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
741549 A. BUILDING __________
B. WING ______________ 		11/06/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
FEATHERLAND HOSPICE INC 6464 SAVOY DRIVE, SUITE 850, HOUSTON, TX, 77036
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)
L0502      
16353 Based on record review and interview the agency failed to ensure that 1 of 1 (#1) Client / family understood the rights on admission before beginning services, in that: Client #1 was diagnosed with Alzheimer's disease and Dementia, was assessed by agency RN #1 as being cognitively impaired, and was allowed to sign the consent forms for hospice services without the knowledge / consent of the Clients' family / medical power of attorney. The failure of the agency to provide the client / family with assistance in understanding consent for services before providing Hospice services, could potentially affect all of the cognitively impaired Clients on service by preventing them from being aware of their rights. Based on record review and interview the hospice Registered Nurse failed to ensure that 1 of 1 (#1) patient understood their rights prior to the hospice providing services in that: Patient #1 was diagnosed with Alzheimer's disease and Dementia, was assessed by agency RN #1 on initial assessment as being cognitively impaired, and was allowed to sign the consent forms for services with the Hospice, without the knowledge / consent of the patients' family or medical power of attorney. The failure of the agency to provide appropriate understanding of services or approval by the patient's medical power of attorney (as needed) could potentially affect all of the cognitively impaired patients on service and prevent them from being aware of their rights. Findings include: Record review of undated agency policy "Admission to Hospice Care and initial assessment" documented "The purpose of the initial visit will be to: explain the hospice philosophy of palliative care with the patient and family care giver as a unit of care .... Explain patient's rights and responsibilities and grievance procedure ...Provide the patient with a copy of notice of privacy practices ...Allow the patient and family/caregiver to ask questions and facilitate a decision for hospice services ..." Record review of the clinical record for client #1 revealed documents titled "External facility transfer summary." An initial assessment dated 5-20-20 from the transferring hospital (#1) to the agency revealed the patient was assesses as "Mental functioning: Alert, confused ...Orientation level: unable to assess ...Insight/Judgement: Poor ..." Further review of paperwork listed patient #1's children as the key people to contact regarding the power attorney for patient #1's telephone number and name. Record review of form titled "Consent for services/release of records" revealed it was signed by Patient #1 and RN #1. Record review of RN #1's initial assessment dated 5-22-20 read in part: " ... 95-year-old black female diagnosed with Alzheimer's. Alert and oriented times 1 today. Thought processes are confused at times (at beginning of the interview told me she had 7 children then later she had 4) ..." Further review of assessment revealed yes was checked for "cognitive impairment - could include patients ...Alzheimer's ...who are confused, use poor judgement, have decreased comprehension ..." Assessment also documented "overall mental status: alert, forgetful; alerted to: person; when confused (reported or observed); during the day and evening but not constantly ..." Interview on 11-6-20 at 11:05 am with patient #1's family member surveyor was informed that when patient #1 was diagnosed with Alzheimer's and Dementia she had power of attorney, but when patient #1 was transferred to an assisted living facility she was not made aware that patient #1 had signed papers to go on Hospice. Surveyor asked the family member when they were told that patient #1 was on Hospice. The family member stated that they found out when patient #1 had to be readmitted into the hospital and the hospital representative told them that patient #1 signed the consent forms for hospice. When asked if the family had spoken to anyone at the agency, the family member stated that she spoke to the agency social worker but was unaware that the agency was a Hospice. The family member further stated that patient #1 received a statement from Medicare that listed the Hospice benefits. The family member stated that the owner of the assisted living told her that patient #1 would be getting a social worker, nurse and nurse aide through the assisted living facility. Interview on 11-6-20 at 12:27 pm the surveyor asked the hospice supervising nurse, in the presence of the administrator, why was patient #1 allowed to sign consent forms for service when she was diagnosed with Alzheimer's disease and Dementia. The supervising nurse stated "When we admitted the patient we accepted the referral from the hospital and nobody was at the hospital with the patient. ...The owner of the facility told us she (patient #1) was there and oriented, then later, maybe the first of the next week we found she had a family member. We only talked to (family member) when she (patient #1) had an incident at the assisted living facility, when she tried to leave." Interview at 1:22 pm the surveyor asked the supervising nurse if the agency had any documentation of contacting the family member after they found out patient #1 had family. The supervising nurse stated "No we don't have any documentation that we contacted her (family member). I talked with the social worker and she said she only heard of the daughter when patient #1 jumped out the window." Record review of the "patient communication" form dated 5-27-20 (5 days after patient #1's admission) the social worker documented "SW called (patient #1's family member) the daughter of Pt. (family member) ... (family member in the process of getting POA (power of attorney) on Pt's behalf." Further review of the same form with a second date of 5-29-20 documented "SW called (family member). (Family member) has been able to obtain POA ..." No additional information was provided.