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
741664 A. BUILDING __________
B. WING ______________ 		01/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CIMA HOSPICE 4444 CORONA DR STE 234, CORPUS CHRISTI, TX, 78411
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)
L0580      
36596 Based on record review and interview, the agency failed to enforce a written policy to control infections and communicable diseases that included requirements to document infections that the clients acquired while receiving services from the agency, in that the Agency had not documented a wound infection acquired by Client #1 while receiving service form the Agency, thus not maintaining a coordinated agency-wide program for the surveillance, identification, and investigation of infections. Failure to document all clinical infections acquired while receiving services from the agency, provides an inaccurate picture for the identification of trends, and affects quality assessment and performance improvement (QAPI) activities. The Findings included: Review of the Agency's Policy and Procedures manual revealed a policy titled "Infection Prevention and Control Program", IC.1, with a revision date of 04/08/19. It read as follows: "1.4 - Documentation will include at a minimum: -Date infection was detected -Clients name -Primary diagnosis -Signs/Symptoms -Type of infection -Pathogen identified, if any -Treatment and... All reported infections will be documented on the appropriate Agency form..." Continued review of the Infection Prevention and Control Program policy read in part: "1.1 -The Quality Assessment and Performance Improvement program (QAPI) committee will be responsible for coordinating all activities related to the Infection Control Program. 1.5 - The Infection Control Program is a part of the Agency's QAPI." Further review of the Infection Prevention and Control Program policy read in part: "1.6 - Summaries of reviews, trend composites, recommendations and related performance improvement activities will be maintained by the Agency." Review of the Agency's Electronic Infection Control Log revealed an Agency form titled "Hospice Infections". In an interview conducted on 01/27/21 at 09:47 a.m. with the Alternate Administrator/Alternate Director of Nursing (AA/ADON). The AA/ADON identified that the electronic form was used by the agency to document all reported infections. Review of Client #1's clinical record revealed a Skilled Nurses (SN) Note that was dated 10/01/20 and signed by Registered Nurse (RN) B. It read in part: "Performed wound care during the nursing visit and patient tolerated wound care well. Physician A ordered to start Client #1 on Clindamycin 300 mg's daily X's 7 days, (according to drugs.com Clindamycin is an effective antibiotic used for a variety of serious infections) due to foul smelling odor from wound. Continued review of the Electronic Infection Control Log for the month of October 2020 failed to reveal any documentation of Client #1's name, the date the infection was detected, the primary diagnosis, any signs or symptoms, the type of infection the pathogen identified, or any treatments provided. During an interview conducted on 01/27/21 at 10:20 a.m. with the Administrator/Director of Nursing (Adm/DON) and the AA/ADON, the Surveyor presented the above finding and asked if Client #1's wound infection had been documented. After review of the Electronic Infection Control Log the AA/ADON stated "No it was not documented." The Agency did not dispute the survey findings and did not provide any additional evidence to explain or correct the findings by the time of exit on 01/27/21 at 10:48 a.m.