-owner #56 and briefed him on what was discovered by the pharmacy staff, and a meeting was set up at 06/03/19 at 1:00 p.m.to discuss the situation. A record of medications dispensed by the local pharmacy dated 05/24/19 thru 05/31/19 indicated Resident #8 received alprazolam (used to treat anxiety, panic disorders, and anxiety caused by depression) 1 mg, 60 tablets, and ropinirole (used to treat stiffness, tremors, muscle spasms, and poor muscle control) 1 mg, 30 tablets were dispensed for Patient #8. An untitled form provided by the pharmacy indicated administrator/RN #55 signed for and picked up alprazolam1 mg, 60 tablets, and ropinirole 1 mg, 30 tablets for Patient #8 on 05/31/19 at 11:59 a.m. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest on 01/21/20 because she had taken a patient's narcotics for herself and replaced them with over-the-counter medications. During interview on 1/28/2020 at 1:45 p.m., pharmacy technician #57 said the pharmacy had multiple issues with RN #55 calling in fraudulent prescriptions. The technician said she was issued a subpoena on September 18, 2019 on behalf of the BON regarding RN #55. The technician said the agency co-owner/ alternate administrator #50 reached out her about the subpoena on 10/1/19. Pharmacy technician #57 said the co-owner/alternate administrator #50 was aware RN #55 was calling in fraudulent prescriptions. An undated Witness Affidavit statement provided on 1/28/2019 by pharmacy technician #57 indicated administrator/RN#55 called in a prescription of ropinirole and alprazolam for Patient #8 on 05/31/19. At 11:59 a.m. the same day RN #55 picked up and signed for the prescriptions. On 06/03/19 RN #54 and MSW #59 came to the pharmacy and made the staff at the pharmacy aware fraudulent prescriptions were called in by RN #55. On June 11, 2019 RN #55 called in more prescriptions. On 9/25/2019 RN #54 and MD #58 informed the staff at the pharmacy of more suspected fraudulent prescriptions. The statement indicated on 10/1/19 the co-owner/Administrator #50 called and asked if pharmacy technician #57 received a subpoena. The statement indicated during the conversation pharmacy technician #57 asked co-owner/alternate administrator #50 if she was aware of what was happening from the beginning and co-owner/ alternate administrator #50 said, 'yes'. The agency incident report log for June 2019, reviewed on 01/29/20, had no documentation of a nurse calling in fraudulent prescriptions, being reported to the BON, or any other reference related to medication issues. Personnel file for RN #55 indicated a hire date of 05/04/15. There was no documentation of any disciplinary actions against the nurse. During an interview on 1/30/2020 at 11:05 a.m., MD #58 said administrator/RN #55 called in and picked up prescriptions for Patient #8 and administrator/RN #55 had no business picking up the medications. The MD #58 said RN #55 called in medication that was not prescribed for Patient #8 that she picked up and did not deliver to the patient. MD #58 said she talked with the co-owner/alternate administrator #50 the first week of June about administrator /RN #55 calling in fraudulent prescriptions. The MD said co-owner/alternate administrator #50 told MD #58 there was no harm done, so it would not be reported. MD #58 said she suggested co-owner/alternate administrator #50 should drug test all employees, do an evaluation of the patients, get patients new medications and audit them but did not think it was ever done. During a phone interview on 1/30/2020 at 2:55 p.m. RN #54 said co-owner/alternate administrator #50 knew about the medication issues on June 6, 2019. RN #54 said she gave copies from the Board of Nursing report to co-owner #56. RN #54 said the alternate administrator #50 knew about it on June 5, 2019 and she was texted by co-owner/ alternate administrator #50 to call her. RN #54 said on June 6, 2019 the alternate administrator #50 texted wanting copies of what was sent to the Board of Nursing, so she could review it, because more information may need to be added. RN #54 said she did not give alternate administrator #50 the copies because they were given to co-owner #56. During a phone interview on 1/30/2020 at 3:21 p.m., MSW #59 said when she and RN #54 met with owner #56 he said he needed to tell co-owner/ alternate administrator #50 about administrator/RN #55 falsely obtaining the