Every finding on record at Alamo Area Home Hospice, LP

Upon patient record review, 1 of 5 (Patient #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 3: The SN documented receiving an order from the MD for Oxybutynin 3/9/26. This was not added to the medication profile.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: The medical record contains evidence of an order for the foley to be changed every other week. The SN has not changed the foley since 3/9/26. The patient continues to have symptoms of leakage, UTI symptoms, and weekly flushes required.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The SN documented on 3/12/26, 3/25/26 that patient has a Peg tube in place they are not using it for feedings. There are no orders for a Peg tube on the POC for site care cleaning or flushing.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 4: The SN documented in IDG note 3/31/26 "the facility is flushing Peg tube twice a day." The POC was not updated to include problems/goals/interventions.

Upon client record review, 1 of 5 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The SN documented on 3/9/26 inserted a 20fr coude catheter inserted. There is no order for a 20fr coude catheter to be inserted. The current POC contains an order for foley irrigation once per week. On 3/13/26 the SN documented educated caregiver that foley can be flushed 2-3 times per week. The SN flushed the foley on 3/13 and 3/16/26 without an order to increase flushes. The SN did not irrigate the foley the week of 3/22-3/28/26 there was no evidence of refusal. On 3/20/26 the SN documented flushed foley with 30ml NS the order is for 60ml flush. The order on 2/27/26 is for changing the foley every other week the foley was changed on 3/9/26 and there is no evidence of the foley being changed up until current.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 3: The SN documented inserting a foley catheter on 3/9/26 though did not document how the procedure was tolerated. SN flushed the foley 3/13/26 and did not state how the patient tolerated the procedure.

Upon patient client record review, 2 of 5 (Patient #3,4) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 3: The SN documents on her biweekly visits that the order for the foley to be changed is every 30 days or as needed for blockage. The order on the POC 2/27/26 has foley to be changed every other week. Patient 4: The SN documented on 4/1/26 the patient does not have a feeding tube. The medical record contains evidence the patient does have a Peg tube and no evidence the feeding tube/Peg tube was discontinued.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 3: The SN documented receiving an order from the MD for Oxybutynin 3/9/26. The nurse did not transcribe the verbal order.

Upon client record review, 1 of 5 (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: The patient was admitted 3/28/26 with orders for SN 3 times per week. The SN made one visit that first week. There is no missed visit documentation or evidence of refusal.

Upon patient record review, 8 of 19 (Patients #2,#5,#6,#8,#10,#11,#12,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained active instructions for cephalexin that was ordered on 7/22/25, and dorzolamide-timolol eyedrops with no instructions for administration in one or both eyes. Patient 5: The medication profile contained instructions for oxygen to be delivered via nasal cannula in error. The order 2/10/26 identified administration of oxygen via a face mask. Patient 6: During home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained an additional acetaminophen PRN, calcium carbonate tablets, lidocaine patches, nitroglycerin, and protein oral liquid that were all missing from the hospice profile. The facility profile also contained instructions for lactulose 30 ml, differing from the hospice dose of 15 ml. Patient 8: The medication profile contained active instructions for cipro that was ordered for 7 days on 4/15/25. Patient 10: During home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained a guaifenesin PRN, morphine 0.5ml every 4 hours PRN instead of 0.25-1ml every 2 hours PRN, and the facility did not have hydrocortisone cream for feet on hospice profile, duoneb on hospice profile, and lorazepam on hospice profile. Patient 11: The plan of care identified patient use of oxygen. There was no evidence of oxygen included on the medication profile. The profile also contained conflicting instructions for senna lax administration. Patient 12: During home visit medication reconciliation the caregiver stated patient has not used the albuterol inhaler since November and there was no zofran or hyoscyamine present for administration if needed. The medication profile contained the inhaler as active. Patient 14: The plan of care identified oxygen use. There was no evidence of oxygen included on the medication profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 9 of 19 (Patients #3,#4,#5,#6,#7,#8,#9,#11,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patients 3,6: The plan of care contained problems, goals, and interventions related to oxygen use that were inaccurate for patients and added in error. Patient 4: The plan of care contained identification of the patient code status as both full code and DNR in error. Patient 5: The plan of care contained problems, goals, and interventions for care needs to be met by a hospice aide. The patient was not receiving aide services. Patient 7: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia requiring a pureed diet. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Patient 8: The medical record contained a prescription for Eliquis since admission. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient history of CVA and seizures, and use of oxygen. There was no evidence of problems, goals, and interventions related to neurological dysfunction and oxygen use included in the plan of care. Patient 11: The medical record contained a prescription for Eliquis since admission. There was no evidence of problems, goals, and interventions related to risk for bleeding included in the plan of care. Patient 13: The medical record contained nursing documentation upon admission identifying patient diagnosis of Alzheimer's dementia. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care.

