Every finding on record at Hospice of South Texas Inc.

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 clinical record review and interview. In 2 of 26 (8%) records reviewed it was revealed that the agency did not ensure that that plans of care identified specific interventions based on problems that were identified in the comprehensive nursing assessments. Clinical Record 1: The comprehensive nursing assessment, dated 6/17/23, documented "perineum area fire engine red" and that the patient was constantly itching in the groin area. Physician orders were received, on that date, to treat "suspected UTI (urinary tract infection) and yeast infection." The plan of care, effective 6/17/23 to current, did not include any problems, goals, or interventions related to skin issues or a urinary tract infection. Clinical Record 20: The initial comprehensive nursing assessment, dated 5/6/23, documented that the patient had 3+ edema from knees to toes. The plan of care did not address any problems, goals, or interventions related to edema. Personnel Record 20: During the joint clinical record review, the Compliance/Quality Associate confirmed that the plans of care for these patients did not address the specific needs identified.

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 5 of 17 (29%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the hospice aide care plans included specific patient care needs or frequency instructions, thus leading the aide to make decisions which were outside the scope of practice. Clinical Record 1: Election of hospice benefit on 3/12/23 and per admission documentation the patient had a gastrostomy tube (G-tube) in place. The aide care plan, effective 3/12/23 to current, included the following relevant tasks: bed bath and assist with dressing. The aide care plan did not inform the aide that the patient had a G-tube or if there were any specific precautions the aide should follow or when to alert the nurse. Clinical Record 7: Hospice aide care plan, effective since patient admission to the in-patient unit (IPU) on 6/12/23, listed the following relevant tasks: meal prep and feeding, oral care, empty foley catheter, peri care, and bed bath. The care plan did not include any specifics for how often these tasks were to be performed. Clinical Record 8: The Hospice aide care plan, effective since patient admission to the IPU on 6/14/23, listed the following relevant tasks: vital signs, shave, incontinent care, and bed bath. The care plan did not include any specifics for how often these tasks were to be performed. Clinical Record 9: The Hospice aide care plan, effective since patient admission to the IPU on 6/17/23, listed the following relevant tasks: assist to toilet, empty foley, vital signs, and foot care. The care plan did not include any specifics for how often these tasks were to be performed. Clinical Record 11: The election of hospice benefit on 4/1/23 and per admission documentation the patient had a colostomy with drain bag in place. The aide care plan, effective 4/1/23 to current, listed the following relevant tasks: bathing - shower chair, every visit. The care plan did not address the colostomy or what if anything the aide needed do that could impact care. Personnel Record 20: Joint record reviews were completed with the Compliance/Quality Associate who agreed that these aide care plans were not specific and should have included information about the G-tube and colostomy. These were also reviewed with the Director of Client Services (DCS, staff 2) who stated, during an interview, that the in-patient aide care plans had been a struggle within the EMR system and agreed that since the aides work full shifts in the IPU some of these tasks are done once a day while others are multiple times a day and the care plan should address this.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that the hospice aides documented notification to the RN of changes in the aide care plan. Clinical Record 13: Patient was admitted on 5/10/23 with a diagnosis of senile degeneration of the brain and documented confusion, thus was not a decision maker. On 5/25/23 the aide documented the patient was "too cold" and that no care was provided for that visit. On 6/6/23 the aide documented that the patient refused the shower. The record did not contain documentation that the RN was informed in either of these instances. Clinical Record 20: On 5/23/23 the aide documented inability to complete the task "change adult diapers" with documented reason, "family is not putting briefs on due to skin being raw." The record did not contain documentation that the RN was informed of a change in the patient's skin condition. Personnel Record 20: Joint clinical record reviews were completed with the Compliance/Quality Associate who stated "They (aides) are supposed to put in the notes that the RN was notified." The DCS also reviewed this, and neither were able to locate any documentation that the aides had notified the RN for either record involved.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (66%) records reviewed, in which volunteer services were requested, it was revealed that the agency did not ensure that volunteer services were provided and included in the plan of care. Clinical Record 11: Election of hospice benefit 4/1/23. The initial comprehensive assessment documented that the family would like to have a Spanish speaking volunteer for patient visits and/or cards of compassion to be sent to the patient. On 5/26/23 the social worker documented that a second request for the volunteer was sent to the volunteer coordinator. The plan of care did not include any documentation regarding the volunteer requests nor if any volunteer had been assigned. An interview was conducted, on 6/21/23, with the volunteer coordinator who indicated that she was aware of the request but did not have any Spanish speaking volunteers. The volunteer coordinator (staff 6) had contacted the family on 6/21/23, and they agreed to a volunteer to write/send cards of compassion, in English that the family would translate for the patient. The volunteer coordinator and the Director of Client Services (DCS) both confirmed that the volunteer services, including attempts to meet the patient needs, should have been included on the plan of care. Clinical Record 19: The initial comprehensive assessment on 5/17/23 documented, "Volunteer cards of compassion are welcomed" and that a request was sent to the volunteer coordinator. The volunteer coordinator reported, on 6/21/23, that this service had not yet been started and thus had not been addressed in the plan of care. Personnel Record 20: The DCS and Compliance/Quality Associate both agreed during an interview on 6/21/23, that the plans of care "Should have included volunteer services," as they were requested and were in the process of being implemented.