medications. MSW #59 said administrator/ RN #55 was off a few days during this time and when she returned to work, around June 2019 the first thing RN #55 did was call in another prescription. MSW #59 said she found out because the pharmacy had called. MSW# 59 said she could not remember dates of the incidents. MSW #59 said there were staff meetings regarding these issues and that it was kept hush hush, and no one dared to talk about it. During an interview on 1/30/2020 at 2:20 pm the co-owner/alternate administrator #50 kept saying she did not remember an incident in June, and kept repeatedly saying, "I don't know, I don't remember, you tell me." She was visibly shaking and tearful. The co-owner/alternate administrator #50 said that might have been when RN #54 and MSW #59 was in co-owner #56's office, co-owner/alternate administrator #50 said she tried asking what was going on but was told it was private and did not remember if owner #56 told her anything. Co-owner/alternate administrator #50 said RN #54 and MSW #59 didn't say anything to her. The co-owner/alternate administrator #50 indicated she did not report anything to the state agency regarding administrator/RN #55. A text message, with a screen shot of an email dated June 5, 2019 at 1:56 p.m. indicated co-owner/alternate administrator #50 texted RN #54 initiating a discussion regarding what was sent to the Board of Nursing. During an interview on 1/30/2020 at 4:22 p.m., co-owner #56 said he honestly was not sure if RN #54 and MSW #59 had told co-owner/alternate administrator #50. Co-owner #56 said he told RN #54 to hold off on reporting to the Board of Nursing until the agency investigation was done. Co-owner #56 said RN #54 said was already been reported to the Board of Nursing. Co-owner #56 said he thought he remembered alternate administrator #50 telling him to let her talk to RN #54 first. Co-owner #56 said RN #54 had a printout of papers of patients she gave him that didn't get medications that were ordered. Owner #56 said he doesn't remember what happened to the copies. Co-owner #56 said MD #58 talked with him about that incident and about administrator/RN #55 but did not remember exactly what was said. The co-owner/alternate administrator #56 indicated he did not report anything to the state agency regarding administrator/RN #55. An abuse, neglect and exploitation procedure dated 8/1/2019 indicated: Purpose: To identify suspected or alleged victims of abuse, neglect, or exploitation (ANE) of a patient or individual, or misappropriation of property. To establish appropriate protocols ... Procedure: II. Agency management will: A. Immediately investigate all alleged violations ... B. Address any allegations of or evidence of abuse to determine if immediate care is needed ...C. Report if there is cause to believe abuse, neglect or exploitation ...within 24hours to ...Texas Health and Human services ...1-800-458-9858 ...E. Report if there is cause to believe ...misappropriation of patient property has occurred by a staff member ...F. Immediately suspend any agency employee ...H. The agency will send a written report, using the Provider investigation form, of the investigation to the TX HHS Consumer Rights and Services no later than the tenth day after reporting the act ...III. All reports of suspected abuse or neglect of a patient or individual, or misappropriation of property will be documented by the agency ... The agency did not provide additional information at the time of exit on 01/30/20 at 5:00 p.m.
L0512      
35215 Based on interview and record review, the hospice failed to ensure effective pain management and symptom control for conditions related to a terminal illness was provided for 1 of 13 patients reviewed for pain and symptom control. (Patient #1) The agency did not provide Patient #1 the appropriate/necessary medication to relieve her pain. The administrator/RN #55 exchanged the prescribed hydrocodone with over-the-counter medications This failure could place patients at risk of uncontrolled pain and abuse of rights to be free of pain. Findings included: The POC for Benefit Period 12/21/19-3/19/20 indicated Patient #1 was an 86-year-old female with diagnoses that included chronic obstructive pulmonary disease, stage 2 chronic kidney disease, heart disease and extreme weakness. Patient #1 was placed on hospice care on 12/21/19. Medications ordered as needed