Every finding on record at Seasons Hospice and Palliative Care of Texas Inc

Based on record review and interview the agency failed to provide medical social services by a qualified social worker currently licensed in the state of Texas as either a master social worker or a baccalaureate social worker for 1 of 1 (Master Social Worker A) social worker reviewed. This failure resulted in the hospice allowing an individual who did not meet the criteria as a qualified social worker in the state of Texas to provide social work services to hospice patients. This failure could have resulted in patients and family members to have psychological and social needs go unmet. --- Findings included: Personnel file reviewed revealed Master Social Worker A was hired by the agency on 7/16/18, had a Social Work - Fellow job description that was signed and dated 2/28/23 by Master Social Worker A, the job application did not reveal a professional license number, and a license verification form did not reveal a license number and it revealed that a license number verification had never been performed. The file revealed a Master of Social Work degree dated 8/14/22. The file also contained a form titled ";Visit Profile Employee and Patient Info" dated and signed by Master Social Worker A on 3/24/2023 and Former Employee MSW, LCSW, ACHP-SW on 3/17/23. The form revealed Social Worker A as the employee, discharged Patient #1 as the patient, Visit Start Date 3/14/2023, Reason for Visit as Competency by like Discipline. The personnel file did not reveal the MSW was approved to be a licensed social worker. During a license verification search on 11/7/24 the Texas Behavioral Health Executive Council website revealed Master Social Worker A did not hold a license as a licensed Bachelor's Social Worker or as a licensed Master's Social Worker. Review of Texas Occupations Code Title 3. Health Professions, Subtitle I. Regulation of Psychology and Counseling Chapter 505. Social Workers Subchapter A. General Provisions on 11/23/21 indicated, " ...Section 505.002 Definitions. In this chapter: ...8. 'Social worker' means a person who holds any license issued under this chapter. Sec 505.351 LICENSE REQUIRED. (a) A person may not use or cause to be used the title 'social worker' ... as a professional or business identification, representation, asset, or means of obtaining a benefit unless the person holds an appropriate license issued under this chapter ..." Retrieved 11/7/24. Source: https://statutes.capitol.texas.gov/docs/OC/htm/OC.505.htm Review of Worker Schedule Report for payroll revealed MSW visits completed by Master Social Worker A from 10/12/2024 through 10/31/2024 with a total of 54 MSW to patient visits by Master Social Worker A. Review of the hospice's job description titled ";Social Worker I – Job Description" Approved: 12/07/2020, read in part, "...Qualifications...2. Qualifications for state-specific requirements above minimum education standards are as follows: ...TX(Texas): Must be licensed to practice social work in the state..." During an interview on 11/8/24 at 12:11 p.m. the Administrator said Licensed Master Social Worker (LMSW) B signed off on Master Social Worker A notes and Master Social Worker A had a masters degree in social work and not passed the licensing boards test yet and was planning to retest. Master Social Worker A would be taking the licensing test soon. During an interview on 11/8/24 at 12:35 p.m., Master Social Worker A said she had her master's degree in social work. She had not passed the licensing boards test yet. She was planning to retest. Master Social Worker A said she was not signing anything as a Licensed Master Social Worker only as MSW. Licensed Master Social Worker (LMSW) B was aware of the patients she was seeing. They discussed the patients by phone and Licensed Master Social Worker (LMSW) B co-signed all the visit notes. Master Social Worker A confirmed performing social worker visits since 3/14/23 and representing Social Work Services during Interdisciplinary Team (IDT) meetings. During an interview on 11/8/24 at 12:45 p.m., the Administrator said she did not intentionally violate the regulation, it was not Licensed Master Social Worker (LMSW) B or Social Worker As fault, she thought they were doing it the right way. The Administrator said she thought Master Social Worker A could see patients with Licensed Master Social Worker (LMSW) B supervising. The Administrator said she thought they were following the regulation but now could see they were not, and the policy did not match the regulation. Review of the hospice's policy titled ";Psychosocial Services" Effective Date: 01/01/2013, Last Revised Date: 03/01/2024, read in part, "...Policy: AccentCare will provide psychosocial services by qualified medical social services professional...The duties and responsibilities of social workers will be identified in appropriate job descriptions..."

