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
971590 A. BUILDING __________
B. WING ______________ 		10/05/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
SUNCREST HOSPICE SAN ANTONIO LLC 911 CENTRAL PARKWAY N SUITE 100, SAN ANTONIO, TX, 78232
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)
L0578      
27459 Based on interview an record review, the agency failed to enforce a written policy to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for one of three active patients (Patients #3) and for two of two inactive patients (Patients #4 and #5) whose records were reviewed, in that: 1. Patients #3 and #4 were prescribed antibiotics (kills infections) and it was not recorded in the infection control log; and 2. Patient #5 had COVID-19 (worldwide infection) and it was not documented in the infection control log. This deficient practice could place the active patients at risk of receiving adequate care when the agency does not track and trend antibiotic use and surveillance of infections occurring at the agency. The findings included: 1. Review of the agency's policy titled "Evaluating and Maintaining Records of Infections Among Patients" dated 4/2019 revealed in part "...All patients with a new, actual, or suspected infection will have a patient infection report completed within 24 hours of discovery...1. The Infection Identification Patient Report form is completed when any of the following occur: A. A new, actual, or suspected infection is clinically observed by personnel, C. a new antibiotic is ordered, D. A patient is admitted to a hospital due to an actual or suspected infection...2. The Case Manager or the nurse caring for the patient in his/her absence should complete the Infection Identification Patient Report within 24 hours of discovering the infection..." 2. Review of the agency's "Infection Report Log" (white binder) dated 2021 revealed no documented evidence that a patient infection report form was completed for Patients #3, #4, and #5. 3. Review of Patient #3's clinical record revealed a POC with a SOC date of 3/26/21 for a certification period from 9/22/21 through 11/20/21 with a diagnosis of Unspecified Arteriosclerosis Native Arteries (the build-up of fats, cholesterol, and other substances in and on the artery walls), and Neurogenic bladder (problems with the nervous system affecting the bladder and urination) and the Patient had an indwelling urinary catheter (a hollow tube that is inserted into the bladder to drain urine into a bag found outside the body). Further review revealed to provide catheter care once a week and to change the urinary catheter every 30 days and as needed. Additional record review revealed SN frequency: 1-2 times per week for 8 weeks and HHA visit frequency: two times a week. Moreover, the POC revealed in section titled "Brief narrative statement: This benefit period the patient was given antibiotics for a UTI when she was confused..." Review of "Medication List" (undated) revealed the Patient #3 received "Ciprofoxacin HCL (antibiotic) 500 mg tab take one tablet by mouth two times a day with a start date on 8/31/21." During an interview on 10/5/21 at 2:30 p.m., with RN A she stated Patient #3 was confused so the Medical Director put her on an antibiotic for a suspected UTI. 4. Review of Patient #4's "Discharge Summary" dated 5/9/21 revealed a SOC on 8/25/20 and was discharged on 5/9/21 with a diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions) and Hypertension heart disease (heart problems that occur because of high blood pressure that is present over a long time). Further review revealed the Patient's FM wanted the Patient transferred to the hospital due to BLE swelling...Patient was transferred/admitted to the hospital with a diagnosis of cellulitis (swelling an inflammation of the tissues)." Review of Client #4's clinical record revealed a SOC on 5/11/21 for a POC certification period from 5/11/21 to 7/9/21 with a diagnosis of Heart Failure and the client was being admitted from the hospital for hospice services. Further review revealed the client was receiving Augmentin (antibiotic) 875-125 mg oral tablet, take 1-tab po every 12 hours for infection (start date 5/11/21). Review of the "Hospice Initial Assessment" dated 5/11/21 revealed in part "Patient returned from hospital due to an exacerbation to include peripheral and pulmonary edema. Patient was suspected to have cellulitis to BLE and sepsis (infection of the blood)..." 5. Review of an e-mail (hospice case manager to the Alternate Administrator) dated 8/8/21 revealed in part "Client #5 is COVID 19 positive and is being isolated in the facility (assisted living) at this time, pharmacy to deliver meds this evening." Review of the Client #5's clinical record revealed a "Discharge Summary" dated 8/18/21 revealed a SOC on 7/23/21 and the client's last day of service was on 8/17/21 with a diagnosis of heart failure (inability of the heart to pump blood throughout the body) and was discharged to the hospital per family request..." 6. During an interview on 10/5/21 at 1:10 p.m., with the Alternate Administrator she stated that she will continue to look for the patient infection report for Clients #3, #4, and #5. During a second interview on 10/5/21 at 2:50 p.m. with the Supervising Nurse and the Alternate Administrator, the Alternate Administrator stated that the nurse or the case manager that identified the infection and/or ordered the antibiotic therapy should have completed a client infection report. The Supervising Nurse stated that she did not complete a client infection report for Client #5, and she should have. They further stated that it was an oversight and that they did not have a process to track clients who were prescribed antibiotics.