Survey Report for 741536

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	741536	A. BUILDING __________ B. WING ______________	02/18/2020
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
CALIDAD HOME HEALTH	1600 E EXPRESSWAY 83, LA FERIA, TX, 78559
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)
L0521
L0521	21741 Based on record review and interview, the hospice failed to ensure that patient specific comprehensive assessments included all areas of hospice care related to the palliation and management of the patients' terminal illness and related conditions for 1 of 1 active patient (#1) and 2 of 2 discharged patients (#2 and #3) whose records were reviewed. This failure could place the agency's active hospice patients at risk of inadequate care from services which were not provided according to the directions of the IDG (Interdisciplinary Group). The findings included: 1. Review of active Patient #1's paper record included a form titled "Referral Intake Sheet" that revealed the referral date as 05/06/19. The form revealed the Primary / Secondary Diagnosis as "Alzheimer's, Rheumatoid Arthritis, Hypertension (High Blood Pressure), Osteoporosis, Dementia, Failure to Thrive, Seizure Disorder and Epilepsy." Patient #1's electronic clinical record included a form titled "Recertification of Terminal Illness" that revealed the admission date as 05/06/19. The form revealed the certification of terminal illness was for the subsequent 60 Day Benefit Period dates from 01/01/20 to 02/29/20 and Benefit Period #4. Patient #1's electronic clinical record included an agency form titled "RN (Registered Nurse) Recertification" Assessment dated 12/30/19. completed by RN C. The form revealed the Terminal Diagnosis as "Alzheimer's Disease, Unspecified." The form also revealed "Comorbidity 1, Comorbidity 2, Comorbidity 3..... and the section "Is this diagnosis related to the terminal illness." The "Comorbidity" and "Is this diagnosis related to the terminal illness" sections were blank, not completed. Further review of the Recertification Assessment form failed to reveal documentation RN C listed and addressed the co-morbidities. The assessment did not include all areas of hospice care related to the palliation and management of the terminal illness and related conditions. The co-morbidities listed on the Referral Intake Sheet which included the included the diagnoses of Rheumatoid Arthritis, Hypertension (High Blood Pressure), Osteoporosis, Dementia, Failure to Thrive, Seizure Disorder and Epilepsy were not listed on the Recertification Assessment. During an interview on 02/14/20 at 2:12 p.m. with the Administrator (Adm)/Licensed Vocational Nurse (LVN) and Director of Nurses (DON), Surveyor A presented the above findings and asked if the assessment included and addressed the Co-Morbidities. After review of the Recertification Assessment, the DON stated "no, only the primary diagnosis." 2. Review of discharged Patient #2's paper record included a Referral Intake Sheet that revealed the referral date as 12/26/19. The form revealed the Primary / Secondary Diagnosis as "ESRD (End Stage Renal Disease) and HIV (Human Immuno Disease Virus)." Patient #2's electronic clinical record included a Hospice form titled "Physician Order" dated 12/26/19. The form revealed the Benefit Period as 12/26/19 to 03/24/20, Terminal Diagnosis as End Stage Renal Disease. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "End Stage Renal Disease." Patient #2's electronic clinical record included an agency form titled "RN Initial Assessment dated 12/26/19 and completed by RN D. The form revealed the Terminal Diagnosis as "End Stage Renal Disease." The form also revealed "Comorbidity 1, Comorbidity 2, Comorbidity 3..... and the section "Is this diagnosis related to the terminal illness." The "Comorbidity" and "Is this diagnosis related to the terminal illness" sections were blank, not completed. Review of an electronic agency form titled "Skilled Nursing Visit" note dated 12/27/19 and completed by LVN (Licensed Vocational Nurse) G. The Skilled Nursing Visit note revealed on Page 3 of 3 "SN [skilled nurse] performed Hospice admission for elderly male with diagnoses of ESRD, HIV, Diabetes, Disuse Atrophy (muscle loss) and History of Stroke." Further review of the Initial Assessment form failed to reveal documentation RN D listed and addressed the co-morbidities. The assessment did not include all areas of hospice care related to the palliation and management of the terminal illness and related conditions. The co-morbidities listed on the SN Visit Note which included the included the diagnoses of HIV, Diabetes, Disuse Atrophy (muscle loss) and History of Stroke were not listed on the Initial Assessment. During an interview on 02/14/20 at 2:29 p.m. with the Adm/LVN and DON, Surveyor A presented the above findings and asked if the assessment included and addressed the Co-Morbidities. After review of the Recertification Assessment, the DON stated "no." 3. Review of discharged Patient #3's paper record included a Referral Intake Sheet that revealed the referral date as 12/06/19. The form revealed the Primary / Secondary Diagnosis as "Alzheimer's Disease and DM (Diabetes Mellitus)." Patient #3's electronic clinical record included a Hospice form titled "Physician Order" dated 12/06/19. The form revealed the Benefit Period as 12/06/19 to 03/04/20, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "Alzheimer's Disease." Patient #3's electronic clinical record included an agency form titled "RN Initial Assessment dated 12/26/19 completed by RN D. The form revealed the Terminal Diagnosis as "Alzheimer's Disease, Unspecified." The form also revealed "Comorbidity 1, Comorbidity 2, Comorbidity 3..... and the section "Is this diagnosis related to the terminal illness." The "Comorbidity" and "Is this diagnosis related to the terminal illness" sections were blank, not completed. Further review of the Initial Assessment form failed to reveal documentation RN D listed and addressed the co-morbidity listed on the Referral Intake Sheet. The assessment did not include all areas of hospice care related to the palliation and management of the terminal illness and related conditions.. During an interview on 02/14/20 at 3:05 p.m. with the Adm/LVN and DON, Surveyor A presented the above findings and asked if the assessment included and addressed the Co-Morbidity listed on the Referral Intake Sheet. After review of the Recertification Assessment, the DON stated "no." The Hospice did not provide additional information by the time of exit on 02/18/20 at 11:16 a.m.
