Every finding on record at Star of Texas Hospice and Palliative Care LLC

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the generic, trade, or brand name of the medication, as well as the amount dispensed, and directions for use, including route, rate, frequency, and method of administration. This standard was not met as evidenced by clinical record review and interview. In 3 of 8 (38%) clinical records reviewed revealed that the agency did not ensure that medication orders contained medication name, dose, and frequency Clinical Record 1: Plan of care dated 12/18/2023 - 3/26/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. Clinical Record 2: Plan of care dated 12/30/2023- 3/28/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. Clinical Record 3: Plan of care dated 12/30/2023- 3/28/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. In an interview on 1/19/2024, the administrator confirmed that the plan of care included the language laxative of choice and enema of choice but argued that it should not be a finding because it was like a standing order from the physician.

It is required that each patient’s individualized written plan of care reflects patient and family goals. Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical and home records reviewed revealed that the agency did not ensure that the patient representatives had a copy and clear understanding of the patient's plan of care. Home Visit 2: During the home visit noted that the patient notebook contained a form "Hospice Initial Plan of Care/Physician Order." This form was a printed form that had Laxative of Choice checked and Foley Catheter PRN checked and was not consistent with the plan of care in the clinical record. The patient folder did not contain a plan of care that identified individualized patient goals. The plan of care in the clinical record dated 12/30/23 - 3/28/24 included interventions for fall risk, pain, and diabetes which were not included in the plan of care in the patient's home. The clinical record contained no evidence that the plan of care reflected the patient or family goals and the plan of care in the clinical record was not in the patient home. Home Visit 3: During the home visit noted that the patient notebook contained a form "Hospice Initial Plan of Care/Physician Order." This form was a printed form that had Laxative of Choice checked and Foley Catheter PRN checked and was not consistent with the plan of care in the clinical record. The patient folder did not contain a plan of care that identified individualized patient goals. Plan of care dated 12/30/23 -3/28/2024 included individualized interventions to address weakness, potential pain, and nutrition. The care plan in the home did not include these individualized interventions. Clinical supervisor present during the home visit on 1/18/2024 and confirmed that the patient care plans in the home were not consistent with physician-ordered care plans and were not written appropriately with patient's individualized goals. An interview with the Administrator and Director of Clinical Services was conducted on 1/18/2024. The Director of Nursing stated she didn't know how that form could have gotten into the patient chart.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that the plan of care was specific to the patient's needs and notified the aide of important precautions. Clinical Record 1: SN assessment dated 12/28/2023 revealed that the patient can only eat semi-solid foods and has difficulty swallowing foods. The HHA plan of care created by the RN on 12/28/2023 did not address the patient's diet feeding or swallowing precautions. In an interview on 1/18/2023, the administrator confirmed that the patient's diet and feeding precautions were not addressed in the HHA plan of care.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that the aide followed the care plan as ordered. Clinical Record 1: The start of care was Thursday 12/28/2023. Agency visit week Sunday through Saturday. HHA Care Plan form dated 12/28/2023 included an aide frequency that stated, 1 wk 1, 2 wk 2, and then 3 x week. However, the physician order dated 12/28/23 and updated 12/29/2023 contained orders for HHA 3/week. Aide visits were completed on 12/29/2023 as the only visit for the week of 12/28/23 -12/30/23. Week of December 31, 2023 - 1/6/2024 the HHA completed visits on 1/2/24 and 1/4/24 but not three times as the physician ordered. There were no missed visit notes or communication to the physician related to the reduced number of HHA visits in the clinical record. Clinical Record 4: AIde care plan dated 12/28/2023 read Aide frequency 3 x weekly. Plan of care dated 12/28/2023 read Hospice Aide 3/wk. No HHA visits and no missed visits documented for aide 12/28/2023 -12/30/2023. Agency visit week Sunday through Saturday. Clinical Record 6: Plan of care dated 10/20/2022 - 1/17/2023 and signed by the physician on 4/18/2023 contains an order for aide 3 x week. The week starting 10/20/2022 and ending on 10/22/2022, the patient was seen by the aide one time on 10/21/2022. There are no missed visit notes or evidence of communication with the physician to explain missed visits. The Director of Nursing and Administrator stated in an interview on 1/18/2024, "Can't we have leniency since it is obviously just how we put it in the computer."