PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 000

Purpose of Visit: Complaint Investigation
Entrance Date: 10/02/15
Census: Hospice - 210 patients
Intake: 63980, 60956, 64318
Substantiated
Exit Date: 10/29/2015
L 546 418.56(c)(1) CONTENT OF PLAN OF CARE

L 546

[The plan of care must include all services
necessary for the palliation and management of
the terminal illness and related conditions,
including the following:]
(1) Interventions to manage pain and symptoms.

This STANDARD is not met as evidenced by:
Based on record review and interview, the
agency failed to provide interventions or care
consistent with current standards of practice
regarding pain and symptom management for
patients on Continuous Care. There was no
documentation of how the intervention for pain or
symptom management was chosen or guided.
The agency's protocol regarding Continuous Care
was not followed nor was there appropriate
documentation available to support the
medication regimen for Continuous Care patients
in 10 (Patients #1, #2, #3, #4, #5, #6, #8, #10,
#12, #13) of 13 patients whose records were
reviewed. The agency had no active patients on
Continuous Care at the time of the investigation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

(X6) DATE

TITLE

12/23/2015
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 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.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 1 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 1

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

This failure resulted in the overmedicating for
symptom management with excessive
medication. This had the potential to affect 210
active patients who are at risk to be
overmedicated when receiving Continuous Care.
Findings include:
The number of current patients also potentially
affected was provided by the agency's
Administrator on 10/07/2015.
Review of the agency's protocol for Continuous
Care titled NOVUS HEALTH SERVICES
Continuous Care Requirements read in part: ..."
7) Uncontrolled Respiratory distress, Patients
breathing pattern is above 30 for longer than 5
minutes, low B/P (blood pressure), fever,
Rapid/ineffective heart rate...Documentation
required 1. Respiratory Rate 2. Medications given
and effectiveness. ... "
On 10/07/2015 at 1:45 P.M. the agency provided
the policy manual and a notebook which was
identified as a Continuous Care notebook. The
notebook contained the NOVUS Continuous Care
Requirements hand out and several pages of
blank Nursing notes for Continuous Care. In an
interview on 10/07/2015 at 2:00 P.M. with a
registered nurse RN/M the surveyor asked about
the notebook and RN/M replied that it was for the
nurses write their assessment and notes
regarding the care of the client on Continuous
Care. She also said the notebook is kept in the
patient's room and taken to the office when the
patient is no longer on Continuous Care.
During an interview on 10/29/15 at 3:10 P.M. with
the Administrator (Employee A), the surveyor
asked if he was familiar with the NOVUS
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 2 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 2

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

Continuous Care Requirements hand out which
was placed in the Continuous Care notebook.
Employee A said he was not familiar with the
hand out. The surveyor asked Employee A to
review the document and if he considered the
handout the agency's protocol for Continuous
Care. Employee A said was the agency's protocol
for Continuous Care.
Patient #1
Review of the Patient #1's Plan of Care dated
9/12/2014 documented a diagnosis of Senile
Degeneration of the Brain. The document titled
"PHYSICIAN ORDER" for Patient #1 on
10/25/2014 read. ... " Admit to Continuous Care
for restlessness and respiratory depression. "
Listed on the agency's form titled "PHYSICIAN
ORDER for Comfort Orders" on 10/25/2014 was
Morphine Concentrate 20 milligrams/milliliter, give
0.25-2 milliliter PO/SL (orally/under the tongue)
every hour PRN (as needed) for Pain/SOB
(shortness of breath. . The time the order was
received was not given on the form.
On 10/25/14 the licensed vocational nurse
(LVN/Q) documented in the "Nursing Note" at
5:00 P.M. that she was unable to obtain a blood
pressure and that Patient #1's respirations were
8. LVN/Q administered Morphine 2 milliliters (20
milligrams/milliliter)and did not indicate the
reason for the Morphine.
On 10/25/14 at 6:00 P.M. and 7:00 P.M. the notes
revealed that (LVN/Q)medicated Patient #1 with
Morphine concentrate 2 milliliters (20 milligrams/
milliliter) under the tongue.
On 10/25/2014 LVN/Q administered Morphine
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 3 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 3