Upon patient record review, 3 of 19 (Patients #3,#5,#9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 3: The recertification frequency order did not contain a frequency for nurse visits. Patient 5: The medical record contained an order 1/6/26 for two visits that week with no identification of discipline to deliver visits. Patient 9: The medical record contained an order 12/30/25 for two visits that week with no identification of discipline to deliver visits.

Upon patient record review, 7 of 19 (Patients #2,#6,#7,#8,#10,#11,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: The medical record contained an order for dorzolamide-timolol eyedrops with no instructions for administration in one or both eyes. Patient 6: During home visit medication reconciliation the facility and hospice medication orders did not match. The facility record contained additional orders for an extra acetaminophen PRN, calcium carbonate tablets, lidocaine patches, nitroglycerin, and protein oral liquid that were all missing from the hospice record. The facility orders also contained instructions for lactulose 30 ml, differing from the hospice order for dose of 15 ml. Patient 7: The medical record contained nursing documentation 2/10/26 identifying patient had an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency, and maintenance. Patient 8: The medical record contained nursing documentation 12/10/25 identifying patient requires a suprapubic catheter. There was no evidence of an order for catheter type, size, change frequency, and maintenance. Patient 10: During home visit medication reconciliation the facility and hospice medication orders did not match. The facility had an order for guaifenesin not on hospice, the order for morphine was for 0.5ml every 4 hours PRN instead of 0.25-1ml every 2 hours PRN, and the facility did not have hydrocortisone cream for feet in hospice orders, duoneb in hospice orders, and lorazepam in hospice orders. The hospice also had an order for oxygen with no delivery method and orders for catheters 1/15/26 and 1/20/26 with no identification of type, size, change frequency, and maintenance. Patient 11: The plan of care identified patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Patient 14: The plan of care identified oxygen use. There was no evidence of an order for oxygen rate, frequency, and delivery method.

Upon patient record review, 11 of 19 (Patients #1,#2,#3,#5,#6,#7,#8,#10,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, 1/13/26 identifying use of a commode, and 1/26/26 identifying use of a trapeze. During home visit, the patient was also observed to have a hospital bed, half rails, overbed table, transport wheelchair, and shower chair. There was no evidence of orders for the DME included in the plan of care. Patient 2,3: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Patient 5: The medical record contained nursing documentation 2/10/25 identifying patient use of oxygen. There was no evidence of an order for the DME included in the plan of care. Patient 6: The medical record contained nursing documentation 1/8/26 identifying patient use of a hospital bed, light touch call bell, fall mat, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Patient 7: The medical record contained nursing documentation 2/10/26 identifying patient use of oxygen, a mechanical lift, pressure relief boots, and catheter supplies. There was no evidence of orders for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon admission and 12/10/25 identifying patient use of a shower chair and catheter supplies. There was no evidence of orders for the DME included in the plan of care. Patient 10:The medical record contained nursing documentation upon admission identifying patient use of a walker, wheelchair, nebulizer, catheter supplies, hospital bed, and overbed table. There was no evidence of orders for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation 1/20/26 identifying patient use of a wheelchair and an order for duoneb to be administered via a nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation 12/16/25 identifying patient use of a Hoyer lift and scoop mattress. There was no evidence of orders for the DME included in the plan of care. Patient 14: The plan of care identified oxygen use. There was no evidence of an order for the oxygen DME included in the plan of care.

Upon client record review, 2 of 19 (Patients #6,#13) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 6,13: The medical record identified patient's attending physician was a community physician not related to hospice services. There was no evidence the IDG was in collaboration with the attending physician for plan of care revisions no less frequently then every 15 days.

