Every finding on record at Reflections Hospice of Texas LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) patient records reviewed revealed the agency did not ensure that the initial comprehensive assessment was completed by all the hospice Interdisciplinary Group within the required five (5) calendar days after the election of hospice care. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/15/2025. A review of the hospice Plan of Care dated 10/15/2025 indicated that chaplain services were ordered at a frequency of 1–2 times per month. However, as of the survey date of 10/28/2025, the chaplain had not completed the initial assessment. During a joint record review and interview with the Administrator on 10/28/2025, she acknowledged that the chaplain had not completed the initial assessment within the required five-day timeframe. This was further confirmed during an interview with the chaplain (Personnel Record 4).

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 and supplements. This standard was not met as evidenced by interview and observation. In 2 of 3 (67%) home visits, it was determined that the hospice agency did not ensure that medications present in the patient's home were reviewed for expiration dates as part of the documented comprehensive assessments. CLINICAL RECORD /HOME VISIT 1: The patient elected the benefit on 01/05/2023. During the home visit with the registered nurse (RN) (Personnel Record 2) on 10/29/2025, it was revealed during medication reconciliation with the patient's daughter that the medications in the comfort kit were expired. Morphine Sulfate 20 mg/ml 1/2 to 1 ml by mouth/sublingual every hour as needed (prn) expiration date 07/2024, Acetaminophen Suppository 650 mg 1 rectally every 4 hours prn, lorazepam 1 mg- 1 tab by mouth/sublingual every 4 hours prn, Levsin 0.125- 1 tab sublingual every 4 hours prn, and Phenergan 25 mg- 1 tab sublingual every 4 hours prn all had the expiration date of 01/2024. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the benefit on 05/23/2023. During the home visit with the Chaplain (Personnel Record 4) on 10/29/2025 revealed during medication reconciliation with the patient's daughter that the medications in the comfort kit were expired. Morphine Sulfate 20 mg/ml 1/2 to 1 ml by mouth/sublingual every hour as needed (prn) expiration date 11/2024, Acetaminophen Suppository 650 mg 1 rectally every 4 hours prn, lorazepam 1 mg- 1 tab by mouth/sublingual every 4 hours prn and Levsin 0.125- 1 tab sublingual every 4 hours prn all expired on 05/2024. Phenergan 25 mg- 1 tab sublingual every 4 hours prn all had the expiration date of 09/2025. Following observations of the home visits conducted on 10/29/2025 and an interview with the Administrator, it was confirmed that the comfort kit medications present in the patients' homes were expired and required replacement. The Administrator acknowledged that these patients had experienced extended lengths of stay and had not utilized the comfort kits, resulting in the medications not being routinely checked for expiration.

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 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure the plan of care included planned interventions based on problems identified in the updated comprehensive assessment. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/04/2024 with a primary diagnosis of Senile Degeneration of the Brain. A skilled nursing assessment dated 10/20/2025 documented that the patient was confused, forgetful, yelling out, and easily agitated—though able to be redirected. Despite these noted symptoms, the Plan of Care dated 10/22/2025 from the most recent Interdisciplinary Group (IDG) meeting did not include orders or interventions to assess or manage cognitive impairment, anxiety, or agitation. Additionally, although the patient was identified as a high fall risk, no safety-related problems or interventions were documented in the Plan of Care. During a joint record review and interview conducted on 10/29/2025, the Administrator acknowledged that the Plan of Care did not consistently include appropriate interventions to address problems identified in the ongoing comprehensive assessments. She further explained that the agency began using a new electronic medical record system at the beginning of October, and staff are still in the process of becoming familiar with it.

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 interview and document review. During a review of the agency’s volunteer program and an interview with the Administrator, who also serves as the Volunteer Coordinator, it was determined that the agency does not maintain documentation of ongoing efforts to recruit and retain volunteers. At the time of the survey, the agency had only one active volunteer and was not engaged in any formal recruitment activities beyond informal word-of-mouth outreach. During a review of the agency’s volunteer program and an interview with the Administrator, who also serves as the Volunteer Coordinator, it was determined that the agency does not maintain documentation of ongoing efforts to recruit and retain volunteers. At the time of the survey, the agency had only one active volunteer and was not engaged in any formal recruitment activities beyond informal word-of-mouth outreach.

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation and has the education and experience as required by the governing body. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) review of the personnel file for the current administrator, it was revealed that the agency did not ensure compliance with the state regulatory requirement for the administrator to complete 12 hours of continuing education annually. PERSONNEL RECORD 1: A review of the personnel record for the Administrator, date of hire 09/13/2010, revealed there was no documented evidence that the Administrator completed the 12 hours of continuing education training that was required annually as outlined in the (State) Administrative Code. The state regulation required that the hours must cover topics relevant to agency administration, including but not limited to, ethics, financial management, quality improvement, risk assessment, community resources, marketing, management principles in health-related settings and skills for working with clients and families. The Administrator had not completed this education since 2022. During an interview with the Administrator, she acknowledged that she has not completed the required 12 hours of annual continuing education in accordance with the (State) Administrative Code since the year 2022.