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

concentrate 1-2 milliliters (under the tongue) 10
times from 12:00 P.M. to 7:00 P.M. to " maintain
comfort. "
On 10/26/14 at 2:30 P.M. LVN/R documented in
the "Nursing Note" Patient #1 had apnea of 3 to 4
seconds and "was resting with eyes closed."
On 10/26/2014 the Continuous Care note
revealed that LVN/Q administered Patient #1 with
Morphine 2 milliliters (20 milligrams/milliliter) 3
times from 8:30 A.M. to 10:30 A.M. There was no
documented response to the medication
administration. LVN/Q continued to administer the
medication even though there was no
documentation of pain or respiratory distress.
Patient #1 was pronounced deceased at 11:17
A.M. on 10/26/2014.
The agency's failure to follow their Continuous
Care protocol could have resulted in Patient #1
being overmedicated.
Patient #2
Review of the Patient #2's Plan of Care dated
7/1/2015 documented a diagnosis of Alzheimer's
Disease secondary to Dementia. The document
titled "PHYSICIAN ORDER for Continuous Care"
on 7/1/2015 read. ... " Admit Continuous Care for
pain and terminal anxiety." The document titled
"PHYSICIAN ORDER for Comfort Orders" on
7/1/2015 read Morphine Concentrate 20
milligrams/milliliter, give 0.25-2 milliliter PO/SL
(orally/under the tongue) every hour PRN (as
needed) for Pain/SOB (shortness of breath).
On 7/5/2015 LVN/S administered Morphine
concentrate 2 milliliters (under the tongue) 9
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 4 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 4

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

times from 8:00 A.M. to 4:00 P.M. for
pain/shortness of breath. There was no
documented response to the medication
administration. LVN/S continued to administer the
medication even though there was no
documentation of Patient #2's pain or shortness
of breath.
On 7/5/2015 at 5:20 P.M. LVN/S documented he
was unable to obtain a blood pressure or heart
rate and that Patient #2's pupils were fixed and
dilated.
On 7/5/2015 Patient #2 was pronounced
deceased at 5:20 P.M. via telephone by the
hospice physician (MD/G). There was no
documented response to the medication
administration. LVN/S continued to administer the
medication even though there was no
documentation of pain or respiratory distress.
The agency did not follow their Continuous Care
protocol for Patient #2 which could have resulted
in Patient #2 being overmedicated.
Patient #3
Review of the Patient #3's Plan of Care dated
7/2/2015 documented a diagnosis of Alzheimer ' s
Disease secondary to Dementia. On 7/3/2015 the
agency's document titled "PHYSICIAN " for
Patient #3 read. ..." Begin CC (Continuous
Care)when available terminal restless. ..." The
document titled "PHYSICIAN ORDER for Comfort
Orders" on 7/3/2015 was written for Morphine
Concentrate 20 milligrams/milliliter, give 0.25-2
milliliter PO/SL (orally/under the tongue) every
hour PRN (as needed) for Pain/SOB (shortness
of breath).
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 5 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 5

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

On 7/6/2015 LVN/R medicated Patient #3 with
Morphine 2 milliliters (under the tongue) 4 times
from 7:00 P.M. to 10:30 P.M. for pain/shortness
of breath and " symptom management. "
On 7/7/2014 LVN/R documented the
administration of Dilaudid 1 -2 milliliters (8
milligrams/milliliter) 9 times from 11:30 P.M. to
7:30 A.M. The "Nursing Note" note indicated the
respirations had been 10. There was no
documented response to the medication
administration.
LVN/R continued to administer the medication
even though there was no documented
respiratory distress, pain or symptoms.
The agency did not follow their Continuous Care
protocol for Patient #3 which could have resulted
in Patient #3 being overmedicated.
Patient #4
Review of the Patient #4's Plan of Care dated
10/4/2014 documented a diagnosis of Acute
Myeloid Leukemia. On 10/9/2014 the PHYSICIAN
ORDER for Client # 4 read. ... " Begin CC
(Continuous Care) when available for respiratory
distress and pain management. ... " The
document titled "PHYSICIAN ORDER for Comfort
Orders" on 10/9/2014 was written for Morphine
Concentrate 20 milligrams/milliliter, give 0.25-2
milliliter PO/SL (orally/under the tongue) every
hour PRN (as needed) for Pain/SOB (shortness
of breath).
On 10/11/2014 LVN/R documented on the
"Nursing Note" administered Morphine
concentrate (20 milligrams/milliliter) 2 milliliters
via a nebulizer at 10:30 P.M. (breathing
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 6 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 6

