Every finding on record at Crown Hospice, LLC

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed for patients that received hospice aide services it was revealed that the agency did not ensure hospice aides were supervised by a registered nurse who made an on-site visit to the patient's home no less frequently than every 14 days. CLINICAL RECORD 9: The hospice benefit was elected on 08/13/2024. Clinical record review lacked evidence of a hospice aide supervisory visit every 14 days. The clinical record contained an aide supervisory visit on the following dates 02/10/2025, 02/13/2025, 02/24/2025, 02/27/2025, 03/03/2025, 03/10/2025, 03/17/2025, 04/03/2025 (17 days), and 04/08/2025. During an interview with the clinical supervisor on 05/15/2025 she stated they have worked so hard on aide supervisory visits, and they will continue to work on it.

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 document review and interview. In 3 of 8 (38%) documents reviewed. it was revealed the agency did not ensure all contracts contained language that required all contracted employees who have direct patient contact or access to patient records to have criminal background checks. Contract 3: Physical therapist contract dated 06/17/2020 did not included the language requiring contracted employees who have direct patient contact or access to patient records to have criminal background checks. Contract 7: Occupational therapist contract dated 05/01/2015 did not included the language requiring contracted employees who have direct patient contact or access to patient records to have criminal background checks. Contract 8: Speech therapist contract dated 04/03/2015 did not included the language requiring contracted employees who have direct patient contact or access to patient records to have criminal background checks. During an interview with the executive director on 05/14/2025 she stated that she did not know that the contracts did not contain the language but that she would be sure to get an addendum with the therapist as soon as possible,

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 the following: drugs and treatment necessary to meet the needs of the patient. THIS IS A CONTINUING REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed the agency did not ensure that the patients' plans of care included documentation of complete orders for treatments necessary to meet the needs of the patient. Clinical Record 2: The updated hospice plans of care dated 05/31/2023 and 06/14/2023 included documentation of the original physician's order, dated 01/06/2023, that stated, "change indwelling suprapubic foley every 30 days and prn contamination, inadequate draining or unintentional removal". The plans of care contained no specific orders that described the size of foley catheter to be inserted. Documentation on the nursing visit note dated 06/04/2023 described the insertion of a 20 Fr, 30cc balloon, suprapubic foley catheter during the visit, which was the most recent nursing visit that included a catheter change. Clinical Record 4: The 05/31/2023 and 06/14/2023 updated hospice plans of care included documentation that described orders to change and irrigate the patient's foley catheter "as ordered". The plans of care contained no specific orders that described the size of foley catheter to be inserted, the frequency for catheter change, and no orders that described the catheter irrigation, including the type and amount of solution to be used, and the frequency or situations for utilizing catheter irrigation. The recertification note entered by the registered nurse on 06/09/2023 stated the foley catheter was changed and a 20 Fr, 30 cc balloon catheter was inserted. In addition, the 06/14/2023 wound care order documented on the updated hospice plan of care read, "clean with NS/WC, pat dry, apply calcium alginate to wound bed 2xweek and prn soiled or dislodged". The wound care order did not contain a description of the location of the wound that was to receive this treatment. Documentation on the 06/09/2023 recertification visit note entered by the registered nurse stated the wound receiving treatment was a stage IV sacral wound. During Interview on 06/26/2023, the Administrator reviewed the associated records and stated the orders were incomplete, clarification orders had been obtained from the physician, and remedial education was provided to the associated clinician.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements and other alternative treatments that could affect drug therapy.The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical records review. 4 of 11(36%) records revealed the hospice did not ensure the medication profiles were updated and drug regimen reviews occurred when new medications were ordered for patients. Record # 9 was reviewed and identified a physician order dated 8/2/2022 for O2 2L/min per nasal cannula PRN for SOB. The oxygen was not a part of the medication list and was not utilized for medication reconciliation. Record # 7 was reviewed and identified a physician order dated 12/13/2021 for O2 2L/min per nasal cannula PRN. The record contained a physician order dated 5/1/2022 for 02 2L/min per nasal cannula PRN for SOB. The oxygen was not a part of the medication list and was not utilized for medication reconciliation. Record # 8 was reviewed and identified a physician order dated on 12/13/2021 for O2 2L/min per nasal cannula PRN. The oxygen was not a part of the medication list and was not utilized for medication reconciliation. Record # 6 was reviewed and identified a physician order dated on 2/2/2022 for O2 2L/min per nasal canula PRN. The oxygen was not a part of the medication list and was not utilized for medication reconciliation. 4 of 5 (80%) of relevant records, the agency failed to ensure that the drug profile contained the patient's current prescription and over-the-counter (OTC) drugs, supplements and other alternative treatments that could affect drug therapy.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Includes all services necessary for the palliation and management of the terminal illness, including the following intervention to manage pain and symptoms, measurable outcomes anticipated from implementing and coordinating the plan of care, medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical records review. 1 of 11 (9%) of clinical records revealed that the hospcie did not ensure that plans of care included all hospice care and servies needed to meet the needs of the patients and families as identified in the comprehensive and ongoing assessments. Clinical Record 6 was reviewed and identified an episode of care from episode 2/02/2022 through 5/02/2022. The RN assessment on 2/2/2022 stated in part, "patient has 3.5cm x 5 cm sacral stage 4 pressure ulcer". Physician orders on 2/2/2022 stated in part, "Stage III or IV specific orders will be requested with no specific wound care orders for this patient". Nursing assessment on 2/2/2022 documented that the patient had a foley catheter. The plan of care for episode 2/02/2022 through 5/02/2022 did not include supplies for wound care or foley catheter. Care plan problems included skin integrity, however, the interventions and goals did not address the wound. The care plan addressed the GU system and foley catheter. There was no documented evidence the plan of care included specific orders to change the catheter and stated in part, “change urinary drainage device as ordered.” No other orders were present in the record for wound care or foley catheter. 1 of 11 (9%) of clinical records revealed that agency did not ensure that plan of care identified services and supplies necessary to meet the needs of the patient.

