Every finding on record at Companion Hospice and Palliative Care of South Texas, LLC

Observed in Emergency Management Session. During review of the Emergency Management plan it was noted the organization had not completed an emergency exercise with documentation of an evaluation of the emergency exercise. For example; review of the Emergency Management Plan revealed an event that had occurred prior to the last survey in July with documentation of a discuss on why the organization failed. However, there was no documentation of an actual Emergency Exercise. This was reviewed, discussed, and validated with the Director of Clinical Services/Alternate Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3's patient records it was noted the organization had not ensured the written plan of care was based on the patient's goals and services required to meet those goals. For example: review of RR# 1 and RR# 2's patient records revealed documentation of a high risk for falls. However, review of RR# 1 and RR# 3's plan of care revealed no goals related to falls. Review of RR# 2's patient record revealed RR# 3 had a risk for aspiration and on a mechanical soft diet with thickened liquids for dysphagia. However, review of RR# 2's plan of care revealed no goals related to the aspiration risk. This was reviewed, discussed, and validated with the Director of Clinical Services/Alternate Administrator.

Observed in Record Review. During RR# 1, RR# 2, and RR# 3's patient record review it was noted the organization had not ensured the patients' plans of care included all interventions to manage pain and symptoms. For example: review of RR# 1 and RR# 3's patient records revealed RR# 1 and RR# 3 were both high risk for falls. However, review of RR# 1 and RR# 3's plans of care revealed no fall safety precautions. Review of RR# 2's patient record revealed RR# 2 had risk for aspiration. However, review of RR# 2's plan of care revealed no aspiration safety precautions. This was reviewed, discussed, and validated with the Director of Clinical Services/Alternate Administrator.

Observed in HR File Review. In 2 of 3 HR files reviewed with date of hire after August 2025, During review of HR# 2 and HR# 3's HR files it was noted the organization had not ensured staff completed an initial competence assessment. For example: review of HR# 2's (Volunteer Coordinator) HR file revealed a blank initial competence assessment form. Review of HR# 3's (Chaplain/Bereavement Coordinator) HR file revealed a blank Chaplain initial competence assessment form and a blank Bereavement Coordinator initial competence assessment form. This was reviewed, discussed, and validated with the Director of Clinical Services.

Observed in HR File Review. In 1 of 4 HR files reviewed, During review of HR# 2's HR file it was noted the organization had not ensured it verified staff qualification required by Texas state law and regulation that required licensure examination for a Master of Social Work to work as a Master of Social Work. For example: review of HR# 2's date of hire was approximately 45 days prior to the surveyor review of the record. Further review of HR# 2's HR file revealed HR# 2 had a LBSW (licensed Baccalaureate Social Worker). This was reviewed and discussed with the Director of Clinical Services/Alternate Administrator that revealed HR# 2 was not licensed in the state of Texas as a Master of Social Work and supervision by a LMSW was required for a LBSW to work as a Medical Social Worker. Further discussion with the Director of Clinical Services/Alternate Administrator revealed HR# 2 had graduated with a Master of Social Work approximately 70 days prior to the surveyor review of the record and was scheduled to take the licensure exam but had not done yet and did not have a temporary license.

Observed in Emergency Management Session. the organization failed to ensure review and evaluate all exercises and actual emergency or disaster incidents. On review of the Emergency Management Program it was noted there was documentation of an actual event in 2025 for inclement weather - icy conditions however there was no documentation of an after action report or analysis of the event to revise the hospice's emergency plan as needed. This observation was reviewed with the Administrator and Executive Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment was documented no later than 5 calendar days after the election of hospice care. On review of RRNHV#6 there was no documentation that the comprehensive assessment was repeated within 5 days of the patient's April 2025 payor change from Non-Medicare payor to Medicare. This observation was reviewed with the Administrator and Executive Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to conduct a patient specific comprehensive assessment that identified the patient's need for hospice care and services. On review of RRHV#2 there was no documentation noted on the record of an initial bereavement risk assessment. This observation was reviewed with the Administrator.