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

apparatus) for pain/shortness of breath.
On 10/11/2014 LVN/R administered Morphine
concentrate 2 milliliters (under the tongue and via
nebulizer) 12 times from 8:00 P.M. to 5:30 A.M.
On 10/12/2014 LVN/Q administered Patient # 4
with Morphine 2 milliliters (20 milligrams/milliliter)
9 times from 7:00 A.M. to 3:30 P.M.
There was no documented response to the
medication administration.
LVN/R and LVN/Q continued to administer the
medication even though there was no
documented respiratory distress or pain.
On 10/12/2014 Patient #4 was pronounced
deceased at 4:37 P.M.
The agency did not follow their Continuous Care
protocol for Patient #4 which could have resulted
in Client #4 being overmedicated.

Patient #5
Review of the Patient #5's Plan of Care dated
3/31/2015 documented a diagnosis of Heart
disease, unspecified. On 6/6/2015 document
titled "PHYSICIAN ORDER" for Patient #5 read.
... " Start cont care (Continuous Care)for terminal
restlessness and uncontrolled G.I. bleeding
(gastrointestinal. ... " The document titled
"PHYSICIAN ORDER for Comfort Orders" on
6/6/2015 was written for Morphine Concentrate
20 milligrams/milliliter, give 0.25-2 milliliter PO/SL
(orally/under the tongue) every hour PRN (as
needed) for Pain/SOB (shortness of breath). On
6/12/2015 the document titled "PHYSICIAN
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 7 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 7

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

ORDER" was written for Dilaudid 4
milligrams/milliliter PO/SL (orally/under the
tongue) 0.25-2 ml (milliliter every 1 hour PRN (as
needed) for increased severe pain or shortness
of breath.
On 6/12/2015 LVN/W documented on the
"Nursing Note" at 8:00 A.M. that Patient #5 was
unresponsive, lethargic, eyes closed and the
respirations were 14.
On 6/12/2015 LVN/W administered Dilaudid 2
milliliters (4 milligrams/milliliters) 5 times from
10:00 A.M. until 6:00 P.M.
There was no documented response to the
medication administration.
LVN/W continued to administer the medication
even though there was no documented
respiratory distress or pain.
On 6/12/2015 Patient #5 was pronounced
deceased at 7:40 P.M.
The agency did not follow their Continuous Care
protocol for Patient #5 which could have resulted
in Patient #5 being overmedicated.
Patient #6
Review of the Patient #6's Plan of Care dated
8/25/2015 documented a diagnosis of Heart
disease, unspecified. On 9/7/2015 the document
titled "PHYSICIAN ORDER" for Patient #6 read.
... " Begin cc (Continuous Care)when available for
terminal restlessness/respiratory. ... " The
document titled "PHYSICIAN ORDER for
Comfort Orders" on 9/7/2015 was written for
Morphine Concentrate 20 milligrams/milliliter, give
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 8 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 8

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

0.25-2 milliliter PO/SL/via nebulizer (orally/under
the tongue/breathing apparatus) every hour PRN
(as needed) for Pain/SOB (shortness of breath).
On 9/7/2015 at 7:00 P.M. LVN/R documented in
the "Nursing Note" that Patient #6 was lethargic,
pupils dilated, and the respirations were 12 with
10-15 seconds of apnea.
On 9/7/2015 LVN/R administered Morphine
concentrate 1-2 milliliters (under the tongue) for
pain/shortness of breath at 9:00 P.M. and 10:30
P.M.
On 9/8/2015 LVN/R administered Morphine
concentrate 4 times from 12:30 A.M. until 4:30
A.M. Morphine concentrate 180 milligrams of was
administered (under the tongue) to Patient #6
over 7 hours.
LVN/R continued to administer the medication
even though there was no documented
respiratory distress or pain.
The "Nursing Note" on 9/8/2015 at 6:00 A.M.
documented Patient #6 deceased.
The agency did not follow their Continuous Care
protocol for Patient #6 which could have resulted
in Patient #6 being overmedicated.
Patient #8
Review of the Patient #8's Plan of Care dated
9/11/2015 documented a diagnosis of Heart
Disease, unspecified. On 9/12/2015 the
document titled "PHYSICIAN ORDER" for Patient
#8 read. ..." Begin CC (Continuous Care)for resp
distress. ... " The document titled "PHYSICIAN
ORDER for Comfort Orders" on 9/12/2015 was
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 9 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 9

