Every finding on record at Hopestone Hospice & Palliative Care LLC

Upon patient record review 1 of 14 (Patient #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #10: On admission, the patient declined social work services and there was no evidence of a psychosocial assessment completed by the IDG.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#7,#8,#13) 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 therapy currently associated with laboratory monitoring Patient #1:On the admission assessment dated 05-29-25, the SN documented the patient was using 2 L of O2, however there was no evidence oxygen was listed on the medication profile. COS by documenting an order for oxygen on the medication profile. Patient #2:The SN notes dated 04-26-25 and 04-27-25 indicated an oxygen concentrator and cylinder was in the patient's home, but there was no evidence of oxygen on the medication profile. COS by documenting an order for oxygen on the medication profile. Patient #3: The admission assessment dated 09-23-25 indicated the patient was using oxygen at 4LPM, however there was no evidence of oxygen listed on the medication profile. COS by documenting oxygen on the medication profile. Patient #7: MiraLAX was listed on the medication profile, but there was no evidence of a diluent. COS by adding the ordered diluent on the medication profile. Patient #8: Polyethylene glycol was listed on the medication profile without evidence of a diluent. COS by adding the ordered diluent on the medication profile. Patient #13: The medication profile listed MiraLAX, but there was no evidence of a diluent. COS by documenting the ordered diluent on the medication profile.

Upon patient record review, 3 of 14 (Patient #10, #12,#14) 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 #10: The patient had no advance directives on admission and there was no evidence of interventions or goals documented on the plan of care which related to advance directives or goals of care. COS by adding advance directives to patient chart. Patient #12:The patient's hospice diagnosis was CHF, however, there was no evidence of a care plan for cardiac related interventions or goals. COS by documenting a cardiac care plan. Patient #14: The patient's hospice diagnosis was senile degeneration of the brain, but there was no evidence of a neuro related plan of care. COS by documenting a neuro care plan.

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#13) 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 #1: The admission assessment dated 05-29-25 indicated the patient was using oxygen at 2LPM, however there was no evidence of an order for oxygen. COS by documenting an order for oxygen. Patient #2:The SN notes dated 04-26-25 and 04-27-25 indicated an oxygen concentrator and cylinder was in the patient's home, however there was no evidence of an order for oxygen. COS by documenting an order for oxygen. Patient #3:The admission assessment documented the patient was using 4LPM of O2, however, there was no evidence of an order for oxygen. COS by documenting an order for oxygen. Patient #13: On 09-01-25 and order was written for SN to provide wound care per orders with skin prep daily. However, the order did not state who was to complete wound care on non-nursing days.

Upon patient record review, 2 of 14 (Patient #9, #14) 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 #9: The admission assessment indicated the patient declined Chaplain services, however the plans of care dated 11-05-25 and 11-19-25 documented chaplain visits 1 x mo. The patient did not receive chaplain visits. Patient #14: The plan of care dated 10-30-25 and 11-13-25 documented SW interventions of providing NOMNC and having patient sign revocation form beginning 10-27-25. However, there was no evidence that patient intended to revoke services. COS by removing the documentation from future care plans.

Upon patient record review, 4 of 14 (Patient #5,#6,#7,#10) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patient #5: The medication profile indicated the patient was taking Eliquis and ASA, but there was no evidence of precautions listed on the aide care plan dated 09-09-25. COS by listing the appropriate precautions on the aide care plan. Patient #6:There was no evidence of universal, fall, bleeding or other precautions listed on the aide care plan dated 08-09-24. COS by documenting appropriate precautions on the aide care plan. Patient #7: The medication profile indicated the patient was using oxygen, but there were no precautions listed on the aide care plan dated 10-03-25. COS by documenting oxygen precautions on the aide care plan. Patient #10: The medication profile indicated the patient was using oxygen, but there was no evidence of any precautions listed on the aide care plan dated 11-04-25. COS by listing appropriate precautions on the medication profile.

