Every finding on record at Hospice Austin

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; Herbal remedies; 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 record review and interview. In 1 of 30 (3%) clinical records reviewed, it was revealed that the agency did not ensure the medication profile was updated with a full review of all medications that the patient was taking. CLINICAL RECORD 14: The hospice benefit of the election was on 09/11/2024 with a diagnosis of esophageal obstruction. The updated nursing assessment, dated 03/24/2025, documented that the patient was using oxygen prn (as needed). All updated assessments through 04/10/2025 documented the use of oxygen prn. The medication profile did not include oxygen or a review of oxygen for side effects. During a joint record review on 04/15/2025, the Quality Manager agreed that the medication profile had not been updated to include all current medications and that the review of medications for interactions was accomplished through the medication profile setting.

It is required that each patient’s individualized written plan of care Identify planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 27 (11%) clinical records reviewed, for routine hospice patients, it was revealed that the agency did not ensure that the plan of care included interventions for problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4: The hospice benefit of election was on 08/10/2022 for a diagnosis of cerebral vascular accident and dementia. The initial comprehensive assessment (08/10/2022) documented aspiration precaution and assistance needed with feeding. Updated nursing assessments documented use of thickened liquids, need for feeding, and monitoring of weight by the facility. The initial plan of care and updated plans of care, to include the documented updates every two weeks, did not include any interventions for these nutrition problems as of the review on 04/15/2025. CLINICAL RECORD 14: The hospice benefit of the election was on 09/11/2024 with a diagnosis of esophageal obstruction. The updated nursing assessment, dated 03/24/2025, documented that the patient was using oxygen prn (as needed). All updated assessments through 04/10/2025 documented the use of oxygen prn. The plans of care, to include the documented updates every two weeks, did not include any respiratory interventions or oxygen interventions, as of the review on 04/15/2025. CLINICAL RECORD 18: The Hospice benefit of election was 01/16/2025. with primary diagnosis of heart disease, and CHF (congestive heart failure). On 01/20/2025 there was a physician order for oxygen 1-2 liters per nasal cannula for increased shortness of breath. Documentation revealed the patient was using it especially at night. The plan of care, effective 01/16/2025 to current, and the documented updates every two weeks, were not updated with interventions for the oxygen, as of the review on 04/15/2025. During a joint record review on 04/15/2025, the Quality Manager stated that the interventions for the problems identified were not documented.

It is required that the hospice inpatient facility has documented and dated written reports of Life Safety Code fire drills at varied times on all shifts. This standard was not met as evidenced by observation, document review, and interview. 1 of 1 (100%) of reviewed inpatient facilities revealed that the hospice did not ensure the documented and dated reports of fire drills were completed as required per the agency's procedure.. The agency procedure for the "Fire Drill Checklist, Fire Safety C2-058 #10" stated in part, "Complete Fire Drill Checklist and return to the Safety Officer." During the inpatient facility tour conducted on 06/28/2022, the fire drill checklists reviewed revealed the required completion of items #1 - # 15 were not documented on the agency's form at each fire drill as per the agency's procedure: The drill conducted at 6:05 am on 12/08/2020 was missing documentation of items #3 through #14; The drill conducted at 5:52 am on 04/14/2021 was missing documentation of item #6; The drill conducted at 3:40 pm on 03/24/2022 was missing documentation of items #8 through #14; The drill conducted at 12:31pm on 05/13/2022 was missing documentation of items # 6 through #15; The drill conducted at 6:06 am on 06/20/2022 was missing documentation of items #5 through #14. The Safety Manager, during an interview, validated that the drills were conducted but did not "adequately document all required areas during the drill."

It is required that the hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any). This standard was not met as evidenced by review of clinical records and interview. 1 of 21 (5%) records reviewed revealed the hospice did not ensure that hospice care and services provided follow the individualized plan of care. Record #48278 was reviewed and identified the patient elected hospice care on 03/22/2022. The the initial comprehensive documented the patient had a power port. The initial plan of care dated 03/22/2022 documented the power port to be flushed monthly. On 04/08/2022 the nursing assessment documented flushing of the power port with saline and heparin. On 06/06/2022 the nursing assessment documented flushing of the power port. The port was flushed with no resistance or signs and symptoms of infection on 06/06/2022. There was no documentation that the port was flushed for the month of May. During an interview the Director of Quality confirmed that the infusion documentation was not sufficient and that the care documented did not follow the plan of care.

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. This standard was not met as evidenced by review of clinical records, document review and interview. 3 of 21 (14%) records reviewed revealed the hospice failed to ensure that the plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. The agency policy #848 "Initial Plan of Care" (date of review 05/15/2019) stated in part, "The initial plan of care intervention.....The plan of care will be updated by the interdisciplinary team". Record #48278 documented the initial comprehensive assessment completed on 03/22/2022 documented, "a power port." The initial plan of care and updated plans of care did not document interventions or goals for management of the power port. Record #38362 with benefit of election 05/03/2022 documented a port-a- catheter on the initial comprehensive assessment. The initial and updated plans of care did not document interventions to include port-a-catheter management. The nursing assessment documented 06/03/2022 documented port flushed with no problems. The medication profile did document medications heparin and saline flush of catheter. Record #65125: The updated comprehensive assessment dated 06/27/2022 documented that a midline catheter was placed and new orders were received for a daily antibiotic infusion and the pain medication Dilaudid via a patient control anesthesia (PCA) infusion. The plan of care was not updated as of 06/29/2022 to include interventions or goals for the midline catheter. During an interview, the Director of Quality and Director of the In-patient Unit confirmed that the plans of care lacked all interventions and goals

It is required that each patient room in the hospice facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by document review and interview that 1 0f 1 (100%) of inpatient units reviewed, the water temperature logs did not follow the required state guidance. The state's Administrative Code, 26, Part1, Chapter 554, Sub-chapter D, Division 5, (1) (F) stated: "For design calculation purposes, resident-use hot water must not exceed 110 degrees Fahrenheit at the fixture. For purposes of conforming to licensure requirements, an operating system providing water from 100 degrees Fahrenheit to 115 degrees Fahrenheit is acceptable." Water temperature logs for 2022 documented the following: March 2022 a temperature of 120 degrees, with an adjustment made. There was no documented re-check to assure the temperature adjusted to 115 degrees; April 2022 a temperature of 118 degrees. There was no documented adjustment to 115 degrees made; May 2022 a temperature of 118 degrees. There was no documented adjustment to 115 degrees made; June 2022 a temperature of 118 degrees. There was no documented adjustment to 115 degrees made. The Safety Coordinator and Director of Clinical Services interviewed on 6/30/2022 validated that the temperatures in 2022 exceeded the required state temperature and did not document an adjustment to the required 115 degrees.

It is required that the hospice inpatient facility provides meals to each patient that are obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by observation that in 1 of 1 (100%) of inpatient units failed to label the date of opening all containers in the patient/family refrigerator. During the Life Safety tour conducted on 06/28/2022, the refrigerator was found to contain an opened, partially used 32 ounce jar of tomato soup and an opened 28 ounce jar of salsa that were not dated when opened. The Director of Inpatient interviewed on 06/29/2022 validated that the family who opened the jars on 06/28/2022 had planned to finish the contents but the patient status changed and the jars were not dated.