included: hydrocodone-acetaminophen 10-325 mg. one tablet every 4 hours as needed for pain, Hyoscyamine 0.125 mg. one tablet every 4 hours as needed for audible congestion, promethazine 25 mg one tablet every 6 hours as needed for nausea/vomiting, Morphine oral solution 20 mg/ml. give 0.25- 1 ml. every 2-3 hours as needed for pain or shortness of breath, lorazepam 0.5 mg. one tablet three times a day and every 4 hours as needed for anxiety, Tylenol PM extra strength, 2 tablets at night as needed for pain, and Tramadol 50 mg two tablets every 6 hours as needed for pain. During a phone interview on 01/27/20 at 3:40 p.m. a family member said she felt Patient #1 was being neglected by the agency because they were not providing the pain care Patient #1 needed. The family member said Patient #1 should not be taking the acetaminophen administrator/RN #55 was giving due to her kidney and liver problems. An undated written statement provided by the family member indicated on 12/21/2019 at approximately 2:00 PM, administrator/RN #55 arrived at Patient #1's home and delivered a "comfort Kit" which contained several medications that included: DSS/Senna (stool softener), promethazine (for nausea), bisacodyl (laxative), hyoscyamine (for secretions), Prednisone (steriod), morphine sulfate oral solution (narcotic for pain), lorazepam (for anxiety), tizanidine (muscle relaxer), and HYDROCO/APAP 10/325 (narcotice for pain). Administrator/RN#55 explained the usage and dosage for all medications. Administrator/RN #55 poured out and counted the Lorazepam in front of the family member and initialed the label and asked the family member to initial the label verifying the count. Administrator/RN #55 performed this routine with the "Tizanidine and the Hydroco/apap". Patient #1 was taking this regimen of medication. The statement indicated daily complaints of pain increased, and Patient #1 reported the "hydroco/apap" was not working. Phone calls were made to administrator/RN #55 to report this problem to the physician. The family member was instructed by administrator/RN #55 to give ".25 oral Morphine" for break thru pain and "a lorazepam." The family member indicated she complied with these instructions. The family member said as the effects of the morphine wore off quickly, the complaints of pain increased. The family member reported to administrator/RN #55 Patient #1's pain was not controlled with "hydroco/apap and .25 morphine" and using the "tizanidine and Lorazepam." Administrator/RN #55 told the family member to increase Patient #1's "morphine to .5" for break thru pain. The family member complied with these instructions. The family member reported that prior to Patient #1's transfer to hospice care, her doctor changed her pain medications from Tylenol 3 to Tramadol since her liver and kidney enzymes had been elevated. The statement indicated the family member filed a police report with the Sheriff's department regarding administrator/RN #55 on 1/12/2020. A police report dated 01/21/20, indicated administrator/RN #55 delivered hydrocodone pills as usual to Patient #1, the pills were poured out to be counted, but the family member for patient #8 noticed the pills had the same numbers as before and refused to sign for the pills and this prompted police attention, who were in the home of Patient #1. The administrator/RN #55 admitted to tampering with Patient #1's narcotics and she was taken to jail from Patient #1's home. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest because she had taken Patient #1's narcotics for herself and replaced them with over-the-counter medications. The local pharmacy records showed administrator/RN #55 picked up Hydrocodone 10-325, 60 tablets for Patient #1 on 1/09/20, 1/20/20, and 1/21/220. The agency Philosophy and Mission Statement reads: " ... [The Agency] works to manage pain and symptoms so patients can embrace life and live as fully and as comfortable as possible." The policy, "Pain Management PC.29 on page 1 of 2 indicated under policy: " ... Agency Staff are committed to pain and symptom prevention and management and will respond quickly to provide effective management. Agency will respect patient's right to receive effective pain management and symptom control for conditions related to the terminal illness ..." The agency did not provide additional information at the time of exit on 01/30/20 at 5:00 p.m.
