Every finding on record at Compassionate Care Hospice of Houston, LLC

Upon patient record review, 1 of 14 (Patient #8) 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 8:The medication profile includes an entry on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the medication profile includes route of administration for oxygen. The medication profile with an entry for Macrobid ordered on 7/22/24 to be administered for 5 days and remains on medication profile on 8/1/24. COS

Upon patient record review, 2 of 14 (Patient #6,#10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. COS Patient 6:The medical record contains documentation of a pureed diet, ongoing issues for nausea and vomiting with multiple medications to treat symptom. There is no evidence of problems, goals and interventions on the plan of care related risk of aspiration. Patient 10:The DME/Supplies list includes the patient's need for a suction machine. There is no evidence of problems, goals and interventions on the plan of care for use and safety of suction. COS

Upon patient record review, 4 of 14 (Patient #2,#5,#7,#8) 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 2:The medical record contains an order for oxygen to be delivered at 3 liters per minute. Nursing documentation on 7/15/24, 7/5/24, 6/24/24 and 6/17/24 include oxygen delivery at 3.5 liters per minute and documentation on 6/3/24 and 6/5/24 that O2 was being delivered at 3 liters per minute. COS Patient 5:The plan of care includes an order for an indwelling catheter. There is no evidence that the order includes a size of the catheter and the amount for balloon inflation. COS Patient 7:The medical record contains an order for oxygen to be delivered at 3 liters per minute. Nursing documentation on 6/17/24 and 6/27/24 include oxygen delivery at 2 liters per minute and documentation on 6/3/24 and 6/5/24 that O2 was being delivered at 3.5 liters per minute. COS Patient 8:The plan of care includes an order on admission of oxygen 2 liters per minute as needed for shortness of breath. There is no evidence that the order includes route of administration for oxygen. COS

Upon patient record review, 2 of 14 (Patient #1,4) 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 equipment and supply needs. Patient 1:The medical record includes documentation on the certification of terminal illness dated 4/12/24 that the patient requires a walker for ambulation. There is no evidence that a walker is included on the plan of care. COS Patient 4:The medical record includes a notation on the certification of terminal illness dated 6/27/24 and SN documentation on 7/18/24 that the patient requires a Hoyer lift for transfers. There is no evidence that a Hoyer lift is included on the plan of care. COS

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1:The medical record contains a diet order change on 5/7/24 to a soft diet with bite size foods due to risk of aspiration. There is no evidence of problems, goals and interventions on the plan of care related risk of aspiration. COS

Upon client record review, 1 of 14 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5:The medical record with documentation upon admission of a Stage II Pressure ulcer to coccyx and stage III pressure ulcer to left thigh with and ordered intervention to assess wound weekly. There is no evidence of documented assessments from 6/20 until 7/22 with documentation that caregiver provided care.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 6:The medical record contains documentation that the patient is at risk for aspiration. The aide plan of care does not include aspiration precautions. COS

Upon patient record review 2 of 14 (Patient #2,#9) 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:The aide plan of care includes the task of shampoo hair assigned on Mondays and Fridays as well as the task of nail care assigned on Mondays. The aide documented that shampoo hair and nail care was completed 3 times the week of 6/2/24 and 6/9/24. Patient 9:The aide plan of care includes the task of nail care assigned weekly on Monday. The aide documented that nail care was performed each visit from 7/9/24 through 7/26/24 with the aide ordered 3 visits per week.