Observed in Record Review. In 9 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of records there were examples of goals that were not specific, measurable and/or time-bound. For example: in RRHV#1 a non measurable goal was Prevent discomfort due to increasing edema. In RRHV#3 an example was Promote rest status for Pt/Family/PCG. In RRNHV#4 a non specific not measurable goal was Facilitate bowel elimination and comfort each visit within 4 weeks -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. In RRNHV#5 an example was Achieve and maintain peripheral circulation for Pt comfort. Another example in RRNHV#7 was Prevent discomfort due to increasing edema by elevating lower extremities when sitting and using compression stockings appropriately. Further examples could be seen in RRNHV#8, RRNHV#9, RRNHV#6, and RRNHV#10. These observations were reviewed with the Administrator and Executive Director.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 there was documentation the patient was a high fall risk yet there was no care plan for fall safety. In RRNHV#4 there was documentation of increased weakness with staggered gait and walker use but no fall safety care plan. Also, there was documentation of dyspnea with ordering of oxygen but no respiratory care plan to guide the care. In RRNHV#5 the documentation noted the patient was using a Pure Wick device for urinary incontinence but the device use was not reflected in the orders of in the care plans. In RRNHV#7 the documentation noted nausea and vomiting with the ordering of Zofran and Cough and congestion with Mucinex ordered but no care plan to reflect the issues and guide the care. These observations were reviewed with the Administrator.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care revisions are based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. On Review of RRHV#1 there were goals that were not addressed over time as they remained without progress to goals IDG to IDG. An example was Pt/pcg will verbalize/express understanding of treatment orders and side effects, of no cardiac medications. The goal was established on admit in February and remained unchanged to date of survey. In RRHV#2 an example was Pt/Family/Caregiver will verbalize understanding of expected symptoms associated with terminal disease process established in December and remained without progress to goal. In RRHV#3 an example was Pt will verbalize improvement of symptoms associated with GERD yet no progress to the goals was noted in the record. In RRNHV#7 a goal established in March read Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects of Spirolactulone and Furosemide within 1 month but remained unchanged to date of survey. In RRNHV#7 an example was Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. within 6 weeks the goals was established in March without progress to survey. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. On review of RRHV#2 the volunteer was ordered a 1 visit a week frequency per the plan of care yet the last visit documented was in June a month prior to survey. This observation was reviewed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure a supervisor evaluate skill by observing the aide's performance of required tasks with a patient or pseudo-patient as part of a simulation. On review of HR#2 for the Hospice Aide there was no documentation of an initial competency evaluation noted in the HR file. Observation was reviewed with the Executive Director. Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, there was no documentation of a competency evaluation that addressed each of the required subjects. On review of HR#2 for the Hospice Aide there was no documentation of an initial competency evaluation documented as part of orientation. This observation was reviewed with the Administrator.

Observed in Tracer Activities. the organization failed to ensure the hospice aide receive ongoing education and training. On review of the hospice aide in-service training records it was noted that there was no documentation of 12 hours of in-service training during the last 12 months for the hospice aides currently employed. There was documentation of 6 hours of education in 2025. Prior to 2025, there were sign in sheets for 4 months (July 2024 - Oct 2024) yet the sheets did not contain content of what was taught or time elapsed during the training. There was no further documentation of aide in-servicing in November or December. These observations were reviewed with the Administrator and Executive Director.

Observed in Record Review. In 3 of 9 patient records reviewed, with aide services assigned, the organization failed to ensure the Registered Nurse provide written patient care instructions for the hospice aide. On review of RRNHV#4 the patient was on Eliquis yet the aide assignment for plan of care did not include bleeding precautions. Further the RN assigned the aide to take vital signs yet there were not parameters for when to report vital sign findings. In RRNHV#5 the patient was also on Eliquis but no bleeding precautions noted on the aide's assigned plan of care. Further, there was documentation the patient was using a Pure Wick device but no specific instruction on how the Aide was to handle the device when providing care. In RRNHV#8 the patient had multiple wounds with dressing but no instruction for how the aide was to handle the dressings during care. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 9 patient records reviewed, with aide services assigned, the organization failed to ensure the hospice aide provide services that were ordered by the physician in the plan of care. On review of RRNHV#4 the aide plan of care specified for the aide to obtain and record vital signs each visit however the aide's documentation for each visit did not include vital signs. This observation was review with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization failed to ensure a registered nurse make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. On review of HR#2 for the hospice aide there was no documentation of annual on-site aide evaluation from hire in 2023 to date of survey as required. This observation was reviewed with the Administrator.

Observed in HR File Review. In 2 of 8 HR files reviewed, the organization failed to ensure documentation of initial orientation for each employee that addressed the employee's specific job duties including those related to infection prevention and control and assessment and managing pain. On review of HR#1 for the RN and HR#5 for the RN Administrator the orientation checklist was noted in the HR file but was blank without documentation that the orientation was completed. This observation was reviewed with the Administrator.