L0517      
35215 Based on interview and record review the hospice agency failed to ensure the right to be free from neglect and misappropriation of property was provided for 2 of 2 patients reviewed for patient rights. (Patient #1 and #8) The agency did not prevent administrator/RN #55 from misappropriation of medications for Patient #1 and #8. The administrator/RN #55 exchanged Patient #1's prescribed hydrocodone with over the counter medications and Patient #1 had unrelieved pain. The Administrator/RN#55 called in fraudulent prescriptions for Patient #8. This failure could place patients at risk for neglect and misappropriation of property. Findings included: 1. The POC for Benefit Period 12/21/19-3/19/20 indicated Patient #1 was an 86-year-old female with diagnoses that included chronic obstructive pulmonary disease, stage 2 chronic kidney disease, heart disease and extreme weakness. Patient #1 was placed on hospice care on 12/21/19. Medications ordered as needed included: hydrocodone-acetaminophen 10-325 mg. one tablet every 4 hours as needed for pain, Hyoscyamine 0.125 mg. one tablet every 4 hours as needed for audible congestion, promethazine 25 mg one tablet every 6 hours as needed for nausea/vomiting, Morphine oral solution 20 mg/ml. give 0.25- 1 ml. every 2-3 hours as needed for pain or shortness of breath, lorazepam 0.5 mg. one tablet three times a day and every 4 hours as needed for anxiety, Tylenol PM extra strength, 2 tablets at night as needed for pain, and Tramadol 50 mg two tablets every 6 hours as needed for pain. During a phone interview on 01/27/20 at 3:40 p.m. a family member said she felt Patient #1 was being neglected by the agency because they were not providing the pain care Patient #1 needed. The family member said Patient #1 should not be taking the acetaminophen administrator/RN #55 was giving due to her kidney and liver problems. An undated written statement provided by the family member indicated on 12/21/2019 at approximately 2:00 PM, administrator/RN #55 arrived at Patient #1's home and delivered a "comfort Kit" which contained several medications that included: DSS/Senna (stool softener), promethazine (for nausea), bisacodyl (laxative), hyoscyamine (for secretions), Prednisone (steriod), morphine sulfate oral solution (narcotic for pain), lorazepam (for anxiety), tizanidine (muscle relaxer), and HYDROCO/APAP 10/325 (narcotice for pain). Administrator/RN#55 explained the usage and dosage for all medications. Administrator/RN #55 poured out and counted the Lorazepam in front of the family member and initialed the label and asked the family member to initial the label verifying the count. Administrator/RN #55 performed this routine with the "Tizanidine and the Hydroco/apap". Patient #1 was taking this regimen of medication. The statement indicated daily complaints of pain increased, and Patient #1 reported the "hydroco/apap" was not working. Phone calls were made to administrator/RN #55 to report this problem to the physician. The family member was instructed by administrator/RN #55 to give ".25 oral Morphine" for break thru pain and "a lorazepam." The family member indicated she complied with these instructions. The family member said as the effects of the morphine wore off quickly, the complaints of pain increased. The family member reported to administrator/RN #55 Patient #1's pain was not controlled with "hydroco/apap and .25 morphine" and using the "tizanidine and Lorazepam." Administrator/RN #55 told the family member to increase Patient #1's "morphine to .5" for break thru pain. The family member complied with these instructions. The family member reported that prior to Patient #1's transfer to hospice care, her doctor changed her pain medications from Tylenol 3 to Tramadol since her liver and kidney enzymes had been elevated. The statement indicated the family member filed a police report with the Sheriff's department regarding administrator/RN #55 on 1/12/2020. A police report dated 01/21/20, indicated administrator/RN #55 delivered hydrocodone pills as usual to Patient #1, the pills were poured out to be counted, but the family member for Patient #1 noticed the pills had the same numbers as before and refused to sign for the pills and this prompted police attention, who were in the home of Patient #1. The administrator/RN #55 admitted to tampering with Patient #1's narcotics and she was taken to jail from Patient #1's home. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest because she had taken Patient #1's narcotics for herself and replaced them with over-the-counter medications. The local pharmacy records showed administrator/RN #55 picked up Hydrocodone 10-325, 60 tablets for Patient #1 on 1/09/20, 1/20/20, and 1/21/220. 