Every finding on record at Prodigious Hospices LLC

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 14 (7%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile. HOME VISIT 1: The patient's date of election was 09/26/2024. The Medication Profile printed 09/22/2025 revealed cholecalciferol (vitamin D3) (Vitamin D3 25 mcg (1,000 unit) tablet) tablet, give 1 capsule by mouth in the morning started 09/26/2024; cyanocobalamin (vitamin B-12) (cyanocobalamin (vit B-12) 1,000 mcg tablet) tablet, give 1 tablet by mouth in the morning started 09/26/2024; ipratropium bromide/albuterol sulfate 0.5 mg-3 mg (2.5 mg base)/3 mL, give 1 vial via nebulizer inhalation three times a day for cough and congestion, started 09/26/2024; multivitamin/ferrous fumarate/folic acid 18-400 mg-mcg, give 1 tablet by mouth in the morning started 09/26/2024; and promethazine HCl (promethazine 25 mg oral tablet) tablet, give 1 tablet by mouth every 6 hours as needed for nausea started 09/26/2024. During the Home Visit (Clinical Record #9) on 09/23/2025 with the Medical Social Worker (Personnel Record #6), the medications at the assisted living facility revealed promethazine HCl tablet 25 mg, give 1 tablet every 4 hours as needed for nausea started 11/28/2022; Diphen/Atrop tablet 2.5mg, give 1 tablet every 6 hours as needed for cough/congestion started 12/26/2023; Hemorrhoidal Cream, give 1 film rectally as needed for hemorrhoids started 12/08/2023; and zofran tablet 4 mg, give 1 tablet every 4 hours as needed for nausea started 10/31/2022. The facility's medication record lacked evidence of the cholecalciferol, cyanocobalamin, ipratropium bromide/albuterol sulfate, and multivitamin/ferrous fumarate/folic acid. The facility's medication record had a different frequency for the promethazine. The agency's medication record lacked evidence of the Diphen/Atrop tablet, Hemorrhoidal Cream, and Zofran. The medications were not reconciled at the time of each comprehensive assessment and/or when new medications were added, or changes were made to existing medications. CLINICAL RECORD 9: The patient's date of election was 09/26/2024. The Hospice SN [skilled nurse] Routine Visit notes dated 07/29/2025, 08/05/2025, 08/13/2025, 08/19/2025, 08/26/2025, 09/02/2025, 09/08/2025, and 09/16/2025 documented, "Medication Reconciliation: Reconciled without issue." The Hospice SN Routine Visit dated 09/22/2025 documented that the physician had ordered that the medications be reconciled to be completed, and medications were changed. CLINICAL RECORD 9: The patient's date of election was 09/26/2024. The Hospice SN [skilled nurse] Routine Visit notes dated 07/29/2025, 08/05/2025, 08/13/2025, 08/19/2025, 08/26/2025, 09/02/2025, 09/08/2025, and 09/16/2025 documented, "Medication Reconciliation: Reconciled without issue." The Hospice SN Routine Visit dated 09/22/2025 documented that the physician had ordered that the medications be reconciled to be completed, and medications were changed. During a joint record review and interview on 09/23/2025, the Administrator/Registered Nurse stated that the registered nurse had made a visit on 09/22/2025 and changed several medications that were completed after the medication profile was printed for the home visit. During a joint record review and interview on 09/23/2025, the Director of Nursing/Bereavement Coordinator confirmed that the nursing documentation from 07/29/2025 through 09/16/2025 stated that the medication reconciliation occurred without issue. On 09/22/2025, the nurse's visit documented reconciling medications to match the facility's medication record. A discussion ensued regarding the review of the nursing visit notes. The Director of Clinical Services/Bereavement Coordinator agreed that the medication reconciliation did not occur at the time of each comprehensive assessment and/or when new medications were added, or changes were made to existing medications.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. In 1 of 3 (33%) home visit observations revealed the agency did not ensure the staff followed the agency hand hygiene policy. Agency Policy: Hand Hygiene IC.15 last reviewed 09/01/2024 stated in part, "Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves." HOME VISIT 3: During the home visit (Clinical Record 8) on 09/24/2025 with the Certified Nurse Aide (CNA) (Personnel Record 9), the CNA was observed donning gloves and removing the patient's shirt and brief. The CNA put the shirt and sheet that had fallen on the floor into the dirty linen bin and the brief into the trash bin. The CNA removed the pair of gloves and donned a new pair. The CNA bathed, dried off, and dressed the patient. The CNA removed the gloves and donned a new pair of gloves to pick up the wet towels on the floor and placed them in the dirty linen bin. The CNA returned the patient by wheelchair to his room. The HA did not decontaminate the hands after removing the gloves. During a joint document review and interview on 09/24/2025, the Director of Clinical Services/Bereavement Coordinator (Personnel Record 2) agreed the staff did not follow the hand hygiene policy.