L0538
L0538	21741 Based on record review and interview, the hospice failed to ensure the plans of care (POC) included all services necessary to meet the specific patient needs for 1 of 1 active patient (#1) and 2 of 2 discharged patients (#2 and #3) whose records were reviewed. This failure could place the agency's active hospice patients at risk of inadequate care and services not provided according to the directions of the IDG (Interdisciplinary Group). The findings included: 1. Review of active Patient #1's electronic clinical record included a form titled "Recertification of Terminal Illness" that revealed the admit date as 05/06/19. The form revealed the certification of terminal illness was for the subsequent 60 Day Benefit Period dates from 01/01/20 to 02/29/20 and Benefit Period #4. Patient #1's electronic clinical record included a Hospice form titled "Physician Order" dated 11/02/19. The form revealed the Benefit Period as 11/02/19 to 12/31/19, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the orders as "Initial Orders" and Primary Terminal Diagnosis as Alzheimer's Disease and Secondary Conditions: blank, not completed. The electronic record included another form titled "Patient Communication" (identified) by the Administrator as the Plan of Care. The form revealed the Terminal Diagnosis as "Alzheimer's Disease, Unspecified, Secondary Conditions: blank, not completed and Benefit Period #4 from 01/01/20 to 02/29/20. Patient #1's electronic record included 12 agency forms titled "Skilled Nursing (SN) Visit" signed by Licensed Vocational Nurse H dated 01/02/20, 01/06/20, 01/08/20, 01/15/20, 01/20/20, 01/21/20, 01/22/20, 01/24/20, 01/29/20, 02/03/20, 02/07/20, 02/12/20, two SN Visit notes signed by RN C dated 01/13/20, 01/27/20 and one SN Visit note signed by RN D dated 02/10/20. The SN Visit notes revealed the SNs assessed Patient #1's Oxygen Saturation Rates of the blood via Pulse Oximetry and performed mid-arm circumference measurements. Continued review of the POCs failed to reveal documentation that included orders for the SN to perform Pulse Oximetry to assess the Oxygen Saturation Rate of the blood, mid-arm circumference measurements and parameters. During an interview on 02/14/20 at 2:12 p.m. with the Administrator (Adm)/Licensed Vocational Nurse (LVN) and Director of Nurses (DON), Surveyor A presented the above findings and asked if the POC included orders for the SN to perform Pulse Oximetry to assess the Oxygen Saturation Rate of the blood and Oxygen Saturation Rate parameters, mid-arm circumference measurements and measurement parameters. After review of the POC, the DON stated "no." 2. Review of discharged Patient #2's paper record included a Referral Intake Sheet that revealed the referral date as 12/26/19. The form revealed the Primary / Secondary Diagnosis as "ESRD (End Stage Renal Disease) and HIV (Human Immuno Disease Virus)." Patient #2's electronic clinical record included a Hospice form titled "Physician Order" dated 12/26/19. The form revealed the Benefit Period as 12/26/19 to 03/24/20, Terminal Diagnosis as End Stage Renal Disease. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "End Stage Renal Disease." Patient #2's electronic record included 11 SN Visit notes signed by LVN G dated 12/27/19, 12/30/19, 01/02/20, 01/06/20, 01/13/20, 01/17/20, 01/20/20, 01/28/20, 01/30/20, 02/03/20, 02/07/20, four SN Visit notes signed by RN D dated 01/09/20, 01/23/20, 01/29/20, 02/06/20 and two SN Visit notes signed by LVN I dated 02/08/20 and 02/09/20. The SN Visit notes revealed the SNs assessed Patient #2's Oxygen Saturation Rates of the blood via Pulse Oximetry and performed mid-arm circumference measurements. During an interview on 02/14/20 at 2:29 p.m. with the Adm/LVN and DON, Surveyor A