Upon patient record review, 3 of 19 (Patients #5,#8,#14) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 5: The medical record contained nursing documentation identifying patient issues with nausea 1/5/26. There was no evidence the plan of care was updated to include problems, goals, and interventions related to nausea. Patient 8: The medical record contained nursing documentation 12/10/25 identifying patient requires a suprapubic catheter. There was no evidence the plan of care was updated to included problems, goals, and interventions related to the suprapubic catheter. Patient 14: The medical record contained nursing documentation 1/16/26 identifying patient use of oxygen. There was no evidence the plan of care was updated to include problems, goals, and interventions related to oxygen use and safety.

Upon client record review, 2 of 19 (Patients #3,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for recertification visit frequencies with no nurse visits ordered. Nurse visits were completed twice the first week of the benefit period then three times a week. Patient 9: The medical record contained an order for nursing visits once weekly. There was no evidence of a visit completed the week of 12/21/25.

Upon patient record review, 5 of 19 (Patients #2,#4,#7,#12,#13) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient needs. Patient 2: The medical record contained nursing documentation identifying patient wounds requiring bandages. There was no evidence of instructions for the aide to manage the wounds during showers on the aide care plan. Patient 4: The medical record contained nursing documentation 2/4/26 identifying patient need for max assist with transfers and wheelchair for ambulation. There was no evidence of instructions for use of chair and assistance with transfers on the aide care plan. Patient 7: The medical record contained wound care orders containing need for wound dressings. There was no evidence of instructions for wound management on the aide care plan. Patient 12: The medical record contained nursing documentation 1/20/26 identifying patient need for use of a wheelchair and max assist transfers. There was no evidence of instructions for use of a wheelchair and transfer instructions on the aide care plan. Patient 13: The medical record contained nursing documentation 12/16/25 identifying patient need for use of Hoyer for transfers. There was no evidence of instructions for use of a Hoyer on the aide care plan.

Upon patient record review 7 of 19 (Patients #1,#2,#3,#6,#7,#8,#9) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group Patient 1: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 12/7/25. Patient 2: The medical record contained an order for aide visits three times weekly. There was no evidence of third visit completed the weeks of 1/4/26, 1/26/26, and 2/8/26. There was also one visit completed the week of 2/1/26. Patient 3: The medical record contained an order for aide visits five times weekly. There was no evidence of a fifth visit completed the week of 1/25/26. Patient 6: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the weeks of 1/19/26, 1/26/26, and 2/1/26. Patient 7: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit completed the weeks of 12/21/25 and 12/28/25. Patient 8: The medical record contained an order for aide visits five times weekly. There was no evidence of a fifth visit completed the week of 1/25/26. Patient 9: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the weeks of 12/21/25 and 12/28/25.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer utilization rate was 0.97% for 2025.

Upon patient client record review, 2 of 19 (Patients #2,#12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 2: The election form identified the patient elected to receive the Notification of Hospice Non-Covered Items. There was no evidence the addendum was provided. Patient 12: The election form identified the patient elected to receive the Notification of Hospice Non-Covered Items upon admission 10/12/24. The addendum was furnished 11/12/24, outside the 5 day timeframe.

Upon patient client record review, 1 of 19 (Patient #8) did not have evidence that each patient record contains Advance Directives. Patient 8: The medical record's patient profile indicated patient has a health care power of attorney in place. There was no evidence the hospice received a copy of the documentation.

Upon client record review, 1 of 19 (Patient #10) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 10: The medical record contained catheter orders 1/15/26 and 1/20/26 that did not specify nursing facility or hospice responsibilities.

Upon patient record review, 2 of 19 (Patients #6,#10) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 6: There was no evidence the hospice provided the facility with the hospice election form, advance directives, and CTIs. Patient 10: There was no evidence the hospice provided the facility with CTIs.