It is required that the hospice must designate a physician to serve as medical director. The medical director must be a Doctor of Medicine or osteopathy who is an employee, or is under contract with the hospice. When the medical director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the medical director. This standard was not met as evidenced by document review and interview revealed during a review of contracts, the Medical Director Agreement contract with the (Name and State) lacked evidence that the medical director designees were listed by name on the contract. The Medical Director (Personnel Record 3) was the only name listed on the contract. The 26 (State)Administrative Code § (Number) required that the physician designee(s) or other contracted physicians be listed by name in a hospice contract. 26 (State) Administrative Code § (Number) effective 05/01/2019, stated in part, " (b) A hospice must designate in writing a physician designee to assume the same responsibilities and obligations as the medical director when the medical director is not available. (c) A hospice may contract for a physician to serve as its medical director with either a self-employed physician or a physician employed by a professional entity or physicians group. The contract for medical director services must specify the name of the physician who assumes the medical director responsibilities and obligations." During a document review and interview on 09/23/2025, the Administrator/Registered Nurse (Personnel Record 1) confirmed that the Medical Director was the only name on the contract agreement. During a review of contracts, the Medical Director Agreement contract with The University of Texas Health Science Center at San Antonio lacked evidence that the medical director designees were listed by name on the contract. The Medical Director (PRR #3) was the only name listed on the contract. The 26 Texas Administrative Code § 558.858 required that the physician designee(s) or other contracted physicians be listed by name in a hospice contract.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This standard was not met as evidenced by document review and interview revealed after reviewing the volunteer program, the documentation lacked evidence of efforts to recruit volunteers from September 2024 through June 2025. The documentation lacked evidence of retention efforts from September 2024 through August 2025. During a joint review of the volunteer program and interview on 09/24/2025, the Volunteer Coordinator (Personnel Record 7) reported that they began the agency/position in May 2025 and started recruiting in July 2025. The Volunteer Coordinator declined to have any other recruitment efforts from before July 2025. The Volunteer Coordinator stated that some retention efforts had been initiated but were not documented electronically or on paper. During a joint review of the volunteer program and interview on 09/24/2025, the Administrator/Registered Nurse (Personnel Record 1) confirmed that the recruitment efforts were not documented from September 2025 through June 2024, and retention efforts through August 2025. Upon reviewing the volunteer program, the documentation lacked evidence of efforts to recruit volunteers from September 2024 through June 2025. The documentation lacked evidence of retention efforts from September 2024 through August 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 revealed after reviewing the volunteer program, the documentation lacked evidence that the 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. The volunteer hours totaled 131.75 and direct patient care hours totaled 3318 hours which equaled 3.97% for September 1, 2024-August 31, 2025. During a joint review of the volunteer program records and interview on 09/24/2025, the Volunteer Coordinator provided the hours for volunteers and direct patient care service hours. The total percentage was 3.97% which was below the 5% requirement. During a joint review of the volunteer program records and interview on 09/24/2025, the Administrator/Registered Nurse confirmed that the agency did not meet the 5% volunteer requirement. Upon reviewing the volunteer program, the documentation lacked evidence that the 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. The volunteer hours totaled 131.75 and direct patient care hours totaled 3318 hours which equaled 3.97%.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment, and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by document reviews, interviews and observations. In 3 of 3 (100%) observations during home visits revealed that the patient/family did not complete an individualized emergency plan in the home as required by the agency Emergency Preparedness Plan policy. Agency Emergency Preparedness and Response Plan Policy E.8, "Emergency Preparedness and Response Plan (Reviewed: 4/2022)," stated in part, "The Agency will assist with the completion of individual emergency plans for each patient that will be included as part of their comprehensive patient assessment. The Agency will provide and discuss the emergency preparedness information with each patient" Clinical Record 1/Home Visit 1: The patient was admitted on 10/3/22. During the patient observation visit on 11/30/22, the patient home information reviewed lacked an Individualized Emergency Plan. The information identified in the patient home was general emergency information. Clinical Record 2/Home Visit 2: The patient was admitted on 10/11/22. During the patient observation visit on 11/30/22, the patient home information reviewed lacked an Individualized Emergency Plan. The information identified in the patient home was general emergency information. Clinical Record 4/Home Visit 3: The patient was admitted on 10/6/22. During the patient observation visit on 12/1/22, the patient home information reviewed lacked an Individualized Emergency Plan. The information identified in the patient home was general emergency information. Interview on 12/1/22 with the Administrator and Director of Clinical Services confirmed the above findings.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician (L683) a copy of the hospice discharge summary, and the patient's record, if requested. This standard is not met as evidenced by a review of a clinical record, a document and interview. In 1 of 1 (100%) clinical record reviewed for patient/family that revoked hospice services, the agency did not forwarded a copy of the hospice discharge summary to the patient's attending physician. The Agency Revocation Policy Policy PE.7, "Patient Revocation (Reviewed: 4/2022)," stated in part, "The Hospice will forward copies of the following information to the patient's attending physician: A. The hospice discharge summary that includes but is not limited to 1. A summary of the patient's care (pain management, symptoms and treatments); 2. The patient's current plan of care, including the current medication profile; 3. The latest physician orders; and 4. Any other documentation requested or that may assist with the patient's post-discharge continuity of care." Clinical Record 3: The patient was admitted on 4/4/22. The patient's family revoked hospice services on 4/5/22 to pursue aggressive treatment. The record lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the patient's attending physician. Interview on 12/1/22 with the Administrator and Director of Clinical Services confirmed the above finding.