Every finding on record at Integracare of West Texas-Hospice, LLC

Upon patient record review, 2 of 19 (Patients #4,#8) 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 side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 4: The medication profile contained active Paxlovid instructions for an order 12/21/25 that was for 5 days only. Corrected on site with medication profile updated. Patient 8: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen included on the medication profile. Corrected on site with medication profile updated.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 13: There was no evidence of a comprehensive physical assessment by an RN between 12/23/25 and 1/13/26.

Upon patient record review, 3 of 19 (Patients #2,#3,#6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 2: There was no evidence of a wound assessment and measurement prior to receiving wound care orders 1/16/25 as required per agency policy. Patient 3: The medical record contained nursing documentation upon admission identifying patient had a peritoneal wound. There was no evidence of weekly wound assessments and measurements as required per agency policy. Patient 6: The medical record contained nursing documentation identifying patient had wounds to bilateral heels. There was no evidence of weekly wound assessments and measurements between 12/31/25 and 1/14/26 as required per agency policy.

Upon patient record review, 4 of 19 (Patients #3,#9,#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 3: The medical record contained nursing documentation upon admission identifying patient history of a CVA and seizures. There was no evidence of problems, goals, and interventions related to neurological dysfunction and seizure precautions included in the plan of care. Corrected on site with plan of care update. Patient 9: The medical record contained nursing documentation upon admission identifying patient history of a CVA and seizures. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 12: The medical record contained nursing documentation upon admission identifying patient history of falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient history of CVA and varices related to liver disease. There was no evidence of problems, goals, and interventions related to neurological dysfunction and risk for bleeding included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 2 of 19 (Patients #2,#8) 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 2: The aide care plan identified patient had an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency and maintenance. Corrected on site with order clarifications. Patient 8: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order clarifications.

Upon patient record review, 5 of 19 (Patients #3,#4,#7,#8,#14) 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 equipment and supply needs. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 4: The medical record contained nursing documentation upon recertification assessment 12/17/25 identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of an order for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon recertification assessment 11/19/25 identifying patient use of a lift for transfers. There was no evidence of an order for the DME included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a walker and shower chair, and 1/7/26 identifying use of trapeze bar. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received.

Upon patient record review, 2 of 19 (Patients #7,#18) 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 7: The plan of care included two active code statuses of both full code and DNR. The plan of care was not updated to remove the full code status when DNR form was signed. Corrected on site with plan of care update. Patient 18: The patient was discharged from hospice 12/17/25. There was no evidence the plan of care was updated to included problems, goals, and interventions related to discharge planning.

Upon client record review, 2 of 19 (Patient #10, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 10: The medical record contained an order for a PT assessment 12/10/25. There was no evidence the agency arranged for the PT evaluation to be completed. Corrected on site with agency communication with contracted agency. Patient 11: The medical record contained an order for spiritual care visits once weekly. There was no evidence of a visit completed the week of 12/7/25. Corrected on site with late data entry of reason for missed visit.

Upon observation, there was no evidence a written plan of correction is developed in response to any QAPI activity that does not meet an acceptable threshold. During QAPI meeting 11/13/25, the hospice agency completed patient chart audits identifying compliance of 90% was not met for medication and treatment orders, following plan of care, aide and LPN supervisory visits, and wound care. There was no evidence of a plan of corrections to address the topics when threshold was not met.

Upon observation and home visit, 1 of 4 (Patients #5) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During observation of the home visit, the RN placed stethoscope around neck prior to and after use on patient, and prior to and after cleansing, before placing back into the bag. The RN also did not use gloves while cleansing the equipment and held the equipment between cleansing and returning them to the bag.

Upon patient record review, 1 of 19 (Patient #17) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved Patient 17: The medical record contained a bereavement care plan with task for monthly contact with the bereaved unless refused and evaluated as low risk, due to initial bereavement assessment as high risk. There was no evidence of any contact with the bereaved after death.

Upon patient record review, 2 of 19 (Patients #6,#7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 6: The medical record contained wound care orders 12/25/25 and 1/14/26. There was no evidence of instructions for the aide regarding treatment of wounds during showers on the aide care plan. Corrected on site with aide care plan update. Patient 7: The medical record contained nursing documentation upon admission identifying patient is a max assist for transfers. There was no evidence of transfer instructions on the aide care plan. Corrected on site with aide care plan update.

Upon patient record review 1 of 19 (Patient #8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 8: The medical record contained an order for aide visits three times weekly. There was no evidence of visits completed the week of 12/14/25. Corrected on site with late data entry of facility refusal.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer utilization rate was 1.54% for 2025.

Upon personnel record review, 1 of 16 (Personnel #15) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 15: There was no evidence the contracted personnel received orientation to hospice philosophy prior to patient contact.

Upon patient client record review, 1 of 19 (Patient #6) did not have evidence that each patient record contains Advance Directives. Patient 6: The medical record contained nursing documentation upon admission identifying patient had a medical power of attorney in place. There was no evidence of MPOA documentation in the record.