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) revocation clinical records reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician. Clinical Record 6: The clinical record contains a discharge note on 10/6/2023 indicating that the caregiver requested revocation to seek treatment at a hospital. The record does not include evidence that a discharge summary was sent to the physician. There is no evidence that the agency attempted to identify a community physician. Clinical Record 7: The clinical record contains a discharge note on 10/6/2023 indicating that the caregiver requested revocation to seek treatment at a hospital. The record does not include evidence that a discharge summary was completed or was sent to the physician. Clinical Record 8: Clinical record contains a discharge note revealing that patient requested revocation on 10/13/2023 to explore alternate hospices. There is no evidence in the clinical record that a discharge summary was completed and provided to the physician. In an interview with the Administrator and Director of Nursing on 1/18/2024, the administrator confirmed by looking in the EMR system that there were no discharge summaries sent to the attending physicians after patient revocations. The director of Nursing argued that the discharge notes reveal that the patients were given copies of their charts therefore this should not be a finding.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient's current plan of care, the latest physician orders and any other information that will assist in post-discharge continuity of care. This standard was not met as evidenced by clinical record review. In 3 of 3 (100%) revocation records reviewed revealed that the agency did not complete a discharge summary that included a summary of the patient stay and the plan of care. Clinical Record 6: The patient revocated services on 10/6/2023. The clinical record contains a note explaining that the agency received a call that the patient would be moving out of town. The note reads that the patient chart and med list were given to the patient. There is no discharge summary written and no documentation that a physician was provided with a discharge summary. Clinical Record 7: The patient revocated hospice services on 10/6/2023. The clinical record did not contain a discharge summary explaining the summary of care and there was no indication that a discharge summary was provided to a physician or alternate care provider. Clinical Record 8: The patient revocated on 10/13/2023. The clinical record did not contain a discharge summary explaining the summary of care and there was no indication that a discharge summary was provided to a physician or alternate care provider. In an interview on 1/17/2023, the administrator stated "Don't these discharge notes count?" Administrator acknowledged that the discharge not in the clinical did not include all of the required components.

It is required that the hospice registered nurse completes an initial assessment within 48 hours of the patient’s election of hospice care, in accordance with CMS §418.24 (the elements of the hospice care election statement). The physician, patient, or representative may request that the initial hospice assessment be completed in less than 48 hours. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) records reviewed revealed the hospice did not ensure the Registered Nurse completed an initial assessment within 48 hours after the patient’s election of hospice care. Document 2: Agency policy, “Plan of Care Process, PC.30,” stated in part, “An initial assessment will be completed by a Registered Nurse (RN) within 48 hours after election of hospice care unless otherwise specified by the physician, patient, or representative.” Clinical Record 5: The patient’s date of election was 5/6/2022. The hospice election statement signed by the patient/caregiver documented 5/2/2022 as the election of hospice benefit date. The initial assessment by the Registered Nurse was not completed until 5/6/2022 with a start of care date of 5/6/2022. There was no documented reason for the delay. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented reason for the delay of the initial RN assessment and delay of the start of care.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 5 (40%) records reviewed revealed the hospice did not ensure the initial comprehensive assessment was completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 4: The patient’s date of election was 11/9/2022. The initial RN assessment documented acceptance of chaplain services. The initial plan of care on 11/9/2022 ordered chaplain to assess spiritual needs within 5 days of admission. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care or reason for the delay. Clinical Record 5: The patient’s date of election was 5/6/2022. The initial RN assessment documented acceptance of social worker services. There was no documented evidence an initial psychosocial assessment was completed no later than five days after the election of hospice care or reason for the delay. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence the assessments were completed or reason for the delay. Additionally, during interview on 10/5/2023, the Administrator stated, “we have a PIP in place for this.”

