Every finding on record at Road to Happiness Home Care Services, LLC

Observed in Record Review. In 1 of 5 patient records reviewed, the record did not contain an accurate list of medications. In review of the medical record RRNHV # 5 the medication list includes Rexulti 1 mg tablet by mouth daily which the caregiver/granddaughter reports the patient has not taken for sometime, as well as Lisinopril 10 mg 1 tablet by mouth daily which the patient receives prn. The caregiver/granddaughter also reported that the patient started Flomax about two weeks ago which is not included on the medication list and reports that the hospice nurse made a visit on 10/22/2025. This was validated with the Owner/Administrator.

Observed in Record Review. In 1 of 5 patient records reviewed, the patient record was not complete and accurately documented. In review of the medical record RRNHV # 5 and in conversation with his granddaughter who is the primary caregiver and manages the patient's medications she reported that the patient is allergic to Penicillin although No Known Allergies are documented in the medical record. This was validated with the Owner/Administrator.

Observed in Tracer Activities. In 1 of 9 tracers conducted, the surveyor observed that there was no initial EM training for volunteer staff. This was reviewed and validated with the HR Director.

Observed in Record Review. In 1 of 9 patient records reviewed, the social worker failed to complete their assessment within 5 days after the election of hospice. In HOSRRNHV #4 the social worker completed the initial assessment on day 8. This was reviewed and validated with the Administrator.

Observed in Record Review. In 10 of 13 patient records reviewed, the initial bereavement assessment was not completed. In HOSRRHV #2 the caregiver daughter, and her two brothers did not have a bereavement assessment completed. In HOSRRNHV #1 there is no bereavement assessment for the daughter. In HOSRRNHV #2 the caregiver and friend did not have a bereavement assessment completed. In HOSRRNHV #3 the son did not have a bereavement assessment completed. In HOSRRNHV #5 and HOSRRBRV #2 the wife did not have a bereavement assessment done. In HOSRRNHV #6 the niece did not have a bereavement assessment completed. In HOSRRDC #1 there is no bereavement assessment for the wife or the daughter. In HOSRRDC #2 and HOSRRBRV #1 the son did not have a bereavement assessment done. Per the agency policy on Bereavement, a bereavement assessment must be completed on all family members or caregivers involved in the patient's care. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to assess the patient's medication management process. In HOSRRHV #2 the medication list states patient has no known allergies. Per the patient's daughter and caregiver she is allergic to furosemide and ciprofloxacin. When asked how long the patient has had these allergies she states for years. The organization has the Comprehensive Assessment Policy which states that allergies will be reviewed during the various comprehensive assessments. This was reviewed and validated with the Administrator.

Observed in Record Review. In 5 of 9 patient records reviewed, the hospice surveyor observed that the organization did not ensure that the goals established on the plan of care were measurable and individualized. In HOSRRHV #1 the pain goal stated, Pt will maintain pain controlled at an acceptable level for Pt/CG. In HOSRRHV #3, HOSRRNHV #2, and HOSRRNHV #3, and HOSRRNHV #5 the care plan states that the patient will have acceptable level of pain. The Pain Management policy states that the nurse will assess the patient's pain goal, in order to develop an individualized and measurable plan of care. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 9 patient records reviewed, the hospice surveyor noted that in HOSRRHV #2 there were PRN orders for 2 pain medications Norco 10 mg-325 mg tablet one tablet by mouth every 6 hours as needed for pain and Acetaminophen 300 mg codeine 30 mg tablet one tablet by mouth every 4 hours as needed for pain. The orders did not include which medication to use first or for what type of pain, e.g. mild moderate or severe.. This was reviewed and validated with the Administrator. Observed in Record Review. In 1 of 9 patient records reviewed, the organization failed to plan the patient's care. The hospice surveyor observed in HOSRRHV #2 where the patient had a foley catheter present and the provider submitted an order that stated change foley catheter. The order did not include documentation on the catheter size, the size of the balloon, and how much and what type of fluid to use to fill the balloon. The order was incomplete. This was reviewed and validated by the Administrator.

Observed in Record Review. In 4 of 9 patient records reviewed, the hospice surveyor noted that the RN did not have a care plan for bleeding precautions. In HOSRRHV #1 the patient was on Apixaban 5 mg by mouth twice a day, and the RN did not include a care plan on bleeding precautions. In HOSRRHV #3 the patient had orders for Plavix 75 mg every day and ASA 81 mg every day and the RN care plan did not include a care plan for bleeding precautions. In HOSRRNHV #1 the patient is on Apixaban 75mg every day and there is no care plan on bleeding precautions. In HOSRRNHV #6 the patient was on ASA 81 mg every day and Clopidogrel 75 mg per day and there was no RN care plan for bleeding precautions. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the plan of care was not followed. In HOSRRHV #3 also had an order for PEG tube flushes the order for water flushes were 30 ml of water before administering meds and flush with 10 ml of water between each med and after final medication flush with 30 ml of water. Per the daughter she is not following this but flushing with about 60 ml of water before and after meals and some with medication. The administrator stated they did not have a protocol.The RN care plan stated that the PEG tube should be flushed per protocol. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the home health aide failed to follow the Hand Hygiene Policy. In HOSRRHV #1 the home health aide entered the home and did not sanitize her hands prior to touching the patient and before donning her gloves per the organizations Hand Hygiene Policy. The home health aide did not bring in any hand sanitizer for the visit. The Administrator stated that the staff are given hand sanitizer and that they are instructed to come to the office to pick up as needed. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, where bereavement services were provided the hospice surveyor observed that the deemed hospice failed to complete a bereavement plan of care in HOSRRBRV #1. In HOSRRBRV #2 the policy states that mailings and calls will be provided and there were no calls or mailings for 8 months and no documentation of decline from family. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, the hospice surveyor observed that the home health aide competencies at hire were not completed. The aide was hired 2 months ago. This was reviewed and validated with the HR Director. Observed in Tracer Activities. In 1 of 9 HR files reviewed, the organization failed to deem the initial competency of the home health aide. The home health aide did not have a completed initial competency and she had been hired 2 months ago. This was reviewed and validated with the HR Director. Observed in HR File Review. In 1 of 9 HR files reviewed, the deemed hospice did not have a completed competency assessment on the home health aide who was hired 2 months ago. This was reviewed and validated with the HR Director.

Observed in Record Review. In 1 of 9 patient records reviewed, the hospice surveyor noted n HOSRRNHV #3 that the home health aide visit assignment did not include specific tasks. The Plan of Care only included frequency of two times per week. This was reviewed and validated with the Administrator. Observed in Record Review. In 3 of 9 patient records reviewed, the hospice surveyor observed that the aide care plan did not include safety precautions. In HOSRRHV #1 the patient was on an anticoagulant and was a fall risk and neither were entered into the aide care plan. In HOSRRNHV #1 the aide care plan failed to include, fall risk, bleeding precautions or instructions what to do if wound dressing is compromised. In HOSRRNHV #5 the aide care plan did not include fall risk as a precaution. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, where the home health aide was present the nurse surveyor noted that the Home Health aide did not follow the aide care plan. In HOSRRHV #1 the aide care plan states that the home health aide will provide oral care with each visit. The home health aide did not offer or provide oral care. This was reviewed and validated with the Administrator.

Observed in Tracer Activities. In 4 of 9 HR files reviewed, the surveyor observed that the organization failed to provide orientation to staff. In HR# 5 Medical Director, HR #6 Alternate Medical Director, HR #8 Volunteer, and HR #9 Volunteer Coordinator failed to be oriented to the organizational policies and procedures related to the provision of care, treatment and services in the environment of infection control and emergency management. This was reviewed and validated with the HR Director.

Observed in HR File Review. In 3 of 9 HR files reviewed, the hospice surveyor noted that initial competencies were not defined for the, Medical Director, Alternative Medical Director, and Volunteer Coordinator. This was reviewed and validated with the HR Director.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice surveyor observed that the medication list in the home was inaccurate. In HOSRRHV #1 the nurse surveyor observed that the patient was taking FeroSul 325 mg tablets, the medication list states the patient is taking this by mouth daily but the prescription bottle states the patient is to take the medication twice a day. The patient is also taking Tamsulosin 0.4 mg the medication list states to take the medication at bedtime but the prescription bottle states a dinner. The patient is also taking Carvedilol 12.5 mg , the medication list states to take twice a day and to hold if diastolic BP<110 and pulse <60, the bottle states to take one in the morning and one in the evening with no indication when to hold the medication. In HOSRRHV #3 the patient has an order on the medication list for Zoloft 50 mg every day via G tube but daughter states she only gives it as needed for agitation. This patient has recurrent agitation and combativeness. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice surveyor noted that the medication list was not accurate. For example in HOSRRHV #1 during medication reconciliation the hospice surveyor noted that the patient was currently taking the following medications but they were not on the patient's medication list, Spironolactone 25 mg 1 tablet by mouth every day, Furosemide 20 mg 1 tablet by mouth before breakfast, and Levetiracetam 50 mg one by tablet by mouth every day. This was reviewed and validated with the Administrator

Observed in Record Review. In 2 of 2 patient records reviewed, where the patients were discharged the hospice surveyor observed that the deemed hospice agency did not provide the inpatient facility with a transfer summary for HOSRRDC #1. The organization did not follow its policy on Transfer and Discharge. In HOSRRDC #2 the deemed hospice failed to send a discharge summary to the community provider after a live discharge. This was reviewed and validated with the Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, the hospice surveyor noted that a criminal background check had not been conducted on the volunteer. This was reviewed and validated with the HR Director.

Observed in Record Review. A review of four records were conducted. Visits made according to orders. Record 2 lacked orders for nursing frequencies. This was confirmed by the administrator.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of a critique for the drills and tabletop exercises for 2020 and 2021 related to Freeze, Flood and Active Shooter.

Observed in Record Review. In 1 of 11 patient records reviewed, In record review #1 there was no documentation in the initial assessment or any other SN notes of a wound on the patient's leg to describe the wound, measurements, treatments by husband etc. Additionally, in the same record the patient's son documented and completed the Nursing Assessment for Psychosocial and Spiritual Assessment and this was confirmed by the DON. Observed in Tracer Visit. In 3 of 3 home visits conducted, it was noted that in all three skilled nursing visits the patient was not assessed as required in agency policy, Nursing Services which stated that every skilled nursing visit the patient is to have ongoing assessment. For example, in home visit #1 the RN/DON did not perform an assessment of the patient's gastrointestinal system, did not listen to bowel sounds or inquire about bowel movements, did not assess the Genitourinary system related to urinary function, signs and symptoms of UTI, did not assess the skin, feet, diaper area, etc. The patient was incontinent, diapered and bedbound. In home visit #2 the RN/DON did not perform an assessment of the patient's lung sounds, gastrointestinal system, did not listen to bowel sounds or inquire about bowel movements, did not assess the Genitourinary system related to urinary function, signs and symptoms of UTI, did not assess the skin, feet, diaper area, etc. The patient was incontinent, diapered and bedbound. In home visit #3, the RN/DON did not assess arm circumference and did not assess a wound on the patient leg. Each of these patient's were only seen by the RN with a frequency of one time per week. This was discussed with the DON.

Observed in Record Review. In 5 of 11 patient records reviewed, it was noted in review of records for home visit #1 and #3, and record reviews #1, 2 and 8 that there was no documentation of a bereavement risk assessment. This was confirmed by the DON.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that no goals contained measurable outcomes or time frames. For example the following were some of the stated goals: Pain will be at an acceptable level, Family will demonstrate improved coping skills, Read scripture and pray, skin integrity will be maintained, Care will be provided in a safe and trusting environment, Adequate food and fluids to maintain comfort and caregiver will restore balance and harmony to negative encounters. This was discussed with and confirmed by the DON.

Observed in Record Review. In 6 of 11 patient records reviewed, it was noted that the plan of care did not contain scope and frequency for all care. For example, in review of record for home visit #1 #2, #3 and record reviews #1 and # 2 it was noted that the chaplain visited the patient 1-2 per month however there were no order for visits or frequencies for this discipline. In record review #1 there were no visit frequencies for nursing, homemaker or spiritual care. This was confirmed by the DON.

Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that there were no orders for wound care. For example, in review of record for home visit #2 the nurse documented providing care to a sacral wound as cleaned and applied medihoney. There were no orders for a cleansing agent or medihoney. Additionally in this same record the homemaker who was functioning as an aide documented cleaning the wound and applying silicone dressing to breakdown on the buttocks. There were no orders for a cleansing agent or dressing. In review of record for home visit #3 there were incomplete orders for wound care as follows: Change sacral area decub as needed with silicone dressing and medihoney. There were also no orders to discontinue foley catheter for the same patient. Additionally the patient was taken to the ER where another foley was inserted but there were no orders of how to manage this foley to include size or when to change. In record review #1 it was noted that there were incomplete orders for wound care to left ankle as follows: Dressing change Left ankle weekly. This was confirmed with the DON. Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the plan of care was not updated to include changes. For example, in review of record for home visit #3 the patient had an ER visit and had a foley inserted and also was diagnosed with dehydration however the plan of care was not updated. Additionally for this patient the plan of care did not reflect that Ceftriasone injections had been completed for another UTI or that a wound to the right heel was healed but remained on the plan of care. This was discussed with the DON.

Observed in Record Review. In 11 of 11 patient records reviewed, it was noted that the plan of care had not been revised based upon updated assessments. For example, in review of record for home visit #2 there was a problem of UTI noted on the plan of care. This infection per the DON was resolved 4 months prior but the care plan indicated it was a current problem. Additionally none of the problems on any plan of care was dated therefore unless the box for current, progressing or completed was checked there was no way to know when the problem began or ended. This was noted in all records reviewed. This was confirmed by the DON.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of an ongoing, hospice wide, data driven performance improvement program. The last documentation of a QAPI meeting was in March 2020 which focused only on Covid 19 response and preparedness. Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of the performance improvement program. The last documentation of a QAPI meeting was in March 2020 which focused only on Covid 19 response and preparedness. Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of the governing body ensuring that the QAPI program met all of the criteria listed in the standard. The last documentation of a QAPI meeting was in March 2020 which focused only on Covid 19 response and preparedness.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of any Performance Improvement Projects since March of 2020.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of any Performance Improvement Projects since March of 2020.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of any infection surveillance for 2020 and 2021.

Observed in Document Review. In discussion with the DON and review of documents it was noted that there had been no documentation of goals for the prioritized risks.

Observed in Tracer Activities. During review of two bereavement records and in discussion with the DON/Administrator it was noted that the organization has not had an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling since 2020.

Observed in HR File Review. In 3 of 3 HR files reviewed, it was noted that individuals providing hands on personal care to a hospice patient for home visits #1, 2 and 3 did not possess the required training requirements. For example, the individuals were hired as a homemaker, had the homemaker job description and competencies in the HR files however the individuals documented providing a bed bath, diaper change, oral care, peri care and skin care for the patients. The DON stated that the agency furnished additional education for these individuals but that it was approximately eight hours in length and did not include any demonstration of skills with a patient or pseudo patient. Upon completion a certificate was provided that stated the following: This program is designed as an in-service to train providers working with Road to Happiness Home Care Services to deliver safe and consistent patient care. A certificate will be awarded as an accomplishment of completing the Road to Happiness provider training program and NOT as a Home Health care provider certification. There were three different staff members referenced in this finding. This was confirmed by the DON.

Observed in Record Review. In 10 of 11 patient records reviewed, it was noted that the plan of care written for the patient was for homemaker tasks and did not include bathing or any hands on care however, the homemaker providing care documented giving the patient a bed bath or peri-care, or skin care, or oral care. This was noted in all record reviews except for record review #7. This was discussed with and confirmed by the DON.

Observed in HR File Review. In 3 of 3 HR files reviewed, for aide services it was noted that individuals providing hands on personal care to a hospice patient for home visits #1, 2 and 3 did not possess the required training requirements. For example, the individuals were hired as a homemaker, had the homemaker job description and competencies in the HR files however the homemakers each documented providing a bed bath, diaper change, oral care, peri care and skin care for the patients. The DON stated that the agency furnished additional education for these homemakers but that it was approximately eight hours in length and did not include any demonstration of skills with a patient or pseudo patient. Upon completion a certificate was provided that stated the following: This program is designed as an in-service to train providers working with Road to Happiness Home Care Services to deliver safe and consistent patient care. A certificate will be awarded as an accomplishment of completing the Road to Happiness provider training program and NOT as a Home Health care provider certification. There were three different staff members referenced in this finding. This was confirmed by the DON.