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

written for Morphine Concentrate 20
milligrams/milliliter, give 0.25-2 milliliter PO/SL
(orally/under the tongue) every hour PRN (as
needed) for Pain/SOB (shortness of breath).
On 9/12/2015 LVN/U documented in the "Nursing
Note" for that she administered Patient #8 with
Morphine concentrate (under the tongue) 0.75-1
milliliter 6 times from 10:30 A.M. to 2:30 P.M. for
shortness of breath. The "Nursing Note" at 12:30
P.M. indicated the respirations were 10. There
was no documented response to the medication
administration.
LVN/U continued to administer the medication
even though there was no documented
respiratory distress or pain.
On 9/12/2015 LVN/U at 3:02 P.M. documented in
the "Nursing Note" that Patient #8. ... "took last
breath."
The agency did not follow their Continuous Care
protocol for Patient #8 which could have resulted
in Patient #8 being overmedicated.
Patient #10
Review of the Patient #10's Plan of Care dated
5/13/2013 documented a diagnosis of Heart
Disease, unspecified. On 1/13/2014 the
document titled "PHYSICIAN ORDER" for Patient
#10 read. ... " Begin cc (Continuous Care)when
available, DX (diagnosis)pain management,
respiratory distress. ..." The document titled
"PHYSICIAN ORDER for Comfort Orders" on
1/13/2014 was written for Hydromorphone 4
milligrams/milliliter, 0.25-2 milliliter PO/SL
(orally/under the tongue) every hour PRN (as
needed) for Pain/SOB (shortness of breath).
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 10 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 10

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

On 1/13/2013 at 7:15 P.M. through 1/14/2013
6:15 P.M. LVN/X administered Hydromorphone 1
milliliter orally 5 times and LVN/Y administered
the medication 4 times.
An interview with a family member (FM/10) of
Client #10 was conducted via telephone on
10/16/2015 at 1:50 P.M. FM/10 said she was not
pleased with the care provided to Patient #10 and
decided to transfer to a different hospice agency
on 2/25/2014. The FM/10 stated an agency staff
member whose name she could not recall, asked
her to consider discontinuing all medications
except for the Comfort Medications. During the
interview, FM/10 named the hospice doctor " Dr.
Fax " because she said " the doctor never made
a visit. " The surveyor asked FM/10 if she had
requested a visit from the hospice physician
(MD/H) and she said yes but the physician did not
make the visit.
There was no documentation of respiratory
distress or symptoms.
The agency Administrator failed to supervise the
provision of quality care of Patient #10 and did
not follow their Continuous Care protocol which
could have resulted in Patient #10 being
overmedicated.
Patient # 12
Review of the Patient #12's Plan of Care dated
4/22/2015 documented a diagnosis of Senile
Degeneration of Brain. The document titled
"PHYSICIAN ORDER" on 6/14/2015 read. ...
"Begin CC (Continuous Care) for respiratory
distress and terminal restlessness. ... " The
document titled "PHYSICIAN ORDER for Comfort
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 11 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 11

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

Orders" on 7/1/2015 was written Morphine
Concentrate 20 milligrams/milliliter, give 0.25-2
milliliter PO/SL (orally/under the tongue) every
hour PRN (as needed) for Pain/SOB (shortness
of breath).
On 6/16/2015 LVN/R administered Morphine 4
times for shortness of breath from 1:00 A.M. until
6:00 A.M. when the respirations were
documented on the "Nursing Note" to be 6-8
breaths per minute. During the 7 hours LVN/R
also administered Lorazepam intensol 3 times
orally , A/B/H gel (Ativan/Benadryl/Haldol) to
wrist, Haldol 2 tablets via rectum, Thorazine
suppository via rectum.
On 6/16/2015 LVN/ZZ administered Morphine
(under the tongue) 2 milliliters for respiratory
distress at 7:00 A.M. when the respirations were
17.
There was no documented response to the
medication administration.
LVN/R and LVN/ZZ continued to administer the
medication even though there was no
documented respiratory distress or pain.
Patient # 12 was pronounced deceased at 7:40
A.M.
The agency did not follow their Continuous Care
protocol for respiratory distress which could have
resulted in Patient #12 being overmedicated.
Client # 13
Review of the Patient #13's Plan of Care dated
11/11/2014 documented a diagnosis of Senile
Degeneration of Brain. The document titled
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 12 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 12

