Every finding on record at Texas Home Health Hospice-Austin, LLC

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that the patient's identified goals in the plan of care were measurable. CLINICAL RECORD 8: During the Registered Nurse (RN) visit on October 31, 2025, the patient's agitation was rated at 2/10, with a PAINAD score also noted at 2, described as generalized. Observations indicated that the patient was withdrawn, confused, restless, and experiencing hallucinations. On November 11, 2025, the nurse assessed a MAHC-10 fall risk score of 7, indicating a significant risk for falls. The patient's medications included Eliquis 2.5 mg daily, Morphine Sulfate (0.25 ml to 1.0 ml every 3 hours, as needed for pain), Sertraline 75 mg daily for mood stabilization, and Lorazepam 0.5 mg every 6 hours, as needed for anxiety and agitation. Pain management was identified as a concern in the patient's plan of care, aiming for the patient, family, and caregivers to report that pain is at an "acceptable" level; however, the term "acceptable" was undefined and not measurable. Anxiety and agitation were also addressed, with the goal of reducing these symptoms within 7 days (dated March 28, 2025), but without clear parameters for what constitutes a "decrease," it remained non-measurable. Fall prevention strategies were included in the plan; however, there was no acknowledgment of the patient's increased bleeding risk associated with Eliquis, nor was there a specific goal related to this risk. During an interview and joint record review with the Director of Clinical Operations (Personnel Record 3) on 11/20/2025, she confirmed that the expectation is that the goals defined for the patient would be measurable.

The Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed revealed that the patient's plan of care was not updated with goals reflecting new information from the updated assessments. CLINICAL RECORD 15: On October 13, the patient reported new-onset dizziness. Additionally, he reported he had experienced chest pain, leading to a physician's order for Nitroglycerin 0.4 mg dissolvable tablets as needed for chest pain. The patient's medication list included Eliquis, and his plan of care identified the patient as a fall risk. The patient’s plan of care for the benefit period from 07/25/2025 to 10/22/2025 was reviewed and revealed that it was not updated to reflect patient-specific goals addressing the patient's new onset of chest pain requiring a new medication, nor was the patient's new onset of dizziness, which heightened the patient’s risk of bleeding with falls secondary to Eliquis addressed with updated interventions or goals. During an interview and joint record review with the Director of Clinical Operations (Personnel Record 3) on 11/20/2025, she confirmed that the expectation is that clinical staff should include updated care planning when new issues are identified during updated comprehensive assessments.