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, supplements, herbal remedies, [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, [and]drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 5 (40%) records reviewed revealed the hospice did not ensure that medications were reconciled and updated to the drug profile at the time of each comprehensive assessment. Clinical Record 1: The patient’s date of election was 8/30/2023. The Registered Nurse (RN) assessment documentation on 8/31/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. The RN comprehensive assessment on 9/14/2023 and 9/28/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. The medication profile reviewed between 8/30/2023-10/2/2023 did not list Tylenol or Biofreeze. During the home visit on 10/4/2023 with the Social Worker, the patient confirmed using Biofreeze and Tylenol for longer than a few months, using Biofreeze at least 3 days a week for shoulder pain, as well as Tylenol regularly when Biofreeze doesn’t work. During a joint review of the record and an interview on 10/3/2023, the Administrator agreed there was no documented evidence the medication profile was updated with Tylenol and Biofreeze at the time of each comprehensive assessment. During a joint review of the record and an interview on 10/4/2023, the Alternate Administrator provided a printed copy of a plan of care order dated 10/4/2023 and stated, since we had IDG yesterday, everything is updated now. Clinical Record 3: The patient’s date of election was 10/20/2022. The medication profile reviewed between 10/20/2022-10/2/2023 revealed medication Apidra SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml, dose 8 units, instructions take 6-8 units QHS. During the home visit on 10/4/2023 with the hospice aide, the medications were reviewed with the spouse. Apidra SoloStar Subcutaneous Solution Pen-Injector 100 unit/ml, inject 6 units under the skin two times a day. The patient’s spouse confirmed the patient has been using 6 units twice a day with breakfast and dinner since before the admit to hospice. Eplerenone 50mg tablet, take 1 every day. The patient’s spouse confirmed the patient has been taking one tablet every day since before the admit to hospice. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence the medications were reconciled, including Apidra SoloStar Subcutaneous Solution Pen-Injector and Eplerenone, at the time of each comprehensive assessment and updated to the drug profile.

It is required that the designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, observation, and interview as follows: Failure to include on the POC patient and family goals and interventions based on problems identified in the comprehensive assessment [418.56(c)/L545]; Failure to ensure the RN member of the IDG provided coordination of care and ensured nursing needs were met[418.56(a)/L540]; and Failure to ensure that each patient's individualized Plan of Care included measurable outcomes of care [HCPC.21.I/L548/418.56(c)(3); and not being provided in accordance with the plans of care (HCPC.19.I/L543); The cumulative effect of these deficiencies could negatively impact the organization's ability to provide safe and effective quality patient care services.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) records reviewed revealed the hospice did not ensure the Registered Nurse coordinated care and services and ensured nursing needs were met through regular assessments and re-evaluation of the patient's status. Document 4: Agency policy, “Implementing Care and Treatment, PC.35,” stated in part, “The hospice designates a Registered Nurse (RN) who is a member of the Interdisciplinary Group/Team (IDG/IDT), who will oversee the following when coordinating the assignments of patient care: The continuous assessment of each patient’s and family’s needs, the implementation of the IDG/IDT Plan of Care (POC) for each patient and family. The hospice will assign appropriate disciplines needed to provide patient care/treatment. The assigned discipline will be provided with information needed to provide patient care/treatment.” Clinical Record 5: The patient’s date of election was 5/6/2022. The primary hospice diagnosis was malignant neoplasm of cervix uterine with a co morbidity of type 2 diabetes. The patient resided in a residential care facility. The Registered Nurse (RN) start of care visit on 5/6/2022 did not include documentation of a wound. The Licensed Vocational Nurse (LVN) documentation on 5/9/2022 revealed wound 1, coccyx wound open, present on admission, pressure injury, suspected deep tissue injury, treatment: cleanse with wound cleanser, pat dry, apply medihoney, cover with allevyn sacral dressing, patient response to treatment tolerated wound care without difficulty, wound pain none. The RN signed off as supervisory on the 5/6/2022 LVN visit note. There was no documented evidence the RN followed up to assess until 5/20/2022. There was no documented evidence the RN or LVN obtained orders for the wound care performed. The next nursing visit was documented on 5/20/2022 by the RN, stage 3, present on admission, pressure injury, 2.5cm x 1.5cm x 0.5cm, serous drainage, SN cleansed with normal