Every finding on record at Standards Hospice Inc.

Based on observation, record review and interview, the Agency failed to enforce written policies that detailed a review of 1 of 10 active patients (Patient #2), whose records were reviewed which included a tracheostomy cleaning treatment order which was not written on the plan of care. This failure could place Agency clients who has a tracheostomy at risk of inaccurate and inadequate care by Agencys staff. --- Findings included: Record review of the Agencys policy titled, ";Verification of Physician Orders-Texas," revised 5/11/2020, revealed in part, ";Orders will be obtained from a licensed physician...for care and services to be provided to hospice patients. The receiving licensed hospice profession must record and sign the order immediately...A qualified individual will review each order...before care is provided...." During an observation of a home visit on 11/19/2024 at 1:00 p.m., with Patient #2 and LVN A, Patient #2 was observed to have a tracheostomy (a tube inserted in the front of the neck to maintain an airway to the lungs). Further observation revealed LVN A cleaning Patient #2s tracheostomy cannula (the tube inserted into the neck). Record review of Patient #2s clinical records reveal a start of care date of 10/25/2024 with a diagnosis of Chronic obstructive pulmonary disease (a lung disease that causes breathing problems) and tracheostomy status. Further review of the plan of care of Patient #2 revealed that Patient #2 was receiving skilled nursing twice weekly with 5 additional as needed visits, hospice aide services twice weekly, medical social worker once monthly and three as needed visits. Further review of Patient #2s clinical records revealed no documentation in the Plan of Care for cleaning orders for Patient #2s tracheostomy. During a joint interview with the Alternate Administrator and Compliance se Nurse on 11/20/2024 at 4:00 p.m., the Alternate Administrator and Compliance Nurse stated that normally orders are were placed on the plan of care without any issues and that the medical director is was aware of the cleaning orders. The Alternate Administrator also stated that the tracheostomy cleaning orders not in the Plan of Care was an oversight, and that the noncompliance was understood.

Based on record review and interview, the agency failed to provide volunteer services in an amount that equaled 5 percent of the total patient care hours of all paid hospice employees for 2022 and 2023. This failure could place Agency clients at risk of inadequate care by not ensuring that Agencys volunteers were being adequately staffed for hospice patients. --- Findings included: Record review of the Agencys volunteer report titled, ";Hospice Volunteer Requirement Report," dated 11/18/2024, revealed the year 2022 total patient care hours provided by paid employees as 1202, with volunteer hours totaling 2.25 (0.19%). Further record review revealed the year 2023 total patient care hours provided by paid employees as 8477, with volunteer hours totaling 46.02 (0.54%). In an interview with the Alternate Administrator on 11/18/2024 at 12:00 noon, the Alternate Administrator stated that the agency had a new volunteer coordinator who was hired in September 2024 and had made a lot of progress with recruiting. Prior to September 2024, the Alternate Administrator stated she herself was the Volunteer Coordinator. The Alternate Administrator also stated that the volunteer cost share was below 5% since 2022 because the agency was not able to maintain the 5% cost share due to time constraints. The current volunteer coordinator was out on bereavement leave. Record review of the Agencys policy titled, ";Volunteer Services" dated 5/11/2020, revealed in part, ";3. The Volunteer Coordinator will track the use of volunteers, the cost saving achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel."