Every finding on record at Carestar Hospice of Texas LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. In 3 of 13 (23%) records reviewed revealed the agency did not ensure that the individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: This patient elected the hospice benefit on 01/11/2025 with a terminal diagnosis of cirrhosis of the liver. The comprehensive assessment dated 01/11/2025 included documentation that the patient rated pain at 6 with a pain goal of 2 and that the patient had a foley size 16fr. The patient received hydrocodone/Tylenol 5/325mg every 8 hours as needed for pain. The review of the plan of care beginning 01/11/2025 did not include interventions for pain and did not include interventions for foley care CLINICAL RECORD 2: This patient elected the hospice benefit on 10/24/2024 with a terminal diagnosis of senile degeneration of the brain. The comprehensive assessment dated 10/24/2024 documented that the patient was administered acetaminophen or ibuprofen for pain when required. The drug administration record included acetaminophen 500 mg every 6 hours as needed for pain and ibuprofen 200 mg every 4 hours as needed. Both medications were started on 05/24/2024. The comprehensive assessment on 10/24/2024 also documented that patient experienced shortness of breath with crackles and rales throughout the lung fields and utilized an inhaler and nebulizer with oxygen at 2-4 liters per nasal cannula. There were no interventions included in the plan of care dated 10/24/2024-01/23/2025 for pain or interventions for dyspnea. CLINICAL RECORD 11: The comprehensive assessment dated 01/15/2025 documented the patient had wounds on right upper abdomen and sacral area. Amoxicillin 875 mg potassium clavulanate 125 mg 1 tablet every 12 hours by mouth for 14 days were initiated for infection of the wound. The plan of care was reviewed for the dates of 01/15/2025-01/23/2025 There were no interventions noted in the plan of care for the wound infection. In an interview conducted on 01/23/2025, the QAPI Coordinator confirmed that the agency did not ensure that the individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 1of 13 (8%) clinical records reviewed with hospice aide services revealed the agency did not ensure that hospice aide services were provided as per the plan of care. DOCUMENT 1: Agency policy "Hospice Aide Services" stated, in part: F. A hospice aide provides services that are: 1. Ordered by the physician. The physician's order must indicate the frequency of the home health aide services required by the beneficiary. 2. The plan of care will be established before providing care and services and the services will be consistent with the plan of care. CLINICAL RECORD 2: This patient was admitted 10/24/2024 with a terminal diagnosis of senile degeneration of the brain. The hospice aide care plan written on 10/24/2024 ordered hospice aide visits 5 times a week. For the week of 12/08/2024-12/14/2024, 4 hospice aide visits were documented. There was no documentation for a hospice aide visit on 12/12/2024. There was no documentation of a missed visit communication. During an interview with the Clinical Manager/Director of Nursing and the QAPI Coordinator on 01/23/2025, it was confirmed that the agency did not ensure that the hospice aide visits were documented as per the hospice aide care plan.