Every finding on record at St. Joseph Hospice of Houston, LLC

Observed in Individual Tracer. In 7 of 14 patient records reviewed, The surveyor noted in (RRHV#2) that there was no assessment of the severity of the patient's dyspnea or level of anxiety and dizziness and vertigo. In (RRHV#4) the dyspnea assessment only stated labored at rest and did not identify the severity of the symptoms, what exacerbates or alleviates the dyspnea. In (RRNHV#5) there was no assessment of the severity of seizures treated with anticonvulsants and noted on the plan of care Also, in (RRNHV#9) there was no assessment of the Suprapubic insertion site, or severity of UTI symptoms. In (RRNHV#10), there was no assessment of the severity of nausea/vomiting/diarrhea or the patient's compliance and ability to self-manage and administer insulin and blood glucose monitoring. In (RRNHV#11) there was no assessment of the severity of orthopnea and ability to self manage insulin and blood glucose monitoring. In (RRNHV#12), there was no assessment of the severity of dyspnea or UTI symptoms or level of bone pain. In (RRNHV#13) there was no assessment of the severity of anxiety and agitation, the PEG-tube insertion sitr or the Suprapubic catheter insertion site. This was confirmed with the director of nursing.

Observed in Individual Tracer. In 4 of 14 patient records reviewed, The surveyor noted (RRHV#2) that the initial assessment and skilled nurse visit notes indicated that the patient's spouse was giving the patient enemas to help her have a bowel movement faster and to get everything out at once and noted that the family required teaching regarding Bowel management and alternatives to water enemas; however, this was not addressed in the plan of care and there was no order for water enemas. Also, there was no care plan for the identified aspiration and choking risk and need for pureed foods and thickened liquids, identified on the assessment. There was no care plan goal for managing the patient's anxiety, as identified with a score of 4. In (RRNHV#10) there were no goals documented until the second certification period, so Nausea and vomiting, diarrhea peripheral edema diabetes and insulin and blood glucose management were not addressed. In (RRNHV#11) there was no plan of care to address the risks identified in the home environment including unsafe pathways, clutter, infestation and weapons in the home. In (RRNHV#14) there were no outcome expectations for managing the patient's dyspnea, falls risk and oxygen safety with a known risk of a smoker in the home. This was confirmed with the nursing director.

Observed in Individual Tracer. In 13 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the plan of care did not include outcome measures or reasonable time frames when the patient was admitted in March. For example the goal demonstrate effective pain management was not measurable and was dated for the end of the 90 day certification period. In (RRHV#2), the goals established in April did not include outcome measures or time frames for managing medications, agitation, nutrition pain and falls risk. For example the goal stated pt/cg verbalizes understanding of medications and pain managed at level acceptable to patient, understanding of dietary modifications. None of the goals include outcome measures or time frames. In (RRHV#3) the care plan included a goas patient/CG verbalizes understanding of oxygen administration and safety-effects of terminal illness on nutrition/hydration pain managed at acceptable level and caregiver will be knowledgeable in care of indwelling catheter. None of the goals were measurable or included times and outcome expectations.. In (RRNHV#7) there were no measurable outcomes for managing medications and cardiac symptoms, it only indicated that cardiac symptoms would decrease and all goals were for end of benefit period (90 days). In (RRNHV#8) the outcomes were not measurable for medication compliance and reduction of cardiac symptoms and all goals were for end of benefit period (90 days). In (RRNHV#10) there were no measurable outcomes for managing the diabetic on routine and sliding scale insulin, and no measures for pain and medication management. In (RRNHV#12) al the goals were the same for the second certification period and they were not measurable and in (RRNHV#14) all the goals were for end of benefit period (90 days). There were no measurable outcomes for most goals in 13 of 14 records reviewed with a few exceptions for pain levels. This was confirmed with the nursing director.

