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

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. No evidence of documentation that the plan to collaborate had been implemented.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's Federal, state, tribal, regional, and local emergency management agencies. Corrected on site.

Upon patient record review, 2 of 19 (Patient #2,#10) 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 #2: During home visit medication reconciliation, found patient is taking Senna Plus 8.6mg-50mg one PO BID. There was no evidence on the Hospice medication profile for the medication. Patient #10: IDG notes on 7/24/2024 identified "patient on Augmentin 3 weeks ago". RN PRN visit made related to medication issue, visit notes from 7/6/2024 stated "daughter concerned antibiotics ordered had not yet been delivered, pharmacy called and time of delivery established" Per Enclara agency pharmacy they did have an order and did deliver Augmentin to patient dated 7/6/2024, there was no evidence of Augmentin on the medication profile.

Upon patient record review, 4 of 19 (Patient #1,#2,#14,#17) 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. Patient #1: Psychosocial assess at SOC identified no funeral planning, "pending". there was no evidence in the POC for problems/Goals/Interventions for funeral planning. Corrected on site. Patient #2: Psychosocial assess at SOC identified no funeral planning, "pending". there was no evidence in the POC for problems/Goals/Interventions for funeral planning. Corrected on site. Patient #14: Psychosocial assess at SOC identified no funeral planning, "pending". there was no evidence in the POC for problems/Goals/Interventions for funeral planning. Patient #17: Patient identified as high fall risk on SN SOC, Falls score 16>10. There was no evidence in the POC for problems/Goals/Interventions for safety/falls.

Upon patient record review, 3 of 19 (Patient #2,#3,#10) 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: During home visit medication reconciliation, found patient is taking Senna Plus 8.6mg-50mg one PO BID. There was no evidence of an order for Senna Plus. Patient #3:During home visit medication reconciliation, the facility did not have the medication Ondansetron 4mg PO Q 4 hr. as needed for nausea listed on their medication record, no evidence in the facility of an order for the medication. (order exists on Hospice record) Patient #10: IDG notes on 7/24/2024 identified "pt. on Augmentin 3 weeks ago". RN visit notes from 7/6/2024 stated "daughter concerned antibiotics ordered had not yet been delivered, pharmacy called and time of delivery established" Per Enclara, agency pharmacy, they did have an order and did deliver Augmentin to pt. dated 7/6/2024. there was no Hospice order documented for Augmentin.

Upon patient record review, 2 of 19 (Patient #15,#18) 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 #15: Patient has O2, is Diabetic, and identified as fall risk on SN SOC assessment. All items on comprehensive POC. No evidence in the aide POC/assignment sheet for O2, fall or diabetic precautions. Patient #18: Patient has O2, no evidence on the aide POC/assignment sheet for O2 precautions.

Upon patient record review 1 of 19 (Patient #12) 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 #12: Order dated 5/15/2024 included aide visits 5xweek. For week of 7/7/2024, 4 visits were completed, no evidence of a missed visit for the 5th visit.

Upon patient record review 2 of 19 (Patient #1,#4) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1: Hospice aide supervision occurred 6/24/2024 and 7/16/2024, no evidence of occurring no less frequently than every 14 days. Patient #4: Hospice aide supervision occurred 6/24/2024 and 7/15/2024, no evidence of occurring no less frequently than every 14 days.

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. There was no evidence of 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. The QAPI report for QTR 1 2024 documented 1.23% for 2023.