Every finding on record at Heart to Heart Hospice of Lufkin, LLC

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. In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient's needs. CLINICAL RECORD 2: The patient elected hospice care on 04/01/2024 with diagnoses of end-stage renal disease, chronic systolic congestive heart failure, chronic obstructive pulmonary disease, and dysphagia. The plans of care for the benefit periods dated 06/24/2025 to 08/22/2025 and from 08/23/2025 to 10/21/2025 ordered HA services five times per week. The HA care plans dated 06/24/2025 and 08/23/2025 (active at the time of the site visit) assigned the HA the relevant tasks: complete bed bath, incontinent care/peri-care, foot care, and skin care to be provided by the HA during each visit. The Registered Nurse (RN) visit note dated 08/18/2025, documented "wound number 3, a stage 2 pressure injury on the patient's sacrum, with an onset date of 07/29/2025, measuring 5 cm x 3.5 cm x 0 cm." A physician's order signed on 08/18/2025 ordered wound care to be performed every two days and as needed by the nurse or caregiver, and that the wound was to be cleansed with soap and water, Thera-honey applied to the wound bed, followed by placement of a 7 x 7 foam dressing (started 08/12/2025). On 09/04/2025, the RN visit note documented: "Wound three: a sacral stage 2 pressure injury measuring 5 cm x 3.5 cm x 0 cm, with a pink wound bed, approximately 90% pink/red and 10% slough. Wound four: a suspected deep tissue injury (DTI) to the right heel, with an onset on 08/21/2025, measuring 3 cm x 3 cm x 0 cm. Wound five: a suspected deep tissue injury (DTI) to the left heel, with an onset on 09/04/2025, measuring 1 cm x 1 cm." A physician's order dated 09/04/2025, ordered wound care: "cleanse the sacral stage 2 wound with soap and water, pat dry, apply alginate to the wound bed, and then place a 7 x 7 foam dressing every two days and as needed for soiling. For the left heel DTI, instructions were to cleanse with soap and water, pat dry, and maintain foam booties on both lower extremities daily." The HA care plan did not include instructions for the HA regarding the wound dressings, should they become soiled, wet, or dislodged during personal care. CLINICAL RECORD 4: The patient elected hospice care on 04/01/2024 with a diagnosis of quadriplegia. The patient resided in a nursing facility (NF). The plans of care for the benefit periods dated 06/06/2025 to 08/04/2025 and from 08/05/2025 to 10/03/2025 ordered HA services five times per week. The HA care plans dated 06/06/2025 and 08/05/2025 (currently active) assigned the HA the relevant tasks: a bed bath, incontinent care/peri-care, and skin care to be performed at each HA visit. A physician's order dated 02/24/2025 ordered wound management for a stage 4 pressure injury on the patient's left hip: "cleansing with wound cleanser, applying collagen powder, followed by alginate, and covering with a dry dressing, to be performed daily by the facility’s wound care nurse and as needed if soiled." During the Registered Nurse (RN) visit on 08/05/2025, the nurse documented that the wound measured 0.2 cm x 1.8 cm x 0.4 cm. On 09/15/2025, the nurse documented the wound as measuring 3 cm x 2.5 cm x 0.2 cm. The HA care plan did not include instructions for the HA regarding the wound dressing, should it become soiled, wet, or dislodged during personal care. The findings were confirmed during a joint review of clinical records and an interview with the Area Executive Director (Personnel Record 11) on 09/25/2025.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During a review of the Volunteer Program documents and interviews with the Area Executive Director (Personnel Record 11) and Volunteer Coordinator (Personnel Record 8) on 09/24/2025, it was determined for the calendar year 01/01/2024 through 12/31/2024, hospice volunteers provided day-to-day administrative or direct patient care services in an amount 0.48% of the total patient care hours of all paid hospice employees and contract staff. During an interview and document review on 09/24/2025, the Volunteer Coordinator, who started on 03/20/2025, confirmed the findings and stated that they currently have two new applicants onboarding and one returning volunteer anticipated to rejoin soon. During a review of the Volunteer Program documents and interviews with the Area Executive Director (Personnel Record 11) and Volunteer Coordinator (Personnel Record 8) on 09/24/2025, it was determined that the average volunteer participation rate for 2024 was 0.48%, below the targeted 5%. The Volunteer Coordinator, who started on 03/20/2025, reported and documented recruitment efforts through online/social media platforms, local high schools and colleges, libraries, and churches. The Area Executive Director and Volunteer Coordinator meet regularly to review volunteer activities, and ongoing engagement with current volunteers documented through in-person meetings, emails, calls, and texts. However, volunteer participation in the first quarter of 2025 was 0%, and in the second quarter, it was only 0.12%. The Volunteer Coordinator noted during the interview that she currently has two new applicants in onboarding and one returning volunteer anticipated to rejoin soon.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed identified that the initial comprehensive assessment was not completed in the first five days from the Election of Hospice Benefits. Clinical Record 7: The patient elected the hospice benefit on 3/11/2022. The initial RN assessment identified that the patient had accepted Social Work services and the Social Worker was to complete an initial assessment. There was a note completed by the Social Worker on 4/19/2022 which stated that the note had been completed "on paper". There was no paper note uploaded to the Electronic Medical Record. There were no communication notes to explain why the initial assessment was not completed within five days. The Executive Director was interviewed on 11/9/2022 and agreed that the initial assessment was not completed by the Social Worker.