It is required that all hospice aide services must be provided by an ndividual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. AND The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. AND The hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes: Option 2: A qualified hospice aide has successfully completed a competency evaluation program that: 1) Evaluates the aide’s competency in the following subject areas by observation of the aide’s performance with a patient or pseudo-patient: a) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff; b) Reading and recording temperature, pulse, and respiration; c) Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: i. Bed bath; ii. Sponge, tub, and shower bath; iii. Hair shampoo (sink, tub, and bed); iv. Nail and skin care; v. Oral hygiene; vi. Toileting and elimination; d) Safe transfer techniques and ambulation; e) Normal range of motion and positioning. 2) Evaluates the aide’s competency in the following subject areas by written exam, oral examination, or after observation of a hospice aide with a patient or a pseudo-patient during a simulation: a) Observation, reporting, and documentation of patient status and the care or service provided; b) Basic infection control procedures; c) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor; d) Maintenance of a clean, safe, and healthy environment; e) Recognizing emergencies and the knowledge of emergency procedures and their application; f) The physical, emotional, and developmental needs of—and ways to work with—the populations served by the hospice, including the need for respect for the patient, his or her privacy, and his or her property; g) Adequate nutrition and fluid intake; h) Any remaining task(s) that the hospice chooses to have an aide perform. AND 3) The competency evaluation is performed by a registered nurse in consultation with other skilled professionals, as appropriate. This standard was not met as evidenced by a personnel record review. 1 of 2 (50%) of aide personnel files reviewed revealed the agency did not ensure that required competency evaluation was completed prior to providing patient care. Staff #4 record was reviewed and identified the date of hire on 4/21/21. The record did not contain an hospice aide competency assessment. Agency provided a binder with competency assessments which included a hospcie aide competency assessment for Staff #4 completed 4/21/22 as part of an annual evaluation, 1 of 2 (50%) of aide personnel files reviewed, the agency did not ensure that required competency evaluation was completed prior to providing patient care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 10 (10%) applicable records with hospcie aide services revealed the agency did not ensure that clear and specific written instructions on the hospcie aide assignments, thus leaving the aide to make decisions that are outside of the aide's scope of practice related to wound care.. Record #6 was reviewed and identified the RN assessment was completed on on 2/2/2022. The assessment documented a 3.5cm x 5 cm sacral stage 4 pressure ulcer. The aide care plan dated 2/2/2022 does not include aided instructions related to what the aide should do related to wound or dressing on sacrum. During an interview on Interview 8/10/2022, the Corporate Compliance Officer stated that she was not surprised that aide care plan did not include instructions related to the wound on the aide care plan. 1 of 10 (10%) relevant records with aide services, the agency did not ensure that the aide care plan included patient specific instructions leaving the aide to make decisions related to the care.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care; the patient’s latest physician orders, any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) of applicable discharge records reviewed, it was revealed that no documentation included a discharge summary with the required information/elements. . Record # 8 was reviewed and identified the documentation in the clinical record stated the patient was discharged from agency because family chose another agency on 6/29/2022. There is no documented evidence that the discharge summary was completed and forwarded to the attending physician or receiving hospice agency. Interview with QAPI Coordinator Interview with QAPI Coordinator: QAPI Coordinator stated in interview on 8/10/2022 that there was no discharge summary documented and that the agency has not been sending discharge summaries to physicians when a patient is discharged or transfers to an alternate agency. Interview with Corporate Compliance Officer QAPI Coordinator stated in interview on 8/10/2022 that there was no discharge summary documented and that the agency has not been sending discharge summaries to physicians when a patient is discharged or transfers to an alternate agency. 1 of 1 (100%) relevant records, the agency failed to ensure that the agency forwarded a copy of the discharge summary to the patient's attending physician after being discharged to transfer to another agency.

It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by personnel record review and interveiw. 1 of 1 (100%)records reviewed for a Social Worker lacked documented evidence of Social Work Supervision for a Bachelor's prepared Social Worker. Record #2 (BSW Social Worker) was reviewed and identified the that this SW was Bachelor's prepared. The record lacked documented evidence of Social Work Supervision for a Bachelor's prepared Social Worker by a Master's prepared SW. Texas Administrative Code 558.833 Medical social services must be provided to a client by a qualified social worker. A qualified hospice social worker must meet one of the following requirements: active licensure in the state of Texas as a baccalaureate social worker, one year of social work experience in a health care setting, and if employed by a hospice after December 2, 2008, must be supervised by a qualified MSW. During an interview on 8/9/2022, the Corporate Compliance Officer/ Director of Corporate Compliance stated that the agency does not currently have a Texas licensed MSW on staff. The MSW left the agency on 7/28/2021, an MSW from an alternate state has been providing telephonic supervision and is trying to get Texas license. On 8/10/22 Director of Corporate Compliance stated their plans to hire a local PRN MSW to provide supervision to BSW. 11 of 11 (100%) of clinical records , the agency did not ensure that the social worker with a BSW was supervised by an MSW.