Observed in HR File Review. In 3 of 8 HR files reviewed, the organization failed to ensure staff competence was initially assessed and documented as part of orientation. On review of HR#4 for the MSW, HR#6 for the Volunteer Coordinator, and HR#6 for the Spiritual Counselor there was no documentation of an initial competency noted in the employee HR file. This observation was reviewed with the Administrator. Observed in HR File Review. In 3 of 8 HR files reviewed, the organization ailed to ensure staff competence was assessed and documented annually as required by organization policy 1-008. On review of HR#3 for the MD, HR#5 for the Administrator, and HR#6 for the volunteer coordinator, there was no documentation on review of the file of annual competency evaluation as required. For HR#3 the last competency was 2023, for HR#5 the last documented was initial in 2022, and for HR#6 the last was the initial in 2021. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the Medical Director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs it's normal course to include all required elements. On review of RRNHV#6 the Certificate of Terminal Illness (CTI) documented at the time of the April 2025 patient payor change from a non-Medicare payor to Medicare did not include current subjective and objective findings. This observation was reviewed with the Administrator and Executive Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure hospice obtains the signature of the patient or representative to confirm that the patient or representative has received a copy of the notice of rights and responsibilities in accordance with 42 CFR 418.52 and obtains a signed election statement in accordance with 42 CFR 418.24. On review of RRNHV#6 there was no Election of Benefits signed at the time of a payor change from non-Medicare to a Medicare payor in April of 2025. This observation was reviewed with the Administrator and Executive Director.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to ensure the patient record contains the information to reflect the patient's care, treatment, services. On home observation for RRHV#2 during medication reconciliation there was discrepancy in the Morphine dosage as the bottle in the home was Morphine 100mg/5ml yet the medication profile per the plan of care stated Morphine 20mg/5ml. This observation was reviewed with the RN and the Administrator.

Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of RRNHV#6 the record was not maintained complete, readily available, or systematically organized to facilitate retrieval for a patient with a April, 2025 payor change from non-Medicare to Medicare. The organization maintained 2 separate records for the same period of time, a discharge record and an April admission record. Staff continued to document their hospice care in the discharged record after the change in payor source to Medicare. Therefore both the discharge record and the April 2025 admission record had to be reviewed by the surveyor in order to determine what care had been provided. This observation was reviewed with the Administrator and Executive Director.

Observed in Competency Session. In 1 of 5 contracts reviewed, the organization failed to ensure the written agreement with and outside agency providing contracted services for the hospice include all the required elements. On review of the contract for pharmacy it was noted the contract did not include all required stipulations such as a stipulation that services may be provided only with the authorization of the hospice - A stipulation that services will be delivered in accordance with the patient’s plan of care - The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice - The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences - Requirements for documenting that services are furnished in accordance with the agreement - The qualifications of the individuals providing the services - A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the Executive Director.

Observed in Record Review. In 2 of 3 patient records reviewed, the written plan of care (POC) was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#1, no goals were included on the POC. Goals identified for the patient had not been individualized and read throughout hospice care including goals for respiratory problems with the exception of one goal patient/caregiver verbalizes/demonstrates pain control within 48 hours of admission. In the chart for RR#2, all goals of care were throughout hospice care, throughout life or until the public health emergency of coronavirus in Texas is resolved, even the patient's pain goal. This was discussed with the QAPI Nurse. Observed in Record Review. In 2 of 3 patient records reviewed, the plan of care (POC) did not include an assessment of the patient’s needs and an identification of the provided services, including the management of discomfort and symptom relief. In the chart for RR#1, on initial assessment the patient was found to be at risk for falls, pressure ulcer development and had oxygen ordered. The POC did not include any interventions or goals related to these risks. In the chart for RR#2, the patient was assessed to be at risk for falls, yet there were no interventions/goals related to these risks on the POC. This was discussed with the QAPI Nurse.