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

"PHYSICIAN ORDER" for Continuous Care on
11/19/2014 read. ... " Continue CC (Continuous
Care) for terminal restlessness, uncontrolled pain
and resp. distress (respiratory distress). The
document titled "PHYSICIAN Order for Comfort
Orders" was written for Dilaudid 4 mg/ml
(milligrams/milliliter) PO/SL (orally/under the
tongue) PRN (as needed) for pain/SOB
(shortness of breath). ... "
On 11/20/2014 at 8:00 A.M. LVN/S documented
in the "Nursing Note" that Patient # 13. ... "very
lethargic, unresponsive, pale and cyanotic noted
with rapid respirations. ... " The vital signs on the
"Nursing Note"were blood pressure 86/41, pulse
77, and the respirations 28.
At 11:30 A.M. on 11/20/2014 LVN/S documented
Patient #13's response to the medication effective
and at 12:30 P.M. administered Dilaudid and
Lorazepam for pain and shortness of breath.

On 11/20/2014 LVN/S administered Dilaudid 5
times and Lorazepam intensol 3 times from 8:00
A.M. until 1:30 P.M.
LVN/S continued to administer the medication
even though there was no documented symptom
of respiratory distress or pain.
On 11/20/2014 at 3:11 P.M. Patient #13 was
pronounced deceased by MD/F via telephone.
The agency Administrator failed to supervise the
provision of quality care to Patient #13 and did
not follow their Continuous Care protocol which
could have resulted in Patient #13 being
overmedicated.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 13 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 546 Continued From page 13

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 546

On 10/29/2015 at 3:15 P.M. during an interview
with the Administrator (Employee A) the surveyor
told Employee A that the nurses were not
following the agency's protocol for the Continuous
Care symptom management. Employee A's
response was that the agency provides ongoing
training for the Continuous Care nurses and he
will speak with them about the medication issues.
L 682 418.104(e)(1) DISCHARGE OR TRANSFER OF
CARE

L 682

(1) If the care of a patient is transferred to another
Medicare/Medicaid-certified facility, the hospice
must forward, to the receiving facility, a copy of(i) The hospice discharge summary; and
(ii) The patient's clinical record, if requested.

This STANDARD is not met as evidenced by:
Based on observation, review of records and
interview, the hospice failed to prepare and send
a Discharge Summary to receiving agencies for
176 patients who were transferred to other
Medicare certified hospices.
Failure to ensure Discharge Summaries were
completed and sent to the receiving agencies for
the 176 patients posed a risk that these patients
would go without necessary medical care, and
durable medical equipment and that necessary
health care would not be coordinated with
receiving agency.
The agency had 34 additional patients with the
potential to be impacted if the agency failed to
complete the Discharge Summary at the time of
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 14 of 15

 PRINTED: 04/14/2016
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

C
671710

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2595 DALLAS PARKWAY #440

NOVUS HEALTH SERVICES
(X4) ID
PREFIX
TAG

10/29/2015

FRISCO, TX 75034

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

L 682 Continued From page 14

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

L 682

transfer or discharge.
FINDINGS:
Review of the agency's policy titled PATIENT
TRANSFER/AGENCY DISSOLUTION NOTICE,
PE.5, Page 2 of 4 read in part. ..." 9. Prior to
transfer, the Agency will provide the receiving
agency with the following: Discharge summary, to
include services being rendered, Specific Care,
Medication...10. The Discharge Summary will
include : Summary of the patients stay including
treatments, symptoms, and pain management...".
The Administrator (Employee A) was asked
during the interview on 10/29/2015 at 3:45 P.M. if
there were discharge summaries on the 176
patients who had been transferred to other
agencies and Employee A answered no.
Employee A said the registered nurses who had
case managed the patients resigned from the
agency without writing the discharge summaries.
He told the surveyor he expected a deficiency for
not having the discharge summaries.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: JUHP11

Facility ID: 7006082

If continuation sheet Page 15 of 15