Upon patient client record review, 1 of 19 (Patient #18) did not evidence that each patient record contains physician orders. Patient 18: Patient was discharged from hospice 12/17/25 with no evidence of a physician order to discharge.

Upon inpatient contract review, 1 of 7 (Kirkland contract) did not have evidence that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished.

Upon inpatient contract review, 1 of 7 (Kirkland contract) did not have evidence that the inpatient provider has established patient care policies consistent with those of the hospice and agrees to abide by the palliative care protocols and plan of care established by the hospice for its patients.

Upon inpatient contract review, 1 of 7 (Kirkland contract) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.

Upon inpatient contract review, 1 of 7 (Kirkland contract) did not have evidence of a method for verifying that the requirements for ACHC standard HSP1-8B and CFR 418.108c (1)-418.108c(5) are met.

Upon client record review, 1 of 19 (Patient #6) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 6: The medical record contained an order for nursing visits twice weekly. There was no evidence of a second visit completed the week of 1/4/26. Corrected on site with late data entry of patient refusal for visit.

Upon patient record review 1 of 13 (Patient #12) 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 #12 The patient was admitted on 5/5/22 and there is no evidence in the patient record that a spiritual assessment was completed.

Upon patient record review, 3 of 13 (Patient #3, 5, 10) 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 side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 The medication entry on 8/11/22 for "Nystatin 100,000 units powder to be applied under skin folds BID x 7 days", does not indicate the specified area of skin folds are not identified. Patient #5 The medication entry for "Lomotil 2.5mg-0.025 2 tabs at first loose stool" no evidence of a frequency to be given. Patient #10 The medication entry on 4/17/22 for "Medihoney topical paste apply 3 x week to wounds beds" does not specify the location of the wound.

Upon patient record review, 5 of 13 (Patient #1, 2, 3, 4, 11) 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 #1 The plan of care includes a problem statement for Altered cardiac/circulatory system that does not contain interventions or goals. The patient has a history of DVT and was taking Eliquis upon admit, now changed to Aspirin. Patient #2 The plan of care does not include a problem statement for safety although the patient has altered mental status due to metabolic encephalopathy related to her hospice diagnosis and was found on the floor of her room at the time of her admit to services. She requires a fall mat next to her bed and assistance with all ADL's and ambulatory/transfer needs. Patient #3 The plan of care includes problem statements for Altered Genitourinary and Altered Skin Integrity, with no interventions or goals. The patient has incontinence and a history of recurrent rashes that require evaluation and medication. Patient #4 The plan of care includes a problem statements for Need to refill planner device, there are no interventions or goals listed. Patient #11 The plan of care includes a problem statement for Altered Cardiac/Circulatory system, but does not contain goals or interventions.

Upon patient record review, 3 of 13 (Patient #3, 5, 10) 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 #3 Medication orders initiated on 8/11/22 for Nystatin 100,000 units powder to be applied under skin folds BID x 7 days, the area of skin folds are not identified. Patient #5 The patient has ordered Lomotil2.5mg-0.025 2 tabs at first loose stool. The order is not written as a PRN order, but confirmed with facility that this is only given as needed. Patient #10 Medication orders written on 4/17/22 for Medihoney topical paste apply 3 x week to wounds beds. The order does not specify the area of wounds.

Upon patient record review, 3 of 13 (Patient #6, 7, 11) 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 #6 The record indicates orders on 9/13/22 for Physical Therapy Evaluate and Treat, there is no evidence in the record of a problem statement with interventions and goals related to this order. Patient #7 The patient record contains orders to discontinue spiritual care services effective 1/24/23, the plan of care has not been updated to resolve the problem statements, interventions and goals. Patient #11 The patient has evidence of a sacral wound documented on 3/25/22 with ongoing wound care until his death, there is no problem statement with interventions or goals for the management of the wound.

Upon client record review, 2 of 13 (Patient #6 and 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 The patient record reflects an order on 9/13/22 for "Physical Therapy: Evaluate and treat", but does not specify a quantity of visits for care. Patient #12 The patient was admitted on 5/5/22 and an order for Spiritual Care evaluation was entered. There is no evidence in the patient record that the spiritual care needs of the patient were evaluated within 5 days or to date, there is no evidence that the patient/family declined services.

Upon patient record review, 1 of 13 (Patient #6) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #6 On 9/13/22 and order for Physical Therapy evaluate and treat was entered. The patient received 12 visits with no evidence of shared information throughout the patient services with the contracted service provided, and the IDG was not informed of the patient care.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #3 During the home visit, it was witnessed that the RN donned a single pair of gloves, utilizing the same gloves throughout the patient visit while assisting the patient with changing her shirt, taking vital signs, picking up items off of the floor, documenting on her tablet and retrieving/replacing items into her bag. It was also witnessed that the RN was utilizing a tote bag made of cloth with a single opening, placing all items into the same pocket before and after use, including her stethoscope, blood pressure cuff, thermometer, tablet and wipes without properly cleaning each item.

Upon patient record review, 1 of 13 (Patient #5) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #5 The hospice has not provided an updated medication list to the facility since 12/5/22. There are noted medication changes in the patient hospice record effective 12/19/22.