Observed in Individual Tracer. In 10 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the care plan update of August indicated that the patient had a wound; however, there were no orders or interventions for the wound care. Also, the patient was ordered Clindamycin for an infected toe; however, there were no interventions indicated to manage the toe infection. In (RRHV#2) the assessment and visit notes indicated that the patient's husband was administering water enemas; however there was no order for the enemas or interventions for managing bowel elimination or patient teaching. In (RRHV#3), the plan of care included a goal caregiver will demonstrate appropriate care of the indwelling catheter; however, it did not include interventions for managing the catheter, the size, the frequency for changing, or the type and volume of irrigation. The assessment indicated that it was a 16F Foley catheter irrigated with sterile water prn. In (RRNHV#5) the plan of care did not include any interventions for Foley care; there were no catheter orders including the size of the catheter and how often it was to be changed and who would change it. Also, there were no orders for the type and volume of irrigation. The care plan only including teaching catheter care and irrigation. This was also noted in In (RRNHV#9) where there were no interventions for managing the patients indwelling catheter and irrigation. There was no detail including the size of the Foley and the type and volume of fluid for irrigation or indication for prn irrigation. In (RRNHV#10), the order for sliding scale insulin did not include the individual dosing parameters and frequency of administration; it read Novolog sliding scale as directed. In the second benefit period, the order was Novolog Flex-pen 100units/ 3ml sq per instructions as directed prn. Also, an order for Aldactone 1 tab, prn for leg swelling, was incomplete and did not include a frequency. In (RRNHV#11), the order for Oxygen 5-10L was incomplete and did not include a route, frequency or parameters for dosing. The order to irrigate Foley catheter did not include a solution ,volume or indication for prn use. In (RRNHV#12) the order for Oxygen 2-5L/NC prn for SOB did not include parameters for dosing and was not included on the medication list as required by policy. In (RRNHV#13) the order for Sterile water catheter irrigation did not include a volume and there were no interventions for managing the PEG-tube, including site care and when to change the catheter or not. The order for Jevity 1.5 calories did not include a volume and frequency of feeding and method of delivery. The assessment indicated that the patient was receiving night time pump feeding from 6 p-6a at 60cc/hr; however, this was not included in an order or on plan of treatment. The patient was admitted on Oxygen; however there was no written order or entry on the plan of care until two months after admission. The order was incomplete O2 2-5 prn and did not include parameters for dosing. The assessment indicated that the patient required continuous oxygen at 2LPM. The patient was NPO; however two medications were ordered to be administered orally (Metoclopramide and Metoprolol). In (RRNHV#14) the order for oxygen was written O2@ 2l as directed for dyspnea and did not include a route or frequency. This was confirmed with the nursing director.

Observed in Individual Tracer. In 5 of 14 patient records reviewed, The surveyor noted (RRHV#1) that the plan of care was not revised to indicate progress toward goals since the patient was admitted in March. There was no update regarding the patient/caregivers ability to manage medications, pain and cardio-respiratory symptoms or include new goals and interventions to manage the symptoms. In (RRHV#3) the surveyor noted that the patient was admitted in 2023 and a July and September 2025 assessments indicated an oxygen saturation level of 87%-89% and that the patient was not compliance with continuous oxygen use; however, the care plan was not updated to indicate progress toward goals or the expected outcomes and updated interventions to manage the oxygenation. The care plan did not indicate the need for continuous oxygen as indicated on the assessment or the desired therapeutic dose. The order was for O2 2-5 LPM as needed and did not include parameters for dosing since the patient was admitted two years prior. In (RRNHV#9) the plan of care did not include progress toward goals or updates to manage the patient Suprapubic catheter. The patient developed a UTI and was prescribed Cipro x 7 days and Phenazopyridine x 5 days and there was no indication of symptom relief or an update to manage the catheter related infection. In (RRNHV#12), the plan of care did not reflect progress toward goals for managing the patient's pain and dyspnea and did not include measurable outcomes and interventions that included adding oxygen as needed and to address oxygen safety related to smoking materials found in the home., added in the second benefit period. Also, the patient was prescribed MSIR 15 mg. BID and Dexamethasone 4 mg. daily for pain and there was no indication in the plan of care that the pain management plan needed to be adjusted as the pain was changing/intensifying. In (RRNHV#13) the plan of care updates did not reflect progress toward goals established in July as tot the progress of managing the patients dyspnea, indwelling catheter for urinary retention, nutritional needs and risk for aspiration related to enteral feedings and the progress of the Stage 2 wound. Also, the patient developed a pneumonia in July treated with antibiotics and this was not included in the plan of care update. The patient was also treated for a UTI in August and the plan of care did not include progress toward resolving the infection. This was confirmed with the executive director and nursing director.