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. In every record most goals were generic and very few included specific, measurable, attainable, relevant, and/or timely outcomes. For example, the family or caregiver will verbalize or demonstrate the following: neurologic manifestations and measures to ensure safety and comfort; preventative measures/response in the event of hemorrhage bleeding and will be recognized early for management; understanding of effect of urinary incontinence; appropriate and safe wound care; adequate knowledge of ostomy care. Other goals included: pain will be managed at an acceptable level to the patient; safety needs will be met; nausea and vomiting will be controlled or reduced; transition peacefully through the dying process. Additionally, there were no identified target dates for completion. This RFI was reviewed with the Director of Clinical Operations and Director of Business Operations.

Observed in Record Review. In 3 of 3 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. For example, in the record of RRNHV#1 the interdisciplinary group documented that the patient had skin tears to the right hand and left forearm; was confused, agitated and aggressive; the patient was depressed and suicidal. In RRNHV#2 documentation included that the patient had dyspnea on exertion; a Pleurx catheter; nausea and decreased appetite. In RRNHV#3 documentation included that the patient had a Porta cath in the right upper chest and a colostomy. None of these assessment findings were addressed in the plans of care. This RFI was reviewed with the Director of Clinical Operations and Director of Business Operations.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured staff followed the organization policy Pain Assessment and Management, policy number HOS 2-049 that included all patients will receive an initial pain assessment upon admission that included intensity, characters and quality, patterns, duration, frequency, precipitating factors, pain goal, pain relief measures, and current pain regimen. For example: review of RR# 3's patient record revealed a start of care RN comprehensive assessment. Review of the start of care comprehensive assessment revealed documentation the patient was not screened for pain and pain was not an active problem with an amendment to the start of care comprehensive assessment dated two days after the start of care with documentation the patient was screened for pain and had no pain on admission. This was discussed, reviewed, and validated with the Director of Patient Care services

Observed in Record Review. In 4 of 4 patient records reviewed, During RR# 1, RR# 2, RR# 3, and RR# 4's patient records review it was noted the organization had not ensured the written plan of care was based on the patent's goals, and services required to meet those goals. For example: review of RR# 2's patient record revealed RR# 2 had multiple wounds. However, review of RR# 2's plan of care revealed no goals for wounds. Review of RR# 1's patient record revealed RR# 1 with documentation of agitation and medication increases to address the increased symptom. However, review of RR# 1's plan of care revealed no goals for agitation/behaviors. Review of RR# 3's plan of care revealed no pain goal. However, review of RR# 3's patient record revealed RR# 3 had pain 7/10 and was prescribed pain medication. Review of RR# 4's plan of care revealed the pain goal that pain would be managed at a level acceptable to the patient with no indication what an acceptable level of pain was for RR# 4. In addition, review of all the patients' plans of care revealed goals with no time frames. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 2 and RR# 4's patient records review it was noted the organization had not ensured the plan of care included all the services needed for the palliation and management of the terminal illness and related conditions. For example: review of RR# 2's patient record revealed RR# 2 was admitted with an indwelling foley catheter. Review of RR# 2's plan of care revealed the order for hospice nurse to insert/maintain indwelling catheter FR_/_ CC balloon, may irrigate with__, change catheter every_ or as needed. Review of RR# 4's patient record revealed RR# 4 was admitted with oxygen. Review of RR# 4's plan of care and update to plans of care revealed no specific oxygen order, such as the route, continuous, or liter flow. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 4 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured it provided interdisciplinary, collaborative care, treatment, or services. For example: review of RR# 4's patient record revealed a Skilled Nurse visit note approximately five days prior to RR# 4 being seen at the emergency for an exacerbation of the primary terminal diagnosis Chronic Obstructive Pulmonary Disease (COPD) and pain with a pain assessment of 9 out of 10 with documentation medication was given. Further review of the SN visit note and RR# 4's patient record revealed no documentation of the physician being notified or any additional interventions or a reassessment of the pain. Further review of RR# 4's patient record revealed a Chaplain visit note dated two days prior to RR# 4 being seen in the ED and admitted to the hospital with a pain assessment of 8 out of 10 with no documentation that anyone was notified of the patient stated pain level to include the case manager, Director of Patient Care Services (DPCS), or the Medical Director. Review of RR# 3's patient record revealed three days after the start of care that RR# 3 called the hospice complaining of pain of 7/10 and was instructed to take Tramadol and RR# 3 shared the Tramadol had not been delivered and a nurse visit was offered and RR# 3 declined a visit from the nurse. Further review of RR# 3's patient record revealed RR# 3 called four days after the start of care informing the hospice she wanted to revoke and call 911. Further review of RR# 3's patient record revealed RR# 3 was seen in the Urgent Care for pain management four days after the start of care and Tramadol was delivered after she returned home from Urgent care.This was reviewed, discussed, and validated with the DPCS.