2. A POC dated 05/14/19-08/11/19 indicated Patient #8 was a 79-year-old female with diagnoses that included Alzheimer's disease, anxiety disorder and dementia. Patient #8 was admitted to the hospice agency on 05/14/19. Medications listed on the POC included: Morphine oral solution (used to treat moderate to severe pain) 10 mg/5 ml, give 0.25-0.5 ml each hour as needed for pain; Hyoscyamine sublingual tablet 0.125 mg, one tablet every 4 hours as needed for audible congestion; Promethazine tablet 25mg, one tablet every 4 hours as needed for nausea/vomiting; lorazepam tablet 0.5 mg, one tablet every hour as needed for anxiety or restlessness; oxybutynin tablet 5mg: one tablet daily; Niacin ER 1000 mg, one tablet at bedtime; donnepizil 10 mg, one tablet nightly; Tramadol 50 mg., one tablet every 8 hours as needed for pain; and lisinopril 10-12.5 mg, one tablet daily for high blood pressure. An undated Texas Board of Nursing complaint form provided by RN #54 indicated on 05/31/19 RN #54 called Patient #8's caregiver to inform him she and MD #58 would be coming out to do a home visit. Patient #8's caregiver mentioned he received a notice that medications were ready to be picked up from the pharmacy and asked if RN #54 could bring them when she came for the visit. The form indicated RN #54 did not recall any medications being ordered for Patient #8 but told the caregiver she would. The form indicated on 06/03/19, RN #54 called the pharmacy to see who had ordered the medications and discovered administrator/RN #55 ordered medications under Patient #8's name. Administrator/RN #55 went to the pharmacy and picked up the medications she ordered for Patient #8 (2 of the medications did not have a physician order). The form indicated on 06/03/19 RN #54 and MSW #59 went to the pharmacy to investigate the medications that were ordered by administrator/RN #55. The form indicated on 06/03/19 at 10:11 a.m. RN #54 called co-owner #56 and briefed him on what was discovered by the pharmacy staff, and a meeting was set up at 06/03/19 at 1:00 p.m.to discuss the situation. A record of medications dispensed by the local pharmacy dated 05/24/19 thru 05/31/19 indicated Resident #8 received alprazolam (used to treat anxiety, panic disorders, and anxiety caused by depression) 1 mg, 60 tablets, and ropinirole (used to treat stiffness, tremors, muscle spasms, and poor muscle control) 1 mg, 30 tablets were dispensed for Patient #8. An untitled form provided by the pharmacy indicated administrator/RN #55 signed for and picked up alprazolam1 mg, 60 tablets, and ropinirole 1 mg, 30 tablets for Patient #8 on 05/31/19 at 11:59 a.m. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest on 01/21/20 because she had taken a patient's narcotics for herself and replaced them with over-the-counter medications. During interview on 1/28/2020 at 1:45 p.m., pharmacy technician #57 said the pharmacy had multiple issues with RN #55 calling in fraudulent prescriptions. The technician said she was issued a subpoena on September 18, 2019 on behalf of the BON regarding RN #55. The technician said the agency co-owner/ alternate administrator #50 reached out her about the subpoena on 10/1/19. Pharmacy technician #57 said the co-owner/alternate administrator #50 was aware RN #55 was calling in fraudulent prescriptions. An undated Witness Affidavit statement provided on 1/28/2019 by pharmacy technician #57 indicated administrator/RN#55 called in a prescription of ropinirole and alprazolam for Patient #8 on 05/31/19. At 11:59 a.m. the same day RN #55 picked up and signed for the prescriptions. On 06/03/19 RN #54 and MSW #59 came to the pharmacy and made the staff at the pharmacy aware fraudulent prescriptions were called in by RN #55. On June 11, 2019 RN #55 called in more prescriptions. On 9/25/2019 RN #54 and MD #58 informed the staff at the pharmacy of more suspected fraudulent prescriptions. The statement indicated on 10/1/19 the co-owner/Administrator #50 called and asked if pharmacy technician #57 received a subpoena. The statement indicated during the conversation pharmacy technician #57 asked co-owner/alternate administrator #50 if she was aware of what was happening from the beginning and co-owner/ alternate administrator #50 said, 'yes'. The agency incident report log for June 2019, reviewed on 01/29/20, had no documentation of a nurse calling in fraudulent prescriptions, being reported to the BON, or any other reference related to medication issues. Personnel file for RN #55 indicated a hire date of 05/04/15. There was no documentation of any disciplinary actions against the nurse. During an interview on 1/30/2020 at 11:05 a.m., MD #58 said administrator/RN #55 called in and picked up prescriptions for Patient #8 and administrator/RN #55 had no business picking up the medications. The MD #58 said RN #55 called in medication that was not prescribed for Patient #8 that she picked up and did not deliver to the patient. MD #58 said she talked with the co-owner/alternate administrator #50 the first week of June about administrator /RN #55 calling in fraudulent prescriptions. The MD said co-owner/alternate administrator #50 told MD #58 there was no harm done, so it would not be reported. MD #58 said she suggested co-owner/alternate administrator #50 should drug test all employees, do an evaluation of the patients, get patients new medications and audit them but did not think it was ever done. During a phone interview on 1/30/2020 at 2:55 p.m. RN #54 said co-owner/alternate administrator #50 knew about the medication issues on June 6, 2019. RN #54 said she gave copies from the Board of Nursing report to co-owner #56. RN #54 said the alternate administrator #50 knew about it on June 5, 2019 and she was texted by co-owner/ alternate administrator #50 to call her. RN #54 said on June 6, 2019 