Every finding on record at Compassionate Care Hospice of Bryan Texas, LLC

Upon patient record review, 3 of 19 (Patient #1,2,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Upon observation of the facility medical record Methocarbamol 500 mg Q6 hrs. was not on the facility medication record. The hospice did not discontinue from the medication record. (Corrected on site Patient #2: Upon observation of the facility medical record Carvedilol 12.5mg BID was not on the facility medication record. The hospice did not discontinue the medication from the medication record. Patient #3: Upon observation of the facility medical record there was a discrepancy between the facility medication record Depakote Sprinkles 250 mg @HS/Depakote Sprinkles 125 mg BID; and the hospice medication record Depakote Sprinkles 250 mg, 2 tablets daily. The hospice did not update the medication record.

Upon patient record review, 3 of 19 (Patient #1,2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Upon observation of the facility medical record Methocarbamol 500 mg Q6 hrs was not on the facility medication record. The hospice did not discontinue the medication on the plan of care. Patient #2: Upon observation of the facility medical record Carvedilol 12.5mg BID was not on the facility medication record. The hospice did not discontinue the medication on the plan of care. Patient #3: Upon observation of the facility medical record there was a discrepancy between the facility medication record Depakote Sprinkles 250 mg @HS/Depakote Sprinkles 125 mg BID; and the hospice medication record Depakote Sprinkles 250 mg, 2 tablets daily. The hospice did not update the medication on the plan of care.

Upon patient record review 1 of 19 (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: There is evidence in the medical record the aide did not provide care as ordered. Aide plan of care states shampoo 1x weekly on Tuesday. The week of 9/21/25, shampoo was completed two times that week. The week of 9/28/25, on 9/30/25 (Tuesday) the shampoo indicated "no-not completed"and on 10/3/25 (Friday) the shampoo indicated "completed".

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon observation of the Volunteer Cost Savings Report the amount equals 1.68%. The hospice currently has a national and regional PIP in place.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1: There is evidence in the medical record an order 8/28/25 for Oxygen 2.5 L via NC as needed for SOB. On 9/11/25 and 9/22/25 of the nurses note under vital signs, the nurse indicated "O2 4L continuous @ rest". Also, the F2F on 9/11/25 indicated "patient continues on O2 @ 5L nasal canula".

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed revealed measurable outcomes anticipated from implementing and coordinating the plan of care were not defined. Clinical Record 3: The patient elected the hospice benefit on 4/29/2022. A physician's order was written on 10/28/2022 for wound care, "Apply barrier cream to Stage II pressure ulcer to the upper right buttock and apply optifoam at each nurse visit." Nursing notes on 10/28/2022 and 11/1/2022 stated in part, "wound to right upper buttock has healed …barrier cream and optifoam applied to the area as a preventative measure." There were no measurable outcomes identified for altered skin integrity included in the plan of care. The Director of Operations was interviewed on 12/1/2022 and agreed that this was missing from the patients plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed revealed that the plan of care did not include medical supplies and appliances necessary to meet the needs of the patient. Clinical Record 3: The patient elected the hospice benefit on 4/29/2022. A physician's order was written on 10/28/2022 for wound care, "Apply barrier cream to Stage II pressure ulcer to the upper right buttock and apply optifoam at each nurse visit. Nursing notes on 10/28/2022 and 11/1/2022 stated in part, "wound to right upper buttock has healed …barrier cream and optifoam applied to the area as a preventative measure." There was no identification of the medical supplies necessary to meet the needs of the patient included in the plan of care. The Director of Operations was interviewed on 12/1/2022 and agreed that this was missing from the patient's plan of care.