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
741790 A. BUILDING __________
B. WING ______________ 		12/23/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
VMS PALLIATIVE HOSPICE CARE LLC 9898 BISSONNET STREET, STE. 4300, 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)
L0544      
32043 Based on interview and record review the agency failed to ensure the patient and the patient's primary caregiver received education and training from RN #52 for 1 of 3 patients (#1) who received wound care by RN #52, in that: The agency had no documentation to describe the patient's or the patient's primary caregiver's response to the teaching, including the level of understanding and the ability to report or demonstrate what was taught regarding wound care as ordered by RN #52. Failure of the agency to ensure that patients and patient's caregivers received detailed education and training in care for which they may be responsible for places all patients at risk of deterioration of a patient's health condition. Findings include: Record review of agency's policy titled "The Plan of Care", revised April 2017, read in part: "As needed, the client and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the client and family/caregiver to provide or follow through with." Record review of agency's policy titled "Client Education Process", revised April 2017, read in part: "Clients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by assessed needs, abilities, learning preferences, and readiness to learn of the client and family/caregiver, as well as by the plan of care." "Documentation of client and family/caregiver education will consist of: A. Describing what was taught to the client. B. Describing the client's response to the teaching, including the level of understanding and the ability to repeat or demonstrate what was taught." Patient #1: Record review of Patient #1's CR revealed SOC on 10/07/2020 with hospice diagnosis of end-stage Parkinson's disease. Physician admitting orders dated 10/07/2020 showed wound care order: "Cleanse stage IV wound to sacrum with normal saline, part dry, apply silver alginate, and cover with bordered [guaze] twice weekly by hospice nurse and trained caregivers and as needed for dislodgement." Record review of the POC for the benefit period 10/07/2020 - 12/16/2020 showed interventions for sacral wound care to include teach and/or demonstrate good or preventive skin care and provide/educate on wound care as ordered. Record review of the initial comprehensive assessment showed no documentation that caregivers were taught on wound care. Patient #1's CR also did not include what the caregivers are were responsible for regarding wound care and what training was given to the caregivers on wound care. Interview with Staff #51/DON on 12/22/2020 at 12:23 p.m., stated that Patient #1 resides in ALF #103. Staff #51 added that RN #52 provided wound care to the patient twice weekly. Staff #51 was asked what would happen if the wound dressing would get soiled. Staff #51 stated that the caregivers were instructed on how to change the wound dressing. Staff #51 explained that the caregivers were only instructed to change the gauze cover on the wound when soiled with feces to prevent the wound from getting contaminated with feces, then notify the agency and the nurse will would go out to do the wound dressing change. Staff #51 was asked for the documentation of the training provided to the caregivers on the wound care. Staff #51 provided an in-service and training record dated 12/09/2020. Interview follow-up was conducted with Staff #51 on 12/23/2020 at 11:52 a.m., she was asked if Patient #1's caregivers were trained on wound care on admission. Staff #51 stated that the caregivers were educated upon admission to change the gauze on the wound when it is soiled with feces. Staff #51 added that the training was documented in the RN initial assessment. Staff #51 then reviewed the initial comprehensive assessment with surveyor and the staff acknowledged that there was no documentation of the training in the note. Staff #51 added that she must have forgotten to document the training. Interview with Staff #52/RN on 12/23/2020 at 1:55 p.m., she stated that she provided wound care twice weekly to Patient #1. Staff #52 also stated that the client's caregiver could change the wound dressing as needed if the dressing was soiled with feces. Staff #52 was asked if the caregivers were trained to provide the wound care. Staff #52 stated that the caregiver were present whenever she provided wound care to the client because the caregivers assisted with repositioning the client. Staff #52 added that since the caregivers were present when she provided the patient's wound dressing, the caregivers learned to do the wound care by observing her provide the care.
L0552      
32043 Based on interview and record review, the IDG failed to revise or update the POC for SN visits as ordered by a physician every 15 calendar days for 1 of 3 patients (#1) whose record was reviewed, in that: The POCs for SN visits for Patient #1 were not updated or revised every 15 calendar days according to physician orders. Failure of the agency to ensure that POCs are reviewed and revised potentially places all patients at risk of harm due to the IDG not making the necessary POC revisions as order that direct the care and services of patients. Findings include: Record review of agency's policy titled "Interdisciplinary Group Plan of Care", revised April 2017, read in part: "The interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every 15 calendar days ... ... ... ..." Patient #1: Record review of Patient #1's CR revealed SOC on 10/07/2020 with hospice diagnosis of end-stage Parkinson's disease. Record review of Physician admitting orders dated 10/07/2020 showed frequency of SN visits twice weekly. Record review of IDG POCs for the benefit period 10/7/2020 - 12/16/2020: POC dated 10/21/2020 showed the SN frequency once weekly; POC dated 11/04/2020 showed the SN frequency once weekly; POC dated 11/18/2020 showed the SN frequency once weekly; POC dated 12/02/2020 showed the SN frequency once weekly; and POC dated 12/16/2020 showed the SN frequency once weekly. The above POCs did not show the frequency of SN visits twice weekly. Record review of Physician order dated 12/09/2020 changed the SN frequency to three time a week on Mondays, Wednesdays & Fridays. Record review showed Patient #1 was discharged to an inpatient facility on 12/16/2020. Interview with Staff #51/DON on 12/23/2020 at 11:52 a.m., was asked why physician orders have SN frequency as twice weekly and IDG POCs showed SN frequency once weekly. Staff #51 stated that initially, the frequency was ordered as once weekly, but after completing the admission assessment, she called the physician and received order for SN twice weekly because of the wound care. Staff #51 was asked how often IDG reviewed the POC. Staff #51 stated that the IDG reviewed the POC during the IDG meeting conducted every other Wednesday an the agency office. Staff #51 was asked why SN frequency was not revised or updated on the POCs. Staff #51 stated that the SN frequency not being updated was an oversight. Staff #51 added that she was responsible for updating the POCs based on the recommendations agreed on by the IDG.