Every finding on record at Cadre Hospice - Texas LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations performed, the agency did not ensure that staff followed the agency's "Infection Prevention & Control in the Home Setting" policy. POLICY: The agency's "Infection Prevention & Control in the Home Setting" policy (Policy No. 6-008, dated 2Q/2023) stated in part, "Hand hygiene shall be performed at a minimum: F. After removal of PPE, including gloves." HOME VISIT 3: A home visit observation was conducted with the Registered Nurse (RN) (Personnel Record 2) on 06/17/2025. During the visit, the RN was observed handling her tablet without performing hand hygiene after removing gloves on several occasions. The RN (Personnel Record 2) was interviewed on 06/17/2025 and stated, "I thought I cleansed my hands every time after removing my gloves, but I appreciate the feedback and will improve."

It is required that medical social services are provided by a qualified social worker per the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, the agency did not ensure that the written plan of care was followed by the social worker. CLINICAL RECORD 2: A review of the clinical record revealed that the patient elected the hospice benefit and was admitted to hospice care on 04/19/2025. The Plan of Care (POC) dated 04/22/2025 included an order for social work visit frequency of one visit per week for one week starting on 04/21/2025. The updated POC dated 05/14/2025 included a social work visit frequency of twice a month for three months starting 04/19/2025. There were documented social work visits made on 04/23/2025 and on 05/30/2025. The social worker made only one visit each month for two months and did not provide services as ordered in the POC. The Administrator (Personnel Record 1) was interviewed on 06/18/2025 and stated, "The social worker made an error when writing the visit frequencies during the IDG meetings on 05/14/2025 and 05/28/2025."