Every finding on record at Encompass Home Health of East Texas, LLC

Based on a review of clinical records and staff interviews, it was determined that the agency failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in one (#12) of thirteen (#2-#6, #8-#12, #14, #16, and #18) clinical records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family.  Findings follow: --- A review of clinical record #12, with a start of care date of 03/09/26, revealed a patient diagnosed with Heart Failure. Review of a document titled "Hospice Certification and Plan of Care" with a certification period from 03/09/2026 to 06/06/2026, revealed orders for a Hospice Aide (HA). The most recent aide supervisory visit was completed on 04/07/26, with the next visit due on 04/21/2026. There is no documentation of any additional supervisory visits.During an interview on 04/22/26 at 2:00 PM, Agency Personnel #1 confirmed the Registered Nurse failed to perform Supervisory Aide Visits every fourteen days as required.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through supervisory aide visits (SAV) every 14 days in 1 (#14) of 14 (#2 - #9, #12,#14,#15,#17,#19 and #20) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: --- 1. Review of clinical record #14, with a start of care (SOC) of 12/15/22 and a diagnosis of Chronic Obstructive Pulmonary Disease revealed a certification period of 03/15/23-05/13/23 and orders for HA services two times per week. The RN documented on a form titled, "visit note report" the first SAV for the current certification period conducted on 03/29/23, 1 day late from the required 14 day time frame. 2. An interview on 04/20/23 at 3:30 PM with Agency Personnel #1 and #2 confirmed the late SAVs.