Observed in Individual Tracer. In 2 of 4 home visits conducted, The surveyor noted (RRHV#1) that the chaplain failed to sanitize his hands when entering the home. Also, he failed to carry any personal protective equipment with him, into the home. Also, in (RRHV#2) the aide failed to sanitize her hands when entering the home to prior to performing care and donning gloves. The organizations policy did not provide guidance for non-nursing staff and only indicated to follow CDC guidelines. This was confirmed with the executive director.

Observed in HR File Review. In 2 of 2 HHA HR files reviewed, The surveyor noted that there was no evidence in the personnel file of two Home Health Aides (HR#7, HR#13) that the organization did not ensure that a supervisor evaluated competence for all skills required of an aide prior to providing care. There was no documentation of direct observation of the following tasks: communication skills, bathing, safe ambulation and transferring techniques, passive range of motion.This was validated by the HR manager. Observed in HR File Review. In 2 of 2 HHA HR files reviewed, The surveyor noted that there was no evidence in the personnel file of two Home Health Aides (HR#7, HR#13) that a supervisor evaluated the following areas by observing a home health or hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation when they were hired or since. The only competency in the file was completed by another aide. This was validated by the HR manager.

Observed in Individual Tracer. In 1 of 5 patient records reviewed, The surveyor noted (RRHV#3) that the HHA plan was not updated when the patient's indwelling catheter was discontinued in 2024. The care plan still included foley catheter care each visit and empty drainage bag each visit. This was confirmed with the executive director.

Observed in HR File Review. In 5 of 13 HR files reviewed, The surveyor noted that there was no documented evidence in the personnel file of (HR#9, HR#10, HR#11, HR#12 and HR#13) that hospice orientation was completed when the employees were hired or since. This was validated by the HR manager.

Observed in Individual Tracer. In 2 of 2 facility care plan, The surveyor noted (RRHV#3) that the care plan did not identify the which provided was responsible for performing the following functions when the patient was admitted: Foley catheter care including who was to change the Foley when the Foley was to be changed, who was to irrigate the Foley and the Solution and volume of irrigation. Also, the care plan was not updated with information about who was to provide wound care, the type and frequency of wound care, and the frequency of wound care assessment on two different benefit periods. Also, the care plan was not updated when the Foley catheter was removed in May of 2024. Also, the care plan did not indicate who was responsible for managing the patient's oxygen or medications. Also, in (RRNHV#13), the plan of care did not specify who was responsible for administering medications by gastrostomy route, enteral feedins, wound care, colostomy care, manage and change both the PEG tube and suprapubic catheter and oxygen. This was confirmed with the executive director.

Observed in Individual Tracer. In 1 of 1 SNF tracer, The surveyor noted (RRHV#3) that the SNF record did not contain an election of hospice benefit statement or the certification of terminal illness and recertifications since the patient was admitted in 2023. This was confirmed with the social worker.