presented the above findings and asked if the POC included orders for the SN to perform Pulse Oximetry to assess the Oxygen Saturation Rate of the blood and Oxygen Saturation Rate parameters, mid-arm circumference measurements and measurement parameters. After review of the POC, the DON stated "no." 3. Review of discharged Patient #3's paper record included a Referral Intake Sheet that revealed the referral date as 12/06/19. The form revealed the Primary / Secondary Diagnosis as "Alzheimer's Disease and DM (Diabetes Mellitus)." Patient #3's electronic clinical record included a Hospice form titled "Physician Order" dated 12/06/19. The form revealed the Benefit Period as 12/06/19 to 03/04/20, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "Alzheimer's Disease." Patient #3's electronic record included three SN Visit notes signed by LVN H dated 12/09/20, 12/11/20, 12/16/20, one SN Visit note signed by RN E dated 12/20/19, one SN Visit note signed by LVN J date 12/24/19 and one SN Visit note signed by LVN K dated 12/25/19. The SN Visit notes revealed the SNs assessed Patient #3's Oxygen Saturation Rates of the blood via Pulse Oximetry During an interview on 02/14/20 at 3:05 p.m. with the Adm/LVN and DON, Surveyor A presented the above findings and asked if the POC included orders for the SN to perform Pulse Oximetry to assess the Oxygen Saturation Rate of the blood and Oxygen Saturation Rate parameters. After review of the POC, the DON stated "no." The Hospice did not provide additional information by the time of exit on 02/18/20 at 11:16 a.m.
L0552
L0552	21741 Based on record review and interview, the hospice IDT (interdisciplinary team) failed to failed to ensure the individualized plans of care (POC) were updated and revised every 15 days for 1 of 1 active patient (#1) whose record were reviewed. This failure could place the hospice's active patients at risk of poor health outcomes due to the interdisciplinary teams inability to identify and address changes in the patient's condition in a timely manner. The findings included: Review of active Patient #1's electronic clinical record included a form titled "Recertification of Terminal Illness" that revealed the admit date as 05/06/19. The form revealed the certification of terminal illness was for the subsequent 60 Day Benefit Period dates from 01/01/20 to 02/29/20 and Benefit Period #4. Patient #1's electronic clinical record included a Hospice form titled "Physician Order" dated 11/02/19. The form revealed the Benefit Period as 11/02/19 to 12/31/19, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the orders as "Initial Orders" and Primary Terminal Diagnosis as Alzheimer's Disease and Secondary Conditions: blank, not completed. Patient #1's electronic record included another form titled "Patient Communication" (identified) by the Administrator as the Plan of Care. The form revealed the Terminal Diagnosis as "Alzheimer's Disease, Unspecified, Secondary Conditions: blank, not completed and Benefit Period #4 from 01/01/20 to 02/29/20. Patient #1's electronic record included an agency form titled "Patient Communication: Plan of Care Update" dated 12/25/19 (identified) by the Administrator as the IDG (Interdisciplinary Team Meeting). Further review of Patient #1's electronic record failed to reveal additional IDG Plan of Care Updates completed by the IDG. During an interview on 02/14/20 at 2:12 p.m. with the Administrator (Adm)/Licensed Vocational Nurse (LVN) and Director of Nurses (DON), Surveyor A presented the above findings and asked if Patient #1's record included other IDG Plans of Care completed by the IDG. After review of the electronic record, the DON stated "no." The Hospice did not provide additional information by the time of exit on 02/18/20 at 11:16 a.m.