saline, pat dry with gauze, applied medseptic cream and covered with safetac coccyx bandage, patient tolerated well. There was no documented evidence the RN obtained orders for the wound care performed. A physician’s order on 6/1/2022 documented a wound order, cleanse with normal saline, pat dry, apply thermahoney, apply alginate, cover with nonstick gauze and foam border and secure with tape twice a week. A physician’s order on 6/20/2022 documented an increase in skilled nurse (SN) visits to twice a week effective 6/20/2022. During the week 6/5/2022-6/11/2022, a SN visit on 6/7/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. On 8/1/2022, the wound was documented as a stage 4. During the week 8/7/2022-8/13/2022, a SN visit on 8/8/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. During the week 8/14/2022-8/20/2022, a SN visit on 8/15/2022 documented wound care, mild odor, not healing well at all. There was no documented evidence of a second nursing visit or reason for the missed visit. During the week 8/21/2022-8/27/2022, a SN visit on 8/23/2022 documented wound care, odor, not healing well at all. There was no documented evidence of a second nursing visit or reason for the missed visit. There was no documented evidence that the patient received wound care twice weekly as ordered by the physician. The nursing visit documentation on 6/3/2022 revealed 16 fr foley catheter with 230cc in bag, SN changed catheter using sterile technique. The nursing visit documentation on 6/7/2022 revealed patient having blood in urine in catheter, felt catheter was pulling, pain at insertion site, nurse attempted to replace foley catheter but due to swelling, irritation and tumor lesions was unable to place catheter. There was no documented evidence of a physician’s order for the foley catheter. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed, there was no documented evidence the RN coordinated care, ensured continuous assessment of each patient’s and family’s needs, and ensured the implementation of the interdisciplinary plan of care. The Administrator stated, “its possible it’s just not documented, we have a PIP on this.” The Administrator did not have any additional information to provide.

It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) record reviewed with a wound revealed the hospice did not ensure wound care was performed and documented as ordered by the physician. Clinical Record 5: The patient’s date of election was 5/6/2022. A physician’s order on 6/1/2022 documented a wound order, cleanse with normal saline, pat dry, apply thermahoney, apply alginate, cover with nonstick gauze and foam border and secure with tape twice a week. A physician’s order on 6/20/2022 documented an increase in skilled nurse (SN) visits to twice a week effective 6/20/2022. During the week 6/5/2022-6/11/2022, a SN visit on 6/7/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. During the week 8/7/2022-8/13/2022, a SN visit on 8/8/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. During the week 8/14/2022-8/20/2022, a SN visit on 8/15/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. During the week 8/21/2022-8/27/2022, a SN visit on 8/23/2022 documented wound care. There was no documented evidence of a second nursing visit or reason for the missed visit. There was no documented evidence the patient received wound care twice weekly as ordered by the physician. During a joint review of the record and an interview on 10/5/2023, the Administrator stated, “it should have been our nurse, but I don’t see they were done” and agreed there was no documented evidence the wound care and nursing visits were completed as ordered. Additionally, during an interview on 10/5/2023, the Administrator agreed, there were no documented reasons for the missed visits or documentation that wound care was completed by anyone else.

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 2 of 5 (40%) records reviewed revealed the hospice did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient’s date of election was 10/20/2022. The primary hospice diagnosis was malignant neoplasm of sigmoid colon with a co morbidity of type 2 diabetes. The medication record revealed Insulin Apidra Solostart at bedtime. During the home visit on 10/4/2023, the patient’s spouse confirmed the patient has been using 6 units twice a day with breakfast and dinner. The patient’s spouse reported checking the blood sugars twice daily, with breakfast and dinner, sometimes running as high as 180s or higher sometimes. The plan of care effective 5/6/2022-8/31/2022 did not include problems, goals and interventions for hyperglycemia. Clinical Record 5: The patient’s date of election was 5/6/2022. The primary hospice diagnosis was malignant neoplasm of cervix uterine with a co morbidity of type 2 diabetes. The medication record revealed Insulin Lispro three times daily with meals on a sliding scale, indication diabetes. The plan of care effective 5/6/2022-8/31/2022 did not include problems, goals and interventions for hyperglycemia. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence the plans of care were individualized to include planned interventions and goals based on the problems identified.