Observed in Record Review. In 4 of 13 patient records reviewed, the surveyor found that the organization had not conducted a comprehensive assessment that included the severity of symptoms. For example, in review of the medical record for RR3, the surveyor found that the nurse documented that pain was a problem for the patient but that a comprehensive pain assessment was not completed. In the same patient, the nurse documented that the patient had a stage II pressure ulcer on the coccyx. However the wound was not assessed at the time of admission and had not been assessed as of the date of survey. This was verified by the staff member assisting with review of the medical record. In review of the medical record for RR9, the surveyor noted that the patient did not have a fall risk assessment completed on admission as required by organization policy 2017. In review of the medical record for RR6 and RR7, the patient did not have a fall risk assessment completed on admission as required by organization policy 2017. This observations were discussed with leadership

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not conducted a further evaluation when the need was identified. For example, in review of the medical record for RR1 and RR3, there were referral orders in the plan of care for the social worker to further evaluate the patient but there was no evidence that these referrals had been completed or that the patient/family/caregiver had refused. This was verified by the staff member assisting with record review.

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that elements of documentation entered into the record were not accurate. For example, in review of the medical record for RR2 and RR9 the surveyor found notes documenting that oxygen equipment was in the home but further review found this equipment was not ordered or delivered to the home.

Observed in Record Review. In 4 of 13 patient records reviewed, the surveyor did not find where the organization had developed an individualized plan of care with goals and interventions that addressed problems identified in the comprehensive assessment. For example, in review of the medical record for RR1, the patient was at risk for falls, had a foley catheter in place and a wound to the coccyx. These issues were not addressed in the Plan of Care. In review of the medical record for RR3, the patient was at risk for falls, had a wound to the coccyx and a PICC line. These issues were not addressed on the Plan of Care. These findings were verified by the staff member assisting with review of the medical record. In addition, the following observations were also noted and discussed with leadership. In review of the medical record for HV1 and HV2, the plan of care did not address the patient's risk for falls. Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor found that the organization did not develop plans of care that were based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in review of each of the 13 medical records it was noted that multiple goals did not include targeted completion dates. This was verified by the staff member assisting with review of the medical record and discussed with leadership.