Based on record review and interview, the hospice failed to enforce written policy to make sure that the rights of a patient who has not been adjudged [to declare or pronounce] incompetent are exercised by any legal representative to the extent allowed by law for 1 of 1 discharged patient (#1) whom record was reviewed in that: Patient #1 with a diagnosis of Alzheimers Disease signed consent for Hospice service and the family/power of attorneys were not informed that Patient #1 was started on hospice services, nor they authorized hospice services for Patient #1. This failure did not allow the patient and family to understand the philosophy of hospice, be fully informed in advance about scope of services, and the plan of care. --- Findings include: Record review of the hospice policy titled ";Patient and Family Rights and Responsibilities" with a revision dated of 07/28/22 read in part: ";The hospice recognizes, respects, and promotes the rights of each individual patient and family member in accordance with fundamental human, civil, constitutional, and statutory rights. The hospice staff will collaborate with the patient to determine and define ";family member (s)." The patient and the family have the right to be informed on admission, orally, and in writing, of their rights and responsibilities. If a state court has not adjudged incompetent, any legal representative designated by the patient in accordance with state law may exercise the patients rights to the extent allowed by state law." Record review of the TULIP intake #409311 under the general intake notes read in part: ";On 2/10/2023, the family went to visit [Patient #1] and noticed she was ";glassy eyed, hallucinating, and had slowed speech. [This hospice] was providing the Patient with morphine. The hospice nurse, [RN C], stated that [Patient #1] had signed herself to the agency. It should be known that [Patient #1] had an MPOA, [FM #2], who was never notified of this. The [Patient #1] is not capable of making her own decisions. The family became concerned and asked for a copy of the paperwork that the patient had signed. Hospice nurse [RN C] would not release this to the family. A nurse of [ALF #1] witnessed [RN C] come into the patients room and told her to sign on an electronic device. on 2/16/2023, [RN C] stated that dementia patients could make decisions on their own and she tried to prove her point by calling the patient by a different name. She asked the Patient three questions such as her location and what year it was. however, the Patient was not capable of answering anything." Patient #1 Record review of the clinical record for Patient #1 included a POC that showed a start of care date of 2/3/2023 and the diagnoses of senile degeneration of brain, Alzheimers Disease [ a brain condition that causes a progressive decline in memory, thinking, learning and organizing skills] with late onset, atrial fibrillation [irregular heart beats], systolic congested heart failure [the heart is weak, and the left ventricle can't contract normally when the heart beats], repeated falls, fracture of right femur [a bone in the thigh] , and hyperlipidemia (high concentration of fats in the blood). Record review of the RN hospice start of care assessment dated 2/3/2023 signed by RN C showed the following assessment information: Altered mental status/confused. Further review of the start of care assessment under the narrative section RN C documented the following ";Patient is 95-year old female that resides at [ALF #1]. Patient was admitted to hospice services after discussing patients medical history and current needs with [this hospice Medical Director]. Primary diagnosis is dementia secondary diagnosis of Alzheimers, atrial fibrillation congestive heart failure, kidney disease. Patient also has a fracture the vertebrae and distal femur related to a fall on January 6, 2023 at nursing home. Patient then moved to hospice [should be ALF] in January as well. Facility states that patient was alert oriented times 3 their admission. Now patient is alert oriented times two. She is very forgetful cannot remember one sentence to the next repeats herself frequently. Repeating the same sentence over and over. Patient is confused at times as well. Previous to admission to [ALF #1] patient was continental bladders she required minimal assist in five out of six ADLS. Patient now requires moderate assist with five out of six ADLS. Patient was able to ambulate with walker prior now patient requiring total assist to transfer and wheelchair for ambulation patient is only able to real self short distances due to dyspnea upon minimal exertion and fracture to right femur. Patient overall cognitive status has changed significantly since admission to ALF #1. Requires more staff interaction to reorientate patient and redirect. All admission paperwork completed and hospice philosophy agreed upon." Record review of the hospice CTI verbal order #22872421 read in part: ";Verbal certification obtained by RN C per discussion with the medical director, on the date of 02/03/2023 I obtained the verbal certification of terminal illness and the order to admit the patient to hospice services....A month ago, she was oriented x (times) 3 and continent. She required minimum assist with 5/6 ADLs and she was ambulatory with walker. She is now oriented times 1 and is very forgetful, and repeats same sentences. She requires moderate assist with 5/6 ADLs and she is bedbound. She is incontinent of bladder." This verbal order was electronically signed by the DON on 02/07/2023 and by the Medical Director on 02/15/2023. Record review of the Medical Power Attorney documentation signed by Patient #1 on October 2, 2015 showed designation of health care agent as follow: A. Primary Agent: Family Member #1 B. First Alternate Agent: Family Member #2 C. Second Alternate Agent: Family Member #3 Record review of the form titled ";Patient/Family Informed Consent" showed Patient #1 electronically signed the consent for hospice services on 02/03/2023. The consent was also electronically signed by RN C. The consent showed that Patient #1 has executed medical power of attorney. During an interview on 3/1/23 at 12:28 p.m. with Family Member #4 stated that ALF #1s staff informed the family that Patient #1 was placed in hospice. Family Member #4 stated that they asked hospice RN C why she signed up Patient #1 for hospice service if she has dementia. And RN C answered that patients can sign up for themselves for services if they can answer a series of questions like where she was, who was the president and what day it was. Family Member #4 stated that Patient #1 could not answer those questions. Family Member #4 was asked if the family requested a copy of the consent signed by Patient #1 and she said that initially it was requested to RN C, and she instructed the family to contact the hospice. The family called the hospice and they said to complete the forms and sign and fax it to the hospice. The family completed and signed the forms and faxed to the hospice but did not receive a copy of the consent. During an interview on 3/2/23 at 1:32 p.m. with RN C, she stated that the hospice received a referral for hospice services for Patient #1 from the director of ALF #1. RN C was asked who signed the consent for hospice service for Patient #1 and RN C stated ";the patient did." RN C was asked if Patient #1 had POA and RN C stated ";yes." RN C was asked why the patients family didnt sign the consent for hospice and RN C stated that the DON and the Liaison arranged for the family to be there for the initial evaluation, the family was there but they had left when she got there. RN C was asked why Patient #1 signed the consent for hospice if she had dementia and RN C stated ";she was still cognitive, she understood the consent paperwork, I explained everything, each page and she understood." During an interview on 3/2/23 at 1:58 p.m. with Family Member #2, she was asked if this hospice contacted her to arrange to meet and sign admission paperwork. Family Member #2 stated that the only person that she talked to was from Hospice #2 prior to admission to this hospice and she never met anybody from this hospice. Family Member #2 stated that she saw a nurse doing wound care to Patient #1 but not sure if she was from this hospice. Family Member #2 was asked if this hospice staff requested a copy of the POA documents and Family Member #2 stated that this hospice never requested the documentation and if they have it, they got it from ALF #1. Family Member #2 stated that the main power of attorney was Family Member #1 but he has Alzheimers and cant make decision. She is next in line and then Family Member #3. Record review of an email dated 3/2/23 from Family Member #3 stated that she found out on February 10, 2023 that Patient #1 was placed on hospice services. Family Member #3 stated that she went to visit Patient #1 and found her lethargic, she couldnt speak, her eyes were so glassy, sunken in and purple rings around her eyes. Family Member #3 stated that on this date she found out that Patient #1 was given Morphine. Family Member #3 stated that the family did not authorize hospice service for Patient #1. During a second interview on 3/3/23 at 10:44 a.m. with RN C, she was asked if she follow up with Patient #1s family about the consent paperwork and RN C stated ";yes, verbally." RN C stated that initially she talked to the second daughter [didnt remember name] and after the admission she called the son [primary POA, that according to the family has Alzheimers Disease] and left a voice message that Patient #1 was admitted to hospice. RN C was asked if she documented that she went over the consent paperwork with the family and RN C stated, ";I dont know, I dont have access to record at this time." During an interview on 3/3/23 at 11:28 a.m. with alternate administrator/ADON, she was asked if the family for Patient #1 requested copy of the consent for hospice services that the patient signed. The alternate administrator/ADON stated that she asked the business office specialist, the DON, the business office manager, the liaison, and the MSW, they all said that family had not requested the consent for hospice. Record review of an email dated 2/17/23 from this hospice business office manager to Patient #1s family showed instructions to complete and fax form ";Authorization for Release of Protected Health Information" to this hospice. Record review of an outbound fax notification dated 2/21/23 showed a fax was successfully sent to this hospice.