Upon patient client record review, 2 of 14 (Patient #2,#7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: The SN completed an aide supervisory visit on 04-28-25, however there was no evidence of an aide visit until 04-30-25. Patient #7: The SN documented a supervisory visit on 10-06-25, however, there was no evidence of an aide visit until 10-07-25.

Based on record review and interview, the agency failed to maintain a system of communication to ensure that the care and services provided were in accordance with the plan of care for 1 (#2) of 1 client residing in a skilled nursing facility. This failure resulted in the client not receiving care according to the plan of care. --- Findings: Review of the clinical record of Client #2 revealed the client was admitted to hospice services 7/6/24. Client #2 resided in a nursing facility. The frequency for aide visits was 3 times a week. Further review revealed documentation that the agency had enacted its emergency preparedness program in response to Hurricane Beryl on 7/7/24. Hurricane Beryl caused the Houston area to be affected by winds, rain, flooding, downed trees, and power outages. Client #2 was seen by a nurse on 7/6/24, 7/7/24, and 7/9/24. The aide visited on 7/11/24. No coordination notes to document communication with the nursing facility prior to and during the time of the emergency was found in the medical record. Review of the emergency preparedness revealed the agency was notified by the administrator on 7/7/24 to notify all patients and to ";enter a coordination note for each phone call." In an interview with the Administrator 10/2/24 at 10:45 am, the administrator stated, ";when I initiated the emergency preparedness plan, I told them to call all patients and facilities and to write a progress note about the communication. They didnt document it so we cant prove it was done." In an interview with RN A 10/2/24 at 11:52 am, RN A stated, ";I called them, but I didnt put it in my notes." The agency had a policy (PC.125) titled, ";Hospice Care in a SNF/ NF or ICF/ IID" dated 090124. The policy read in parts: ";...Purpose: To describe the process for providing care to residents of a skilled nursing facility/ nursing facility (SNF/ NF)... ...Policy: ...II. The hospice will assume responsibility for professional management of the patients hospice services provided... Procedure: ...VIII. Coordination/ Continuity of Care: A. The hospice will: 1. Authorize services to be provided in the facility... 3. A. Provide overall coordination of the hospice care of the patient with the facility representatives; b. communicating with the facility representative ...to ensure quality of care for the patient and family; ...d. maintain professional management responsibility and coordination of services to ensure services are furnished in a safe, timely, and effective manner, according to the POC..." The agency had a policy (PC.110) titled ";Coordination of Care" dated 100121. The policy read in parts: ";...Purpose: To ensure coordination of all care provided for patients receiving hospice services and/ or services from other providers. Policy: I. The hospice will provide for and ensure the ongoing sharing of information between disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, by the hospice, or by other providers. II. The hospice will provide for an ongoing sharing of information with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. III. The hospice will develop and maintain a system of communication with each provider of care to ensure development of an integrated plan of care, achieving unduplicated services, and facilitating effective coordination of patient services. Procedure: ...VII. All communications and coordination of care is documented in the clinical record."

Based on record review and interview, the agency failed to have a written agreement or delineation of the agencys responsibilities for 7 (#2, #3, #4, #5, #6, #7, #8) of 7 clients residing in a nursing facility. This failure resulted in the clients not receiving care as outlined on the plan of care. --- Findings: Review of the clinical record of Client #2 revealed the client was admitted to hospice services 7/6/24. Client #2 resided in a nursing facility. The frequency for aide visits was 3 times a week. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #3 revealed the client was admitted to hospice services 7/6/24. Client #3 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #4 revealed the client was admitted to hospice services 7/6/24. Client #4 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #5 revealed the client was admitted to hospice services 7/6/24. Client #5 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #6 revealed the client was admitted to hospice services 7/6/24. Client #6 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #7 revealed the client was admitted to hospice services 7/6/24. Client #7 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. Review of the clinical record of Client #8 revealed the client was admitted to hospice services 7/6/24. Client #8 resided in a nursing facility. No written agreement or delineation of the agency and facility responsibilities was found in the medical record. At 11:40 am on 10/2/24, the surveyor requested a copy of the delineation of duties forms that was given to the nursing facility. The administrator stated, ";there isnt one in the medical record." The agency had a policy (PC.125) titled, ";Hospice Care in a SNF/ NF or ICF/ IID" dated 090124. The policy read in parts: ";...Purpose: To describe the process for providing care to residents of a skilled nursing facility/ nursing facility (SNF/ NF) ... ...Policy: ...II. The hospice will assume responsibility for professional management of the patients hospice services provided... Procedure: ...VIII. Coordination/ Continuity of Care: A. The hospice will: 1. Authorize services to be provided in the facility... 3. A. Provide overall coordination of the hospice care of the patient with the facility representatives; b. communicating with the facility representative ...to ensure quality of care for the patient and family; ...d. maintain professional management responsibility and coordination of services to ensure services are furnished in a safe, timely, and effective manner, according to the POC..."