Upon patient record review, 7 of 13 (Patient #1, #2, #3, #7, #11, #12, #13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile date 12/31/2022 included O2 2-4 L as needed for dyspnea, there was no evidence of a route. Dated 1/27/2023 included Medrol dose pak 4 mg oral as directed per instructions, there was no evidence of how to dispense the medication. Corrected on site. Patient 2: The medication profile dated 2/4/2023 include O2 2-4L daily for SOB. There was no evidence of a route. Corrected on site. Patient 3: The medication profile dated 12/15/2022 included Medihoney 80% topical gel application 1/2 inch to affected area. There was no evidence of a frequency or area to apply. Dated 1/11/2023 included Bactrim 400mg-80mg tab oral 2 x daily. There was no evidence of an end date. corrected on site. Patient 7: The medication profile dated 8/21/2022 included Oxygen 2L as needed SOB/Dyspnea. There was no evidence of a route. Corrected on site. Patient 11: The medication profile dated 4/6/2022 included Miralax 17G oral powder pak, one pk QD PRN constipation. There was no evidence of a diluent. Patient 12: The medication profile dated 6/28/2022 included O2 2-5L PRN SOB/Dyspnea, there was no evidence of a route. Patient 13: The mediation profile dated 6/8/2022 included Oxygen 2-5L PRN SOB/Dyspnea. There was no evidence of a route.

Upon patient record review, 3 of 13 (Patient #6, #8, #9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 6: SOC 10/27/2022, Bereavement assessment completed 11/7/2022. Patient 8: SOC 12/14/2022, Bereavement assessment completed 12/20/2022. Patient 9: SOC 12/22/2022, Bereavement assessment completed 1/2/2023.

Upon patient record review, 1 of 13 (Patient #4) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 4: There was no evidence of a comprehensive assessment update from 11/27/22-12/20/22.

Upon patient record review, 1 of 13 (Patient #5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 5: Admitted with Dysphagia after CVA, On SOC SN evaluation neuro assessment included dysphagia, with aspiration risk. There was no evidence of problem/interventions/goals for risk of aspiration on POC. Corrected on site.

Upon patient record review, 7 of 13 (Patient #1, #2, #3, #7, #11, #12, #13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The POC date 12/31/2022 included O2 2-4 L as needed for dyspnea, there was no evidence of a route. Dated 1/27/2023 included Medrol dose pak 4 mg oral as directed per instructions, there was no evidence of how to dispense the medication. Corrected on site. Patient 2: The POC dated 2/4/2023 include O2 2-4L daily for SOB. There was no evidence of a route. Corrected on site. Patient 3: The POC dated 12/15/2022 included Medihoney 80% topical gel application 1/2 inch to affected area. There was no evidence of a frequency or area to apply. Dated 1/11/2023 included Bactrim 400mg-80mg tab oral 2 x daily. There was no evidence of an end date. Corrected on site. Patient 7: The POC dated 8/21/2022 included Oxygen 2L as needed SOB/Dyspnea. There was no evidence of a route. Corrected on site. Patient 11: The POC dated 4/6/2022 included Miralax 17G oral powder pak, one pk QD PRN constipation. There was no evidence of a diluent. Patient 12: The POC dated 6/28/2022 included O2 2-5L PRN SOB/Dyspnea, there was no evidence of a route. Patient 13: The POC dated dated 6/8/2022 included Oxygen 2-5L PRN SOB/Dyspnea. There was no evidence of a route.

Upon client record review, 1 of 13 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: Order dated 1/17/2023 included SC visits weekly per family request. There was no evidence of a visit or missed visit for week of 1/17/2023.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: RN cleansed hands, did patient care, and reached into clean bag to retrieve thermometer and other materials without cleansing hands. Patient 7: RN placed dirty bp cuff and thermometer into clean bag, without cleansing.

Upon patient record review, 5 of 13 (Patient #1, #2, #5, #8, #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1, 2: Patient is on O2, aide assignment has no evidence of O2 precautions. Corrected on site. Patient 5: Admitted with Dysphagia after CVA, on SOC SN evaluation neuro assessment included dysphagia with aspiration risk. There was no evidence of aspiration precautions on the aide assignment. Corrected on site. Patient 8: On SOC SN narrative patient identified as risk for falls, included on POC. There was no evidence of fall precautions on the aide assignment. Corrected on site. Patient 12: Patient is on O2, aide assignment has no evidence of O2 precautions.

Upon patient record review, 1 of 13 (Patient #1) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient Patient 1: there was no evidence of physician certification and recertification or terminal illness in the SNF record. Corrected on site.