Observed in Record Review. In 9 of 9 patient records reviewed, During the record review of nine active patients' records, it was identified that the organization's written plans of care did not provide individualized and measurable patient goals, nor specify time frames for meeting selected goals. Identified in record reviews for HV#1, HV#2, HV#3, and for RR#5, RR#6, RR#7, RR#8, RR#9, and RR#10, the organization's plans of care lacked specific metrics for determining goal achievement. For example in HV#1, and RR#10 the goal pain will be managed at a level acceptable to patient, does not provide specific and measurable data or specify the time frame in which acceptable pain level is to be achieved. In HV#3, and RR#10, the goal: patient will have safety needs met, does not specify which safety needs are of consideration, and the time frame that achievement of safety was expected. This was discussed and validated with the Executive Director.

Observed in Patient Home. In 3 of 3 home visits conducted, The organization reduces the risk of infections associated with medical equipment, devices, and supplies. Observed in HV#1, HV#2, and HV#3 home observations, the clinicians failed to follow the organization's Policy No. 9-014.1,2 not performing equipment cleaning with the recommend alcohol cleaner. For example, observed in HV#1, the Registered Nurse cleaned her equipment with bleach wipes after the assessment of the patient. Observed in HV#2, the Medical Social Worker cleaned her tablet device with an unknown cleaning wipe not stored in its original container. During HV#3 home observation, the Home Health Aide failed to clean the tablet device before returning it to the bag's compartment where clean gloves were located. This was discussed and validated with the Executive Director and Clinical Supervisor. Observed in Patient Home. In 2 of 3 home visits conducted, The organization implements the infection prevention and control activities it has planned. In HV#1 home observation, and in HV#2 home observation, the clinicians failed to follow infection prevention and control activities per organizational Policy No. 9-009.1,2 Hand Hygiene. For example in HV#1 home observation, the Registered Nurse (RN) failed to change gloves when moving from a dirty to clean site during the assessment as evidenced by assessing and touching the patients colostomy bag prior to palpating the patients impaired skin integrity in the coccyx area; and, not performing hand hygiene at the completion of the assessment and subsequent removal of the gloves, but instead immediately cleaning the equipment. In HV#2, home observation, the Medical Social Worker did not follow the organization policy as evidenced by not performing hand hygiene following entry into the residence.

Observed in Record Review. In 1 of 3 home visits conducted, The organization plans the patient's care. During HV#3 home observation, the Hospice Home Health Aide provided the patient with a shower. Upon review of the clinical record's Aide Care Plan, there was no shower assigned by the Registered Nurse. This was discussed and validated by the Executive Director.

Observed in HR File Review. In 1 of 10 HR files reviewed, During the Competency and Human Resources Record Review, it was identified that the Nurse Practitioner's competency in the role was documented on the Initial Competency Assessment Skills Checklist for Registered Nurse. The education, skill level, and medical responsibilities described in the organization's job description for Nurse Practitioner are not included in the Registered Nurse Competency Assessment. For example, the Nurse Practitioner responsibilities include Manages oversight of the patient's medications and treatments, with prescriptive authority. This was discussed and validated with the Executive Director

Observed in Patient Home. In 1 of 1 home visits conducted, The patient record contains information that reflects the patient's care, treatment, or services. Observed in HV#1 home observations, the patient's record did not contain accurate medication as evidenced by medications being given to the patient that were not documented on the organization's medication administration record. For example, the medication reconciliation identified that Trazadone 150 mg was being administered to the patient at bedtime, and Colace 50 mg. was being given as needed. Neither of these medications were on the medication administration record. The contents of the organization's Comfort Pack including Acetaminophen 650mg rectal suppository, Bisacodyl 10mg rectal suppository, Haloperidol 1mg tablet, Hyoscyamine 0.125mg sublingual tablet, Lorazepam 0.5mg tablet, and Morphine concentrate 100mg/5ml (20mg/ml) oral solution, were listed on the medication administration record but were not found in the home nor did the patient's caregiver recall ever receiving them. This was discussed and validated with the Executive Director and Clinical Supervisor.