the alternate administrator #50 texted wanting copies of what was sent to the Board of Nursing, so she could review it, because more information may need to be added. RN #54 said she did not give alternate administrator #50 the copies because they were given to co-owner #56. During a phone interview on 1/30/2020 at 3:21 p.m., MSW #59 said when she and RN #54 met with owner #56 he said he needed to tell co-owner/ alternate administrator #50 about administrator/RN #55 falsely obtaining the medications. MSW #59 said administrator/ RN #55 was off a few days during this time and when she returned to work, around June 2019 the first thing RN #55 did was call in another prescription. MSW #59 said she found out because the pharmacy had called. MSW# 59 said she could not remember dates of the incidents. MSW #59 said there were staff meetings regarding these issues and that it was kept hush hush, and no one dared to talk about it. During an interview on 1/30/2020 at 2:20 pm the co-owner/alternate administrator #50 kept saying she did not remember an incident in June, and kept repeatedly saying, "I don't know, I don't remember, you tell me." She was visibly shaking and tearful. The co-owner/alternate administrator #50 said that might have been when RN #54 and MSW #59 was in co-owner #56's office, co-owner/alternate administrator #50 said she tried asking what was going on but was told it was private and did not remember if owner #56 told her anything. Co-owner/alternate administrator #50 said RN #54 and MSW #59 didn't say anything to her. The co-owner/alternate administrator #50 indicated she did not investigate, prevent further exploitation or report anything to the state agency regarding administrator/RN #55. A text message, with a screen shot of an email dated June 5, 2019 at 1:56 p.m. indicated co-owner/alternate administrator #50 texted RN #54 initiating a discussion regarding what was sent to the Board of Nursing. During an interview on 1/30/2020 at 4:22 p.m., co-owner #56 said he honestly was not sure if RN #54 and MSW #59 had told co-owner/alternate administrator #50. Co-owner #56 said he told RN #54 to hold off on reporting to the Board of Nursing until the agency investigation was done. Co-owner #56 said RN #54 said was already been reported to the Board of Nursing. Co-owner #56 said he thought he remembered alternate administrator #50 telling him to let her talk to RN #54 first. Co-owner #56 said RN #54 had a printout of papers of patients she gave him that didn't get medications that were ordered. Owner #56 said he doesn't remember what happened to the copies. Co-owner #56 said MD #58 talked with him about that incident and about administrator/RN #55 but did not remember exactly what was said. The co-owner/alternate administrator #56 indicated he did not investigate, prevent further exploitation or report anything to the state agency regarding administrator/RN #55. An abuse, neglect and exploitation procedure dated 8/1/2019 indicated: Purpose: To identify suspected or alleged victims of abuse, neglect, or exploitation (ANE) of a patient or individual, or misappropriation of property. To establish appropriate protocols ... Procedure: II. Agency management will: A. Immediately investigate all alleged violations ... B. Address any allegations of or evidence of abuse to determine if immediate care is needed ...C. Report if there is cause to believe abuse, neglect or exploitation ...within 24hours to ...Texas Health and Human services ...1-800-458-9858 ...E. Report if there is cause to believe ...misappropriation of patient property has occurred by a staff member ...F. Immediately suspend any agency employee ...H. The agency will send a written report, using the Provider investigation form, of the investigation to the TX HHS Consumer Rights and Services no later than the tenth day after reporting the act ...III. All reports of suspected abuse or neglect of a patient or individual, or misappropriation of property will be documented by the agency ... The Drug Free Workplace HR.1 policy, revised on 09/01/19, indicated, "...VI. Per Federal Law 41 U.S. Code 8102 and the Drug-Free Workplace Act of 1988 employees are informed of the following: A. All employees are prohibited from the unlawful or authorized manufacture, distribution, dispensing, possession or use of a controlled substance, narcotics, or other illegal drugs, alcohol, or prescription medication without a prescription while on company or patient premises or on agency paid time..." The policy, "Pain Management PC.29 on page 1 of 2 indicated under policy: " ... Agency Staff are committed to pain and symptom prevention and management and will respond quickly to provide effective management. Agency will respect patient's right to receive effective pain management and symptom control for conditions related to the terminal illness ..." The agency admit pack undated contained an introductory letter to the patients that read: " ... Hospice Care has several Elements that set it apart from other Health Care ...Pain and symptom Control: The objective of pain and symptom control is to help you to achieve comfort while allowing you to remain control of your life ..." The agency did not provide additional information at the time of exit on 01/30/20 at 5:00 p.m.
