Every finding on record at Clp Regency of Texas, LLC

The Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the patient's plan of care was updated with new information obtained from the patient's updated assessment. CLINICAL RECORD 9: During the Registered Nurse’s (RN) visit on 10/10/2025, she noted that the caregiver reported the patient fell the previous night. The patient sustained a skin tear on the right inner arm and stated that he was walking approximately 40 feet when his legs felt unsteady, and he began to feel dizzy. A physician’s order dated 10/02/2025 included Eliquis 5 mg tablets to be taken orally twice daily for anticoagulation. During the Interdisciplinary Group Meeting on 10/17/2025, the nurse added that the "...patient has expressed a desire to avoid hospital readmissions." The patient is taking an anticoagulant and has a defibrillator inserted on 10/02/2025 but does not wish to have the device deactivated. The plan of care or the benefit period from 10/02/2025 to 12/30/2025 listed universal precautions, oxygen precautions, and fall precautions. No specific interventions or goals related to the patient’s reported dizziness resulting in a fall were identified. Although a safety and autonomy concern was identified at admission on 10/02/2025, there were no specific interventions or goals documented for falls or for managing the potential increased bleeding risk associated with Eliquis on the plan of care or the Interdisciplinary Group Meeting on 10/17/2025. After a joint clinical record review with the Area Executive of Clinical Operations (Personnel Record 2) on 10/22/2025, she confirmed that the patient’s high risk for bleeding was not identified in the plan of care, nor were there any interventions or goals related to fall risk or bleeding prevention. The patient’s plan of care was updated to ensure compliance before the end of the site visit.

It is required that Hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) clinical records for patients receiving hospice aide services, the agency did not ensure the aide reported changes in the patients needs to the Registered Nurse. Clinical Record 7: The Plan of Care dated 11/13/22-2/10/23 ordered Hospice Aide services two times a week for thirteen weeks. During the week of of 11/20/2022, the Hospice Aide provided services one time. There was documented evidence of a missed Visit form, but there was no documentation that the Director of Clinical Services (DCS) or RN was notified. During a joint record review with the DCS, she stated, “the aide did not notify the agency the visit was missed.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 11 (18%) clinical records reviewed, the agency did not ensure physician orders for treatments provided by the Skilled Nurse. Clinical Record 3: The patient was admitted for hospice services and the Initial Plan of Care (POC) was dated on 8/9/2022 - 11/6/2022. The Skilled Nurse (SN) documented two wounds on the initial comprehensive assessment. Wound # 1 upper buttock, stage II wound measuring 3 cm x 2.8 cm x 0.1 cm and Wound # 2 stage II pressure ulcer medium buttock measuring 2.8 cm x 2.5 cm x 0.1 cm. The Skilled Nurse (SN) visit note dated 8/9/2022 and 8/17/2022, documented “clean with wound care spray, pat dry, apply zinc oxide, cover with nonstick pad, covered with island dressing." There was no documented evidence of Physician Orders for the wound care provided. During the joint record review on 11/29/22 with the Director of Clinical Services (DCS), she stated, “there are no wound care orders on the POC or Physician orders”. Clinical Record 9: The patient was admitted for hospice services with diagnoses including Obstructive and Reflux Uropathy and Acute Kidney Failure and the Initial Plan of Care was dated 9/24/22-9/29/2022 On the initial comprehensive assessment dated 9/24/2022, the SN documented the patient had a Foley catheter. There is no documented evidence on the Plan of Care (POC) that orders were provided for the Foley catheter. During joint record review with the DCS on 11/29/22, she stated, "there are no orders for the Foley."

It is required that all entries in the patient record are legible, complete, appropriately authenticated, and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 1 of 11 (9%) clinical records reviewed of patients receiving skilled nursing, the agency did not ensure the clinician completed the missed visit form as defined in the agency policy and procedure. The Agency Procedure: C_09A.1 Missed Visits, Revision Date 7/8/2022, stated, "Purpose: To Provide specific direction for addressing scheduled visits that are not completed according to the plan of care and addressing a patient/caregiver request to cancel or reschedule a visit. 2B a coordination note documenting the reason missed visit is required from the clinician. The visit should be rescheduled, if possible, within the Medicare Week (Sunday to Saturday)." Clinical Record 2: The Plan of Care dated 10/14/2022-1/11/2023 ordered the Skilled Nurse visit frequency as two (2) times a week x thirteen (13) weeks. The Skilled Nurse completed a missed visit note dated 11/19/22. The missed visit coordination note section where the reason for the missed visit is to be documented was blank. During a joint record review with the Director of Clinical Services on 11/30/2022, she stated " the nurse didn't complete the missed visit form."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records, documents, and interviews. In 1 of 3 (33%) clinical records reviewed of discharged patients, the agency did not ensure the Discharge Summary was sent to the patient's attending physician. The Agency Policy C04-Discharge/Transfer/Revocation dated December 4, 2017, Revocation # 5 stated, “Agency will provide a discharge summary to the attending physician or receiving facility containing treatment, symptoms and pain management, current Plan of Care, latest Physician orders, other documentation facilitating continuity of care and/or requested by the attending physician or receiving facility. Clinical Record 11: The patient elected the Hospice Benefit on 9/4/2022 and a revocation statement was signed on 10/25/2022. There was no documented evidence that the discharge summary was sent to the patient's attending physician. During a joint record review with the Director of Clinical Services on 11/29/22, she stated “we didn’t send a discharge summary to the patient’s attending physician.”

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of documents and interviews. This standard was not met as evidenced by a review of documents and interviews. In 1 of 14 (7%) contracts reviewed, the contract for XRAY services did not include the required verbiage. Contract # 12: The contract for XRAY services lacked evidence of the clause for criminal background checks for employees that have access to patients and their clinical records. During a joint review of Agency contracts on 11/30/2022 with the Director of Clinical Services, confirmed, "the contract didn't state they do criminal backgrounds on their staff."