L0553
L0553	21741 Based on record review and interview, the hospice failed to ensure the revised plan of care included the patient's progress toward the goals and outcomes specified in the plan of care for 1 of 1 active patient (#1) and 1 of 2 discharged patients (#2) whose records were reviewed. This failure could place the hospice's active patients at risk of unmet needs if the interdisciplinary team did not have up-to-date information on the patients for whom the team was responsible. The findings included: 1. Review of active Patient #1's electronic clinical record included a form titled "Recertification of Terminal Illness" that revealed the admit date as 05/06/19. The form revealed the certification of terminal illness was for the subsequent 60 Day Benefit Period dates from 01/01/20 to 02/29/20 and Benefit Period #4. Patient #1's electronic clinical record included a Hospice form titled "Physician Order" dated 11/02/19. The form revealed the Benefit Period as 11/02/19 to 12/31/19, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the orders as "Initial Orders" and Primary Terminal Diagnosis as Alzheimer's Disease and Secondary Conditions: blank, not completed. The electronic record included another form titled "Patient Communication" (identified) by the Administrator as the Plan of Care. The form revealed the Terminal Diagnosis as "Alzheimer's Disease, Unspecified, Secondary Conditions: blank, not completed and Benefit Period #4 from 01/01/20 to 02/29/20. Patient #1's electronic record included an agency form titled "Patient Communication: Plan of Care Update" dated 12/25/19 (identified by the Administrator as the IDG [Interdisciplinary Team Meeting]). Further review of the IDG Meeting failed to reveal documentation that noted the patient's progress toward outcomes and goals specified in the plan of care. Further review of Patient #1's electronic record failed to reveal additional IDG Plan of Care Updates that would note the patient's progress toward outcomes and goals specified in the plan of care. 2. Review of discharged Patient #2's paper record included a Referral Intake Sheet that revealed the referral date as 12/26/19. The form revealed the Primary / Secondary Diagnosis as "ESRD (End Stage Renal Disease) and HIV (Human Immuno Disease Virus)." Patient #2's electronic clinical record included a Hospice form titled "Physician Order" dated 12/26/19. The form revealed the Benefit Period as 12/26/19 to 03/24/20, Terminal Diagnosis as End Stage Renal Disease. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "End Stage Renal Disease." Patient #2's electronic record included three Patient Communication: Plan of Care Update forms dated 01/08/20, 01/22/20 and 02/05/20 (identified by the Administrator as the IDG Plan of Care). Further review of the IDG Plans of Care failed to reveal documentation that noted the patient's progress toward outcomes and goals specified in the plan of care. During an interview on 02/18/20 at 10:45 a.m. with the Administrator (Adm)/Licensed Vocational Nurse (LVN), Surveyor A presented the above findings and asked if the Plans of Care included documentation that noted the patient's progress toward outcomes and goals specified in the plan of care. After review of the POC, the Adm/LVN stated "no." The Hospice did not provide additional information by the time of exit on 02/18/20 at 11:16 a.m.
L0667
L0667	21741 Based on record review and interview, the hospice failed to ensure the medical director or physician completed a written certification of terminal illness that anticipated that the patient's life expectancy was 6 months or less if the illness ran its normal course for 2 of 2 discharged patients (#2 and #3) whose records were reviewed. The failure could affect the hospice's active patients by placing them at risk of inadequate medical management of the patient's conditions unrelated to the terminal illness. The findings included: 1. Review of discharged Patient #2's paper record included a form titled "Referral Intake Sheet" that revealed the referral date as 12/26/19. The form revealed the Primary / Secondary Diagnosis as "ESRD (End Stage Renal Disease) and HIV (Human Immuno Disease Virus)." Patient #2's electronic clinical record included a Hospice form titled "Physician Order" dated 12/26/19. The form revealed the Benefit Period as 12/26/19 to 03/24/20, Terminal Diagnosis as End Stage Renal Disease. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "End Stage Renal Disease." Further review of Patient #2's electronic or paper records failed to reveal documentation the hospice physician completed an initial certification of terminal illness form to provide written certification that it anticipated that the patient's life expectancy was 6 months or less if the illness ran its normal course. During an interview on 02/18/20 at 10:47 a.m. with the Administrator (Adm)/Licensed Vocational Nurse (LVN), Surveyor A presented the above findings and asked for documentation of an initial certification of terminal illness form. The Adm/LVN stated "I will look to see if is to be filed." The Adm/LVN then stated it was still in the doctor's office. 3. Review of discharged Patient #3's paper record included a Referral Intake Sheet that revealed the referral date as 12/06/19. The form revealed the Primary / Secondary Diagnosis as "Alzheimer's Disease and DM (Diabetes Mellitus)." Patient #3's electronic clinical record included a Hospice form titled "Physician Order" dated 12/06/19. The form revealed the Benefit Period as 12/06/19 to 03/04/20, Terminal Diagnosis as Alzheimer's Disease, Unspecified. The form revealed the Physician Orders as the "Initial Orders" and Primary Terminal Diagnosis as "Alzheimer's Disease." Further review of Patient #3's electronic or paper records failed to reveal documentation the hospice physician completed an initial certification of terminal illness form. During an interview on 02/18/20 at 10:48 a.m. with the Adm/LVN, Surveyor A presented the above findings and asked for documentation of an initial certification of terminal illness form. The Adm/LVN stated it was still in the doctor's office. The Hospice did not provide additional information by the time of exit on 02/18/20 at 11:16 a.m.