Observed in Individual Tracer. In 4 of 13 patient records reviewed, an initial bereavement assessment was not conducted. Upon review of documentation in the records, in HV #1, 2 and 3 and RR #1, there was no evidence that an initial bereavement risk assessment had been conducted. This was discussed with the Administrator/Director of Patient Care Services.

Observed in Individual Tracer. In 10 of 10 patient records reviewed, with aide services, the written patient care instructions did not specify the duties of the hospice aide. For example, upon review of RR #1, 2, 4, 5, and 7, it was noted the patient had oxygen therapy ordered; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding oxygen precautions, whether it was continuous or as needed, or if it could be removed during personal care. Upon review of RR #1, 2, 3, 4, 5, and 7, it was noted that the patient was identified as a fall risk with risk scores ranging from 7 - 10; however, on review of the aide plan of care, there were no specific instructions for minimizing risk for falls. Upon review of RR #5, it was noted the patient had dysphagia; however, on review of the aide plan of care, there were no specific instructions provided to the aide regarding swallowing precautions. Upon review of HV #1 the patient was on anticoagulant therapy, Warfarin, but there were no instructions regarding bleeding precautions. This was discussed with the Administrator/Director of Patient Care Services.

Observed in HR File Review. In 2 of 9 HR files reviewed, staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. Organization policy requires annual competency. Upon review of documentation in the personnel records, there was no evidence of competency for HR #4 for two years and HR #7 for one year. This was discussed with the Administrator/Director of Patient Care Services.

Observed in Individual Tracer. In 3 of 3 home visits conducted, the organization did not create an accurate list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, during the medication reconciliation process, for HV #1 Dexilant 30mg, Dexilant 60mg, were on the hospice medication profile but not on the facility profile. Fentanyl was listed as 75mcg on the hospice medication profile and 50mcg on the facility profile. Hydrocodone was listed as every 6 hours as needed on the hospice medication profile and every 4 hours as needed on the facility profile. Hyoscyamine was listed as 1-2 tabs on the hospice medication profile and 1 tab on the facility profile. Morphine concentrate was listed as 0.25 ml on the hospice medication profile and 0.5 ml on the facility profile. Warfarin was listed as 7mg daily except Saturday and 8 mg on Saturday on the facility profile and 8mg weekly on the hospice profile. Zofran, Tessalon pearls, Simbrinza eye drops, and Acetaminophen were listed on the facility profile but not on the hospice medication profile. For HV #2, Acetaminophen rectal suppository was missing from the facility medication profile. Hydrocodone 7.5 mg was listed on the hospice medication profile, but listed as 1 mg three times a day on the facility profile. Novolin was listed as 6 units 3 times a day and per instructions on the hospice profile with no sliding scale specifics. Bisacodyl was listed on the facility medication profile but not on the hospice profile. For HV #3, Fluticasone was listed as 100 mcg on the hospice profile and 50 mcg on the facility profile. Plavix and Tessalon Pearls were on the facility medication profile but not on the hospice profile. This was discussed with the Administrator/Director of Patient Care Services.