Survey Report for 741708

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	741708	A. BUILDING __________ B. WING ______________	08/13/2021
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
BRITE HEALTHCARE SERVICES	508 W LEWIS ST, CONROE, TX, 77301
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)
L0543
L0543	39332 Based on record review and interview, the hospice failed to ensure that all care and services furnished to patients and their families followed the individualized written Plan of Care established by the hospice interdisciplinary group in collaboration with the attending physician in that; The agency failed to provide hospice aide services as ordered in the Plan of Care for 1 of 2 patients (#1) whose records were reviewed. The failure to ensure that the plan of care was followed as ordered placed its patients at risk of decline due to the client not receiving adequate care. Findings included: The review of Client#1's clinical records revealed Client#1 was admitted to the hospice agency on 04/16/2021; the plan of care established by the interdisciplinary team contained a Start of Care dated 04/16/2021, with episode 04/16/2021 through 07/14/2021. The record review of Client#1's plan of Care revealed hospice Aide services were included in the Plan of Care; the Hospice Aide visit start date was 04/19/2021 with the frequency of two times a week. Further review of Client#1's clinical records revealed Client#1 revealed there was no record of a Hospice Aide visit. The review of Client#1's discharge records revealed Client#1's Hospice service was revoked on 04/28/2021. Interview with the Administrator and the Supervising Nurse/ RN Coordinator on 08/12/2021 at 11:15 AM the above findings were presented. The Administrator stated that "there was a breakdown in communication" about hospice aide assignment. The Supervising Nurse/ RN Coordinator stated that "It was my fault for not going behind, making sure that schedule was followed ... Hospice Aide G was the one who said she did not see her assignment ..." The Alternate Administrator added the issue has been identified, and a plan of action was in the agency's QAPI meeting. The Alternate Administrator also stated that Hospice Aide G was no longer working for the agency. The record review of the minutes of the QAPI provided to the surveyor reads in part; " ...Wrong HHA assigned ..." The QAPI minutes did not include documentation of a specific plan of action to prevent the recurrence of the issue. In a follow-up interview with the Alternate Administrator and the Supervising Nurse/ RN Coordinator on 08/12/2021 at 11:30 AM, the Supervising Nurse/ RN Coordinator stated that there was not enough space to document the specific plan of action on the minutes of the QAPI.