Observed in Record Review. In 7 of 13 patient records reviewed, the surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in review of the medical record for RR1, the plan of care had Tramadol and Hydrocodone 7.5/325 ordered as needed for pain without further defining when each one should be taken. In addition, the surveyor noted that the nurse documented completing a dressing change to the coccyx wound per the physician's order. No order for the dressing change was found. In review of the medical record for RR3, the plan of care had Hydrocodone10/325 and Morphine ordered as needed for pain without further defining when each one should be taken. This findings were verified by the staff member assisting with review of the medical records. In addition, the following observations were noted in the medical records and discussed with leadership. In review of the medical record for HV1, the plan of care had an oxygen order but it did not include the delivery system and a foley catheter flush order that did not include the type of solution or the frequency of the flush. In review of the medical record for RR4, the patient was on oxygen at admission but there was no order for oxygen found. In review of the medical record for RR6, the plan of care had acetaminophen, oxycodone and morphine sulfate ordered as needed for pain without further defining when each one should be taken. In RR8, the patient was admitted with a foley catheter in place which was changed approximately 15 days later. The plan of care did not address the foley catheter, its care or maintenance. In RR9, acetaminophen and morphine were ordered as needed for pain without further defining when each one should be taken.

Observed in Tracer Activities. In 2 of 13 patient records reviewed, the surveyor found that the plan of care did not include the medical equipment that was present in the home. For example, during the home visit for HV1, the surveyor noted that equipment observed in the home (hospital bed, Hoyer lift, O2 concentrator, and oxygen cylinder) was not included in the plan of care. In review of the medical record for RR4, the nursing assessment notes that the patient has an oxygen concentrator and an oxygen cylinder but these were not included in the plan of care.

Observed in Record Review. In 1 of 13 patient records reviewed, the surveyor found that the organization had not provided care, treatment, or services according to the patient's individualized plan of care. For example, in review of the medical record for RR2, the patient had an order for a physical therapy evaluation. This evaluation was not completed and there was no documentation that it had been refused. This was verified by the Regional Clinical Support Specialist assisting with record review

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed inconsistent practice in performing hand hygiene as defined by organization policies 4003 and 4004. For example, during the home visit for HV2 and HV3, the staff member did not consistently perform hand hygiene prior to re-entering the equipment bag after being in contact with the patient or things in the patient's environment. During the home visit for HV2, the staff member did not consistently perform hand hygiene with each glove change. When using alcohol based hand rub, the staff member did not consistently rub the product on his hands until they were dry but instead attempted to don gloves with the product still wet on his hands. This observation was discussed with leadership.

Observed in Record Review. In 5 of 12 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for HV1, the patient was on Xarelto, was on continuous oxygen and had a Hoyer lift for transfers. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to the Xarelto, when or if the oxygen could be removed during the bath. It also did not specify the use of the Hoyer lift but only to use assistive device for transfers. In review of the medical record for HV2, the patient had a PleurX drain and dressing in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. In RR4, the patient was on Clopidogrel. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. In RR7, the patient was on Eliquis. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. In RR9, the patient had a sacral wound dressing in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this. These findings were discussed with leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, where hospice aide services were ordered, the surveyor found that the aide had not completed an appropriate record of the care provided. For example, in review of the medical record for RR3, the hospice aide documented on multiple visits that a bed bath and a shower was provided. This observation was verified by the staff member assisting with review of the record.

Observed in Record Review. In 3 of 10 patient records reviewed, where the patient had oxygen ordered, the surveyor did not find where the organization had instructed the patient and/or family on causes of fire, ways to prevent fire related injury, risks to neighboring residences and buildings, specific recommendations that addressed any identified risks, safe use, storage and maintenance of oxygen equipment. For example, this education was not found for RR3. During the home visit for HV1, the patient was missing a functional smoke detector and had a gas stove. The patient and/or caregiver had not been educated on specific recommendations to address these risks. There was also no evidence that education had been provided on causes of fire, ways to prevent fire related injury, risks to neighboring residences and buildings, safe use, storage and maintenance of oxygen equipment. In review of the medical record for RR4, the home oxygen risk assessment identified smoking materials and the potential for open flames in the home. There was no documented education of specific recommendations to address these risks. This was discussed with leadership