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
971593 A. BUILDING __________
B. WING ______________ 		02/15/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
ABUNDANT HOSPICE, LLC 12500 SAN PEDRO AVE STE 150, SAN ANTONIO, TX, 78216
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      
26151 Based on record review and interview, the Supervising Nurse failed to ensure that care was provided according to the patient's plan of care (POC) for two of three of patients (Patients #2 and #3), whose records were reviewed, in that: 1. Patient #2 did not receive Skilled Nurse (SN) visits as ordered in the POC. 2. Patient #3 did not receive SN visits as ordered in the POC. This failure placed Patients #2 and #3 at risk of not having their needs met and could result in negative client outcomes, which could also affect the agency's other 30 active patients. The findings included: Review of Patient #2 electronic clinical record (ECR) revealed an (interdisciplinary group/plan of care) IDG/POC dated 02/02/22 for benefit period 12/20/21-02/17/22 which included orders for skilled nurse (SN) visits of 2 times a week plus four prn (as needed) visits for symptom management. Continued review of the IDG/POC dated 02/02/22, under "Summary/Comments" read in part: "IDG meeting held today...POC's have been updated and discussed with the IDT (interdisciplinary team) to ensure individualized care...Agency will continue to provide care per the POC discussed..." Review of Patient #2's ECR revealed the following skilled visits made: Week of 12/26/21 only one SN visit was made on 12/28/21. Week of 01/02/22 only one SN visit was made on 01/04/22. Week of 01/09/22 only one SN visit was made on 01/12/22. Week of 01/16/22 only one SN visit was made on 01/18/22. Week of 01/23/22 only one SN visit was made on 01/25/22. Week of 01/30/22 only one SN visit was made on 02/02/22. Continued review of Patient #2's ECR included the following physician's orders: 12/27/21: change certified nurse aide (CNA) frequency, 1 weekly to 3 X weekly (one time a week to 3 times a week). 02/02/22 Chaplain 1 X/monthly (one time per month). 02/09/22 Verbal orders: recertify CTI (Certificate of Terminal Illness). Continued review of Patient #2's ECR did not reveal physician's orders for change in SN visit frequencies to once a week. Review of Patient #3's ECR revealed an IDG/POC dated 02/02/22 for benefit period 01/07/22 - 03/07/22 which included orders for SN visits of 2 times a week plus four prn visits for symptom management. Continued review of the IDG/POC dated 02/02/22, under "Summary/Comments" read in part: "IDG meeting held today...POC's have been updated and discussed with the IDT (interdisciplinary team) to ensure individualized care...Agency will continue to provide care per the POC discussed..." Review of Patient #3's ECR revealed the following skilled visits made: Week of 01/02/22 only one SN visit was made on 01/05/22. Week of 01/09/22 only one SN visit was made on 01/12/22. Week of 01/16/22 only one SN visit was made on 01/21/22. Week of 01/23/22 only one SN visit was made on 01/27/22. Week of 01/30/22 only one SN visit was made on 02/03/22. Continued review of Patient #3's ECR included the following physician's orders: 01/03/22: "Written Recertification for certification period 01/07/22 - 03/07/22. Continued review of the ECR did not reveal physician's orders for change in SN visit frequencies to once a week. In an interview and concurrent record review on 02/15/22 at 3:46 p.m., the Administrator/Supervising Nurse stated, "that the nurses are not putting in orders to change the SN visit frequencies to once a week and the SN visit frequencies were not being updated in the patient's record to once a week." Review of the agency's policy (LD. 6) titled, "Responsibilities of the Supervising Nurse", revised dated 01/01/18 read in part: "The responsibilities of the supervising nurse include, but are not limited to...Ensuring that a patient's POC is executed as written."
L0617      
26151 Based on personnel record review and interview, the agency failed to ensure that two of two Hospice Aides (HA F and HA G) whose personnel records were reviewed, were trained, observed, and evaluated by a RN prior to providing patient care. This failure could result in the Hospice Aides providing unsafe or incompetent care to agency patients. The findings Included: During the Entrance Conference on 02/10/22 at 3:07 p.m., with the Administrator/Supervising Nurse, the Surveyor requested and received a list of the Agency's Active Employees with their hire dates. Review of the Agency's active Employee list provided by the Administrator/Supervising Nurse revealed four hospice aides. Review of HA F's personnel record revealed a document titled, "Hospice/Home Health Aide Job Description" signed and dated on 12/06/21 by HA F's and by the (human resource coordinator) HRC on 12/7/21, that read in part: "Job Qualification - Education - Has successfully completed the Training program and Competency evaluation that complies with regulations...Skills: "...Must pass Aide Competency Evaluation Skills Checklist...and written skills test." Continued review of HA F's personnel record revealed an Agency form titled "Hospice Aide Competency Evaluation and Written Exam" it was signed and dated on 12/06/21 by HA F and also signed and dated by the HRC on 12/07/21 and not by a Registered Nurse. The space titled "Scored by" (which was where the signature was required) was left blank. Review of HA G's personnel record revealed a document titled, "Hospice/Home Health Aide Job Description" signed and dated on 10/28/21 by HA G's and by the HRC on 10/29/21, that read in part: "Job Qualification - Education - Has successfully completed the Training program and Competency evaluation that complies with regulations...Skills: "Must pass Aide Competency Evaluation Skills Checklist...and written skills test." Continued review of HA G's personnel record revealed an Agency form titled "Hospice Aide Competency Evaluation and Written Exam" it was signed and dated by HA G on 10/28/21 and also signed and dated by the HRC on 10/29/21 and not by a Registered Nurse. The space titled "Scored by" (which was where the signature was required) was left blank. In an interview and concurrent record review conducted on 02/15/22 at 2:47 p.m., with the Administrator/Supervising Nurse and the HRC, the surveyor presented the above findings. The Administrator/Supervising Nurse and the HRC agreed with the following: -Hospice Aide Competency Evaluation and Written Exam for 2021 for HA F and HA G were not signed by an RN as required by regulation. The Administrator/Supervising Nurse stated that, "Competency A and B must be signed off by an RN." Review of the agency's policy (HR. 9) titled, "Hospice Aide / Homemaker Competency Evaluation", revised date of 01/01/18, read in part: "The Competency evaluation and skills checklist, administered by a Registered Nurse (RN)...The RN will sign date and include direct observation of the RN of all required skills. "