It is required that each patient’s individualized written plan of care reflects patient and family goals, includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 5 (60%) records reviewed revealed the hospice did not ensure the plan of care (POC) contained patient-specific and measurable goals and outcomes. Clinical Record 1: The patient’s date of election was 8/30/2023. The Registered Nurse (RN) assessment documentation on 8/31/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. The RN comprehensive assessment on 9/14/2023 and 9/28/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. During the home visit on 10/4/2023, the patient confirmed using Biofreeze and Tylenol for longer than a few months, using Biofreeze at least 3 days a week for shoulder pain, as well as Tylenol regularly when Biofreeze doesn’t work. The plan of care was reviewed for 8/30/2023-10/4/2023. Pain was identified as a problem on 8/31/2023 with the goal pain will be at a tolerable level. The patient’s tolerable level was not identified. There was no documentation of measurable outcome as to what the tolerable level was expected for the patient. Clinical Record 2: The patient’s date of election was 4/13/2023. The plan of care was reviewed for 4/13/2023-10/4/2023. Pain was identified as a problem on 4/13/2023 with the goal pain will be at an acceptable level. The patient’s acceptable level was not identified. There was no documentation of a measurable outcome as to what the acceptable level was expected for the patient. Nutrition/Weight loss was identified as a problem on 5/26/2023 with the goal optimal nutrition/hydration. There was no documentation of a measurable outcome as to what the optimal nutrition and hydration was for the patient. Clinical Record 3: The patient’s date of election was 10/20/2022. The plan of care was reviewed for 10/20/2022-10/3/2023. Pain was identified as a problem on 10/20/2022 with the goal pain will be at an acceptable level for patient and family. The patient’s acceptable level was not identified. There was no documentation of a measurable outcome as to what the acceptable level was expected for the patient. Edema was identified as a problem on 10/20/2022 with the goal symptoms managed. There was no documentation of a measurable outcome as to what the acceptable level of edema was expected for the patient. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence the plans of care were individualized to include patient-specific and measurable goals and outcomes.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visits observed revealed the agency did not ensure personnel followed the hand hygiene policy. Document 3: Agency policy, “Hand Hygiene IC.15,” stated in part, “Staff may use an alcohol-based hand rub for routinely for routinely decontaminating hands in the clinical situations described…immediately before touching a patient, after touching a patient or the patient’s immediate environment, after contact with contaminated surfaces, after removing gloves.” Home Visit 2: During the home visit on 10/4/2023 with the Hospice Aide (HA) (Staff 9), the HA was observed donning gloves, leaving the patients living room area to fill the water basins in the bathroom, using gloved hands to turn on and off the sink faucet in bathroom, returning to the patient’s bedside and adjusting the bed with the remote, placing cleaning linens and bathing supplies at the bedside, adjusting the bed rail position of the bed before removing gloves and donning new gloves and proceeding to bathe the patient in bed. The HA was not observed performing hand hygiene after contact with the bathroom sink faucet handles, bed remote, bedrails, after removing gloves and prior to touching the patient. During an interview on 10/5/2023, the Administrator confirmed, the hospice aide is required to perform hand hygiene in the situations identified, as per agency policy.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 2 (100%) records reviewed with a discharge due to death, the hospice did not ensure that bereavement services were provided to the bereaved. Document 1: Agency policy, “Bereavement, PC.130,” stated in part, “The Bereavement Coordinator will complete a follow-up assessment and develop a POC for bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services. This POC will be discussed at the next IDG/IDT meeting. The Bereavement Coordinator will ensure bereavement services reflect the needs of the bereaved. The bereavement POC will include delineation of services and frequency to be provided. A bereavement file will be maintained on each family and/or caregiver and will contain bereavement POC, bereavement clinical notes and documentation of letters and or resources sent to the bereaved, and contacts, delineations of bereavement assistance, inability to contact and referrals will be documented in the patient’s medical record.” Clinical Record 4: The patient’s date of election was 11/9/2022. The patient died on 11/17/2022. The bereavement risk assessment on 11/9/2022 documented a medium risk. There was no documented evidence of a bereavement POC, declination of bereavement, or that bereavement services were provided. Clinical Record 5: The patient’s date of election was 5/6/2022. The patient died on 8/31/2022. The bereavement risk assessment on 6/24/2022 documented a low risk. There was no documented evidence of a bereavement POC, declination of bereavement, or that bereavement services were provided. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence that bereavement services were provided. Additionally, during interview on 10/5/2023, the Administrator stated, “we have a bereavement PIP started in 2022 when we realized it wasn’t being done.” The Bereavement Coordinator was interviewed on 10/5/2023 and stated, “I have no record of any patients receiving bereavement services at this hospice.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review, interview and observation. In 2 of 5 (40%) records reviewed revealed the hospice did not ensure the clinical records included all physician orders. Clinical Record 1: The patient’s date of election was 8/30/2023. The Registered Nurse (RN) assessment documentation on 8/31/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. The RN comprehensive assessment on 9/14/2023 and 9/28/2023 revealed bilateral shoulder pain daily, but not constantly, Tylenol effective, Biofreeze prn shoulder pain. During the home visit on 10/4/2023 with the Social Worker, the patient confirmed using Biofreeze and Tylenol for longer than a few months, using Biofreeze at least 3 days a week for shoulder pain, as well as Tylenol regularly when Biofreeze doesn’t work. The medication profile and plan of care reviewed between 8/30/2023-10/3/2023 did not include physician’s orders for Tylenol or Biofreeze. There was no documented evidence of a physician’s order for the Tylenol or Biofreeze. During a joint review of the record and an interview on 10/3/2023, the Administrator agreed there was no documented evidence of a physician’s order for Tylenol or Biofreeze. Clinical Record 5: The patient’s date of election was 5/6/2022. The nursing visit documentation on 6/3/2022 revealed 16 fr foley catheter with 230cc in bag, SN changed catheter using sterile technique. The nursing visit documentation on 6/7/2022 revealed patient having blood in urine in catheter, felt catheter was pulling, pain at insertion site, nurse attempted to replace foley catheter but due to swelling, irritation and tumor lesions was unable to place catheter. The Licensed Vocational Nurse (LVN) documentation on 5/9/2022 revealed wound care provided to coccyx, cleanse with wound cleanser, pat dry, apply medihoney, cover with allevyn sacral dressing, patient tolerated wound care without difficulty. The Registered Nurse (RN) documentation on 5/20/2022 revealed wound care provided to coccyx, cleansed wound with normal saline, pat dry with gauze, applied medseptic cream and covered with safetac coccyx bandage. There was no documented evidence of a physician’s order for foley catheter or wound care provided. During a joint review of the record and an interview on 10/5/2023, the Administrator agreed there was no documented evidence of a physician’s order for the foley catheter or wound care. During a joint review of the record and an interview on 10/4/2023, the Alternate Administrator provided a printed copy of a plan of care order dated 10/4/2023 and stated, since we had IDG yesterday, everything is updated now.

It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above and at least one (1) year of social work experience in a health care setting. This standard was not met as evidenced by clinical record review, interview and personnel record review. In 1 of 2 (50%) personnel records of social workers reviewed revealed the hospice did not ensure the social worker was licensed. Personnel Record 7: (Social Worker); hire date 7/25/2022. The Hospice Medical Social Worker job description signed by the employee on 7/25/2022 stated job qualifications: licensure: Texas certification. There was no documented evidence that the Social Worker was licensed prior to providing care as a social worker. During an interview on 10/4/2023, the Administrator agreed, there was no documented evidence the social worker was licensed prior to providing care to the patients as a social worker. During an interview on 10/4/2023, the Alternate Administrator agreed, there was no documented evidence the social worker was licensed. Additionally, during an interview on 10/4/2023, Alternate Administrator stated, “I did not realize she had to be licensed, I guess we will have to let her go.”