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
741596 A. BUILDING __________
B. WING ______________ 		01/15/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ST. GABRIEL'S HOSPICE AND PALLIATIVE CARE 1313 COLLEGE AVE, SUITE A, FORT WORTH, TX, 76104
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)
L0671      
22360 Based on record review and interview, the agency failed to ensure clinical records were in accordance with accepted principles of practice for two of four hospice patients (Patient #1 and #2) whose record was reviewed, in that: 1. Patient #1's medication list did not include oxygen. 2. Patient #2's medication list contained inaccurate information regarding the client's allergies. This failure could place the agency's 175 active patients at increased risk of not receiving the necessary care and services and could result in miscommunication between agency staff, patients and families. The findings included: A. Review of the agency's policy titled, "Medical Record Content," revised date 10/01/11, revealed in part, "Agency will initiate and maintain an individual and accurate medical record for each patient receiving care...Each medical record will contain the following...An updated medication profile to include medication, allergies, and/or sensitivities..." B. Review of the agency's policy titled, "Medication List and Monitoring," revised date 05/01/10, revealed in part, "...Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient..." C. Review of Patient #1's plan of care for the benefit period 11/26/19 to 02/23/20 revealed in part, "...DME (Durable Medical Equipment) and supplies...oxygen supplies..." Review of a physician order for Patient #1 dated 01/15/20, read in part, "...start date 11/26/19...Oxygen...2 - 5 LPM (liters per minute) as needed...SOB (shortness of breath)..." Review of Patient #1's "Client Medication Report (Medication Profile)," print date 01/15/20, revealed no documented evidence of the oxygen as ordered by the physician. During an interview with the Alternate Administrator on 01/15/20 at 4:00 p.m., she stated that the hospice physician orders oxygen for all the clients upon admission and that she would look for additional information. During an interview with the Supervising Nurse on 01/15/20 at 4:02 p.m., he stated that when the agency went to the new electronic computer system, the oxygen was left off the medication list. D. Review of Client #2's "Client Medication Report," print date 01/15/20, revealed in part, "...Client Allergies...Hydrocodone (an opioid narcotic medication prescribed to treat moderate pain)...Codeine (an opioid narcotic medication used to treat mild to moderate pain)...Morphine (a narcotic pain reliever prescribed for moderate to severe pain)..." Further review of Client #2's "Client Medication Report," revealed she was prescribed "Hydrocodone/Acetaminophen 325 mg (milligrams) one table every 6 hours" as needed for pain and "Morphine 20 mg/ml (milliliter)" in the amount of "0.5 to 1 ml every hour" as needed for "pain/SOB (shortness of breath)." During an interview with Client #2's RN (Registered Nurse) case manager (Staff D) on 01/15/20 at 3:35 p.m., he stated that Client #2 does not have an allergy to Hydrocodone or Morphine. Staff D stated that Client #2 was taking Hydrocodone prior to her admission into hospice. Staff D further stated that the Morphine was ordered as part of the comfort pack for the client in case of severe or end of life pain. During an interview with the Supervising Nurse and Alternate Administrator on 01/15/20 at 4:02 p.m., the above findings were reviewed and discussed. The Supervising Nurse stated that Client #2 was not allergic to Hydrocodone or Morphine and he did not know why they were included in the medication list as allergies. E. During the exit conference on 01/15/20 at 5:05 p.m., the Administrator and Supervising Nurse were informed that the agency had two additional business days to provide additional documentation for review. One business day after the exit, on 01/16/20, the agency submitted the following documentation for Client #1: a physician order dated 01/15/20 and signed by the hospice physician on 01/15/20, which read in part, "...Oxygen...start date 11/26/19...2 - 5 LPM (Liters per minute) as needed...SOB (shortness of breath)..." The agency also submitted a plan of care for Client #1 for the benefit period 11/26/19 to 2/23/20 which read in part, "...DME and supplies...Oxygen supplies..." One business day after the exit, on 01/16/20, the agency submitted the following documentation for Client #2: a coordination note dated and entered by Staff D on 09/30/19, which read in part, "...spoke with...pharmacy and reviewed allergies to...Tylenol/Norco...Morphine not true allergy...spoke with daughter...doctor...aware..." The agency also submitted an updated "Client Medication Report" for Client #2 dated 01/16/20, which read in part, "...Client Allergies...Hydrocodone voided 01/15/20...Codeine voided...01/16/20...Morphine voided 01/16/20..." The Alternate Administrator provided a census of 175 clients from the active client lists on 01/15/20.