Observed in Record Review. In 1 of 3 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for RR#1, the RN indicated that an order was obtained for oxygen at the initial visit. No order for oxygen was found, nor was it on the POC. This was verified with the QAPI Nurse.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that an initial bereavement risk assessment was not done. This was noted in record review #1, #2, #4 and in record review for home visits #2 and #3 and record review #7 and discussed with hospice director.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the plan of care did not contain individualized goals which were measurable or timed. For example, the following are examples were noted, Pt pain level will be controlled to his comfort level throughout the cert period, Pt expresses management of edema through the cert period, Patient will have a slow comfortable decline as evidenced in overall demeanor in record review #1, #2, #3, #4 for the spiritual goal. In review of record #5 it was noted that there was no goal stated for a new upper respiratory infection with antibiotic use, additionally in this record all goals stated on the plan of care were to be achieved in two weeks. In other records the following goals for skin integrity were noted, Skin remains intact within limits of the disease process during the certification period. In record review for home visit #3 the Cardiovascular goal was stated as Pt. verbalizes methods to manage edema and Pt. will manage edema through this recert period. The spiritual goal for this patient was stated as Pt. will have a comfortable decline while in her apartment and the goal for Anticipatory grief was stated as Pt. demonstrates coping with grief, coping well with terminal diagnosis verbalized understanding. This was discussed with the hospice director. Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the plan of care did not reflect the patient's needs based on the assessment. For example in record review #4 for a patient with primary diagnosis of Mild protein-calorie malnutrition it was noted that the plan of care did not include any interventions or goals related to nutrition/hydration. In another example, in record review #3 the plan of care had interventions and goals related to bleeding issues however there was no indication from the patient assessment or medication profile of any need for bleeding precautions. In record review #5 it was noted that the patient's secondary diagnosis was Major Depressive Disorder however there were no interventions or goals on the plan of care for this issue. In record review for home visit #2 the primary diagnosis was Hypertensive Heart Disease with failure and the patient had pedal edema but this was not addressed on the care plan. Additionally, secondary diagnosis included depression and dementia however these were also not addressed on the plan of care. This was discussed with the hospice director.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that there was no order for oxygen in record review #2 however the nurse documented teaching the family member on the use of the oxygen and the application of the nasal cannula in an nursing note. In another example, it was noted that there was no order for oxygen usage in record review #5. This was discussed with the hospice director.

Observed in Record Review. In 2 of 11 patient records reviewed, it was noted that the care was not provided as ordered. For example, in record review #3 it was noted that on 4/26/22 the MSW visits were increased to 1 time per month however no MSW visits had been made during May or June. In another example, during home visit #3 it was noted that the order for oxygen was 3L/nc continuous however the patient was using 2L/nc PRN. This was discussed with the hospice director.

Observed in Document Review. During review of documents and discussion with leadership it was noted that the organization did not have an effective QAPI program that reflected the complexity of the organization. For example, there were no performance improvement minutes documented since fourth quarter of 2020 and there were no documented PIP's. The only data being collected was from chart audits, incidents and infections. There were no palliative outcomes indicators being assessed as part of the QAPI process. The QAPI program did not involve any services related to bereavement, contracted services or any other factors other than nursing documentation. This was discussed with hospice director. Observed in Document Review. During review of documents and discussion with leadership it was noted that the organization did not have an effective, ongoing, organization wide, data driven QAPI program. For example, there were no performance improvement minutes documented since fourth quarter of 2020 and there were no documented PIP's. The only data being collected was from chart audits, incidents and infections. This was discussed with hospice director. Observed in Document Review. During review of documents and discussion with leadership it was noted that the organization did not have an effective, ongoing, organization wide, data driven QAPI program. For example, there were no performance improvement minutes documented since fourth quarter of 2020 and there were no documented PIP's. The only data being collected was from chart audits, incidents and infections. This was discussed with hospice director.

Observed in Document Review. During review of documents and discussion with leadership it was noted that there were no performance improvement minutes documented since fourth quarter of 2020 and there were no documented PIP's. This was discussed with hospice director.

Observed in Document Review. During review of documents and discussion with leadership it was noted that there were no performance improvement minutes documented since fourth quarter of 2020 and there were no documented PIP's. This was discussed with hospice director.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.58, 418.100

Observed in HR File Review. In 3 of 7 HR files reviewed, it was noted that competencies had not been performed annually as per agency policy. For example, in review of Medical Director file it was noted that the last competency was documented 4/14/19, for the chaplain the last competency was in 2018, and for an RN the last competency was documented in March of 2020. This was discussed with the hospice director.

Observed in Tracer Visit. In 2 of 3 home visits conducted, it was noted that the medication sheet did not match what the patient was actually taking. For example, in home visit #2, Loratadine 10 mg daily was being given but was not on the medication sheet. In home visit #3 the following medications were on the current medication list but were no longer being taken: Miralax, Iron Supplement and Metalozone. Additionally, the patient was taking Wixela BID which was not on the medication sheet and the following discrepancies were noted: Spiriva patient taking 2 puffs daily, no dosage on the medication sheet Senna on the medication sheet as daily but is only used PRN, Gabapentin on the medication sheet as TID only taken BID and oxygen on the medication sheet as 3L/nc however patient only using 2L/nc. This was discussed with the hospice director.

Observed in Tracer Visit. In 1 of 3 home visits conducted, it was noted that the patient's education needs were not met. For example, during home visit #3 the patient stated that she did not know how to use the E cylinder for oxygen. The nurse performing the visit provided education at the end of the visit. This was discussed with the hospice director.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that at the last renewal period for an RN the license expired on 8/31/21, but the primary source verification was not run until 9/27/21.