Bethany Hospice, LLC
Georgetown, Texas · CCN 671517
2913 Williams Drive, 320
30 federal deficiencies across 3 surveys, January 6, 2023 to February 20, 2026.
Excludes the inspector’s preamble, which is not a finding
Federal surveys with at least one deficiency
Findings against a Condition of Participation — a compliance grade, not a measure of harm
What level the findings sit at
- Condition-level13.3%
- The agency was out of compliance with a federal Condition of Participation — a requirement it must meet to take part in Medicare at all.
- Standard-level2996.7%
- A requirement within a Condition of Participation. The Condition itself was not cited.
These are compliance grades, not harm grades: how deep in the regulation a finding sits, not whether anyone was harmed.
Who conducted the surveys
ACHC.
Federal surveys are carried out by the state agency or a CMS-approved accrediting organisation.
Most-cited requirements
- L0530Content of Comprehensive Assessment3
- L0549Content of Plan of Care3
- L0523Timeframe for Completion of Assessment2
- L0540Approach to Service Delivery2
- L0545Content of Plan of Care2
Survey record
Condition-level
| Survey | Type | Deficiencies | Condition-level |
|---|---|---|---|
| Feb 20, 2026 | Follow-Up | 4 | — |
| Jan 9, 2026 | Reaccreditation | 17 | 1 |
| Jan 6, 2023 | Reaccreditation | 9 | — |
In the inspector’s words
The complete written findings for this hospice, in the inspector’s own words.
Hospice findings published by CMS on QCOR, covering surveys from January 6, 2023 to February 20, 2026. The inspectors’ written findings come from a single CMS survey-report extract.
Federal survey findings only. State licensure findings for hospices are not shown.
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