L0650      
35215 Based on interview and record review the hospice failed to ensure that care and services provided gave priority to the comfort and dignity and family needs for 1 of 1 patients reviewed for care and services (Patient #1) The agency did not provide pain management for the comfort of Patient #1 This failure could place Patients at risk of pain and patient and family needs not being met. Findings included: The POC for Benefit Period 12/21/19-3/19/20 indicated Patient #1 was an 86-year-old female with diagnoses that included chronic obstructive pulmonary disease, stage 2 chronic kidney disease, heart disease and extreme weakness. Patient #1 was placed on hospice care on 12/21/19. Medications ordered as needed included: hydrocodone-acetaminophen 10-325 mg. one tablet every 4 hours as needed for pain, Hyoscyamine 0.125 mg. one tablet every 4 hours as needed for audible congestion, promethazine 25 mg one tablet every 6 hours as needed for nausea/vomiting, Morphine oral solution 20 mg/ml. give 0.25- 1 ml. every 2-3 hours as needed for pain or shortness of breath, lorazepam 0.5 mg. one tablet three times a day and every 4 hours as needed for anxiety, Tylenol PM extra strength, 2 tablets at night as needed for pain, and Tramadol 50 mg two tablets every 6 hours as needed for pain. During a phone interview on 01/27/20 at 3:40 p.m. a family member said she felt Patient #1 was being neglected by the agency because they were not providing the pain care Patient #1 needed. The family member said Patient #1 should not be taking the acetaminophen administrator/RN #55 was giving due to her kidney and liver problems. An undated written statement provided by the family member indicated on 12/21/2019 at approximately 2:00 PM, administrator/RN #55 arrived at Patient #1's home and delivered a "comfort Kit" which contained several medications that included: DSS/Senna, promethazine, bisacodyl, hyoscyamine, Prednisone, morphine sulfate oral solution, lorazepam, tizanidine, and HYDROCO/APAP 10/325. Administrator/RN#55 explained the usage and dosage for all medications. Administrator/RN #55 poured out and counted the Lorazepam in front of the complainant and initialed the label and asked the family member to initial the label verifying the count. Administrator/RN #55 performed this routine with the "Tizanidine and the Hydroco/apap". Patient #1 was taking this regimen of medication. The statement indicated daily complaints of pain increased, and Patient #1 reported the "hydroco/apap" was not working. Phone calls were made to administrator/RN #55 to report this problem to the physician. The family member was instructed by administrator/RN #55 to give ".25 oral Morphine" for break thru pain and "a lorazepam." The family member indicated she complied with these instructions. The family member said as the effects of the morphine wore off quickly, the complaints of pain increased. The complainant reported to administrator/RN #55 Patient #1's pain was not controlled with "hydroco/apap and .25 morphine" and using the "tizanidine and Lorazepam." Administrator/RN #55 told the family member to increase Patient #1's "morphine to .5" for break thru pain. The family member complied with these instructions. The family member reported that prior to Patient #1's transfer to hospice care, her doctor changed her pain medications from Tylenol 3 to Tramadol since her liver and kidney enzymes had been elevated. The statement indicated the family member filed a police report with the Sheriff's department regarding administrator/RN #55 on 1/12/2020. A police report dated 01/21/20, indicated administrator/RN #55 delivered hydrocodone pills as usual to Patient #1, the pills were poured out to be counted, but the family member for patient #8 noticed the pills had the same numbers as before and refused to sign for the pills and this prompted police attention, who were in the home of Patient #1. The administrator/RN #55 admitted to tampering with Patient #1's narcotics and she was taken to jail from Patient #1's home. During an interview on 1/28/20 at 10:37 a.m. alternate administrator #50 said administrator/RN #55 was placed under arrest because she had taken Patient #1's narcotics for herself and replaced them with over-the-counter medications. The local pharmacy records showed administrator/RN #55 picked up Hydrocodone 10-325, 60 tablets for Patient #1 on 1/09/20, 1/20/20, and 1/21/220.On 01/30/20 at 10:30 a.m. RN #52 submitted a copy of the Provider investigation report which read under Complaint & Incident Intake report "Provider of Self-Reporting of incidents" indicated the report was filed by RN#52 on 01/22/20 at 1:49 p.m ... Incident Information: " ...Date the agency first learned of the incident 01/21/20 ...at 12:40 a.m. ...Allegations reported by: Police Officer, Allegations: Exploitation ... Report Details: It was reported by a police officer to the agency staff the administrator needed to call the police officer because the employee was being placed under arrest for medication issues in the patient's home ..." During interview on 01/28/20 at 10:25 a.m. Co-owner/alt.admin.