Observed in Leadership Session. Discussion with the DON and Alternate Administrator who also serves as Volunteer Coordinator it was noted that there has not been an active volunteer program and therefore no recruitment for the year of 2020. There were two months of activity for volunteers in January and February of 2021 but no cost savings data calculated. There was no further volunteer activity for 2021 and there are currently no volunteers and no cost savings to report

Observed in Leadership Session. Discussion with the DON and Alternate Administrator who also serves as Volunteer Coordinator it was noted that there has not been an active volunteer program for the year of 2020. There were two months of activity for volunteers in January and February of 2021 but no cost savings data calculated. There was no further volunteer activity for 2021 and there are currently no volunteers and no cost savings to report Observed in Leadership Session. Discussion with the DON and Alternate Administrator who also serves as Volunteer Coordinator it was noted that there has not been an active volunteer program and therefore no recruitment for the year of 2020. There were two months of activity for volunteers in January and February of 2021 but no cost savings data calculated. There was no further volunteer activity for 2021 and there are currently no volunteers and no cost savings to report

Observed in Leadership Session. Discussion with the DON and Alternate Administrator who also serves as Volunteer Coordinator it was noted that there has not been an active volunteer program for the year of 2020. There were two months of activity for volunteers in January and February of 2021 but no cost savings data calculated. There was no further volunteer activity for 2021 and there are currently no volunteers and no cost savings to report

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews: 418.56, 418.58, 418.76, 418.100, 418.104, 418.114 and 418.116.

Observed in HR File Review. In 3 of 7 HR files reviewed, t was noted that there were no documented competencies done on the Medical Director and Alternate Medical Director. Additionally, the DON competency evaluation initially simply was a self evaluation of having previously performed this task. This was confirmed by the Alternate Administrator assisting with HR file review. Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the DON signed off on her own competencies in 2020 and 2021. This was confirmed by the Alternate Administrator assisting with HR file review.

Observed in Record Review. In 3 of 3 patient records reviewed, it was noted that the medication profile did not reflect what the patient was actually taking. For example, in home visit #1 the following discrepancies were noted: The medication profile listed Losartan 100mg, however the patient was taking Losartan/HCTZ 100/25. Senna was listed on the medication profile but was not being taken and Atorvastatin was listed on the medication profile as 20 mg daily however the patient was taking 10 mg daily. The following medications were being taken but were not on the medication profile, Tylenol Arthritis, Iron 65 mg daily, Propanolol 10mg TID and Meloxicam 10 mg at hs. In home visit #2 the following discrepancies were noted: Rifampin 300 mg and mitazapine 15 mg were on the medication profile but were not being taken. In home visit #3 the following discrepancies were noted: Cipro was on the medication sheet but was discontinued in August, Temazepam was being taken but was not on the medication sheet and the MS Contin on the medication sheet had no frequency stated. This was discussed with and confirmed by the DON. Observed in Record Review. In 3 of 11 patient records reviewed, it was noted that documentation was not specific related to wound measurements. For example, in record review for home visit #2 in two different nursing notes the sacral wound was described as about 4 cm and the buttocks wound was described as about 3-4 cm. In record review #2 it was noted that the Nursing Assessment for Psychosocial was incomplete and no other psychosocial assessment was done because the patient refused MSW. In record review #1 there were no palliative outcomes scores documented in the initial nursing assessment and also no documentation in the initial about a wound or wound care. In record review for home visit #3 there were no palliative outcomes scores documented in the initial nursing assessment.

Observed in Record Review. In 1 of 11 patient records reviewed, it was noted that the homemaker notes were not appropriately authenticated. For example, in record review #4 the homemaker signed all notes with simply her initials, AA. This was discussed with and validated by the DON.

Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that there was no current CPR card for the RN. This was confirmed by the Alternate Administrator assisting with HR file review. Observed in HR File Review. In 1 of 7 HR files reviewed, it was noted that the primary source verification for the RN/DON was not run since it expired on 12/31/20. This was confirmed by the Alternate Administrator assisting with HR file review. On the second day of survey the verification was run and license was current.

Observed in HR File Review. In 2 of 7 HR files reviewed, it was noted that there was no criminal background check done on the Medical Director and Alternate Medical Director. This was confirmed by the Alternate Administrator assisting with HR file review.

Observed in Tracer Activities. During review of documents, HR files, patient clinical records and discussion with the DON it was noted that homemakers were providing personal care to patients including bathing, peri-care, skin care and oral care as documented on the homemaker notes. Texas Administrative Code 558.845 specifically refers to the homemaker tasks in assisting to maintain the safety of the environment and to assist in helping the patient per the treatment plan. It does not allow for personal care. This was discussed with the DON.