#50 said she and LVN #53 went out on Friday 01/24/20, to check all the patient's medications to see if they were accounted for after the incident with administrator/RN #55 on 01/21/20. During a phone interview on 01/28/20 at 12:10 p.m. LVN #53 said she and Co-owner/alt.admin.#50 had never gone on visits to the Patient's homes to check their medications. During a phone interview on 01/29/20 at 7:41 a.m. LVN #53 said she felt that if this problem had been taken care of by the agency a while back when RN#54 and MSW#59 had reported this to the board of nursing this would have never happened. During an Interview on 1/30/2020 at 11:05 a.m. MD #58 said she talked with the co-owner/alt. admin.#50 the first week of June about the admin/RN#55 calling in fraudulent prescriptions. Co-owner/alt. admin. #50 told MD#58 that because there was no harm done so it would not be reported. MD #58 said she suggested that co-owner/alt. admin. #50 should drug test all employees, do an evaluation on the patients, get patients new medications and audit them but doesn't think it was ever done. MD #58 said these issues were never discussed in IDT meetings she attended. The policy, "Pain Management PC.29 on page 1 of 2 indicated under policy: " ... Agency Staff are committed to pain and symptom prevention and management and will respond quickly to provide effective management. Agency will respect patient's right to receive effective pain management and symptom control for conditions related to the terminal illness ..." The agency admit pack undated contained an introductory letter to the patients that read: " ... Hospice Care has several Elements that set it apart from other Health Care ...Pain and symptom Control: The objective of pain and symptom control is to help you to achieve comfort while allowing you to remain control of your life ..." Agency did not provide additional information at time of exit on 1/30/2020 at 5:00 p.m.
L0662      
35215 Based on interview and record review, the agency failed to provide an initial orientation for an employee that addressed the employee's specific job duties for 1 of 1 office employees (Compliance Officer #60) The agency did not ensure Compliance Officer RN #60 was oriented and trained for the position of compliance officer. This failure could place the clients at risk for harm. During an interview 1/29/2020 at 1:58 p.m. RN #60 said she has been the compliance officer since August 2019. When RN #60 was asked if she had received training for that position and what type of training she received RN #60 said she had received none, "I've had no training so far". RN #60 said she had referenced a consulting agency web site and taught herself what she knew. On 1/29/2020 and 1/30/2020 requests were made on separate occasions for copies of the compliance officer job description and records to indicate what training RN #60 received for the position of Compliance Officer. A job description for the compliance officer was provided on 1/30/2020 that indicated RN #60 and Co-owner/alt. admin. #50 signed on 8/26/2019. No records were ever provided that documented the training RN #60 had for the position of compliance officer. The undated Job Description signed by RN#60 on 08/26/19, under Job summary read: " ...Responsibilities include overseeing and monitoring the implementation of the compliance program ..." The policy, Employee Grievance/Complaint Resolution HR.18 dated 04/01/17, under Reporting of Suspected or Potentially Improper activities on page 3 of 5 indicated: " ... III. All communication regarding compliance issues, reports of suspected or actual improper activities will be recorded and reviewed by the compliance officer ...IV. The compliance Officer is responsible for investigating the claim ...Responsibility ...III. Ultimate responsibility for the Compliance Program falls to the Compliance Officer ..." Agency did not provide additional information at time of exit on 1/30/2020 a 5:00 p.m.