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 a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 17 (6%) applicable clinical records reviewed with Hospice Aide (HA) services revealed that the agency did not ensure that the HA was provided complete instructions to care for the patient. CLINICAL RECORD 9: The patient's plan of care for the benefit period from 09/10/2025 to 12/08/2025 was reviewed and included orders for the HA to visit the patient five times a week. The physician's certification of terminall illness for the same benefit period noted that the patient was incontinent of bowel and bladder. The clinical record contained a physician order dated 09/11/2025 for daily wound treatment to the patient's stage 4 pressure ulcer on the right hip: cleanse with wound cleanser, pat dry, apply MediHoney with Calcium Alginate dressing. Cover with a foam dressing. Change as needed in addition for a soiled or loose dressing. On 10/14/2025, the Registered Nurse (RN) documented the right hip wound measurement of 2.8cm x 3cm x 2.4 cm with an onset date of 08/14/2025, and it was restaged from a stage 3 to a 4 on 10/14/2025. The HA plan of care effective 10/23/2025 included interventios for a seated shower chair and perineal care every visit. There were no instructions provided to the HA on what to do should the dressing become wet, loose, or soiled. During an interview with the Director of Clinical Operations (DCO) on November 18, 2025, she highlighted the importance of including specific instructions in the HA care plan. She stated that the HA's care plan should direct the aide to coordinate the patient's shower with the facility's wound care nurse, ensuring the patient’s bath is completed prior to wound care. However, she noted that these instructions were not included in the current care plan.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During the review of the Volunteer Program documents and an interview with both the Volunteer Coordinator (VC) for the parent site (PERSONNEL RECORD 10), the VC for the Alternative Delivery Site (ADS) (PERSONNEL RECORD 11), and the Area Manager of Volunteer (AMVS) services on 11/19/2025, it was determined that the average volunteer contribution for January 1, 2024 to December 31, 2024 was 2%, with a rolling year-to-date average also 2% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation/refresh of a Performance Improvement Project (PIP) on January 1, 2025 and also has been included in the agency's strategic plan. The PIP includes monthly meetings with the VCs, AMVS, and the Executive Director to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. Prior to the onboarding of the VC for the parent location in June of 2025, the branch VC was having to cover both areas. NOTE: the total patient care hours for the organization have been trending up since February of 2025. The total volunteer hours increased from 26 hours in September 2025 to 43 hours in October of 2025. The parent location has doubled the total number of active volunteers and the branch location has developed a resource for volunteers at a local school with healthcare-centered focus. Documented retention activities included phone calls, texting, one to one meetings and introductions, birthday and acknowledgement cards. During the review of the Volunteer Program documents and an interview with both the Volunteer Coordinator (VC) for the parent site (Personnel Record 10), the Volunteer Coordinator for the Alternative Delivery Site (ADS) (Personnel Record 11), and the Area Manager of Volunteer (AMVS) services on 11/19/2025, it was determined that the average volunteer contribution for January 1, 2024 to December 31, 2024 was 2%, with a rolling year-to-date average also 2% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation/refresh of a Performance Improvement Project (PIP) on January 1, 2025 and also has been included in the agency's strategic plan. The PIP includes monthly meetings with the Volunteer Coordinators, AMVS, and the Executive Director to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. Prior to the onboarding of the VC for the parent location in June of 2025, the branch VC was having to cover both areas. Additionally, the total patient care hours for the organization have been trending up since February of 2025. The total volunteer hours increased from 26 hours in September 2025 to 43 hours in October of 2025. The parent location has doubled the total number of active volunteers and the branch location has developed a resource for volunteers at a local school with healthcare-centered focus. Documented retention activities included phone calls, texting, one to one meetings and introductions, birthday and acknowledgement cards.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 1 of 2 (50%) applicable clinical records reviewed of transferred patients revealed that the agency did not ensure that the discharge summary was sent to the receiving hospital upon the patient's discharge. CLINICAL RECORD 15: The patient elected the hospice benefit on 07/05/2025 and was discharged on 10/22/2025 due to seeking aggressive treatment at a non-contracted hospital. The patient's medication list included Nitroglycerin 0.4mg sublingually as needed for chest pain every 5 minutes, Metoprolol Succinate ER 12.5mg daily for hypertension, Jardiance 25mg daily for blood sugar control, Metformin 500mg daily for blood sugar control, Eliquis 2.5mg daily for anti-coagulation, and Norco 5mg-325mg tablet as needed for pain every 8 hours. There was no evidence in the scanned documentation, the coordination of care note, the documented phone call, or the post-discharge Interdisciplinary Group Meeting note that the discharge summary was provided to the hospital upon the patient's discharge to help ensure continuity of care. During a joint clinical record review and interview with the Director of Clinical Operations (DCO) on November 20, 2025, no evidence was found that the discharge summary had been sent to the hospital. The DCO explained that the established process requires the Team Assistant (TA) to fax the discharge summary to the hospital and subsequently document this action in the clinical record. She confirmed that this procedure had not been followed.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: the hospice election form and physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 1 (100%) home observation visits at a nursing facility revealed the agency did not ensure that the signed hospice election forms or the physician's certification and recertification of terminall illness documents were in the hospice facility chart. HOME VISIT 2: The patient elected the hospice benefit on June 12, 2025. During the home visit observation on November 18, 2025, at the nursing facility, a review of the hospice facility chart revealed that the binder was missing the patient's signed hospice election statement, as well as the physician's certification of terminal illness for the benefit period from August 5, 2025, to November 2, 2025, which was signed by the hospice physician on August 20, 2025. Additionally, the physician's recertification of terminal illness for the period from November 3, 2025, to January 31, 2026, signed by the hospice physician on October 29, 2025, was also absent. During a joint review of the hospice facility chart on November 18, 2025, with the Director of Clinical Operations (DCO), it was discovered that the facility chart was missing required documents, including the patient's signed hospice election statement and the physician's certification and recertification of terminal illness. The DCO outlined the standard procedure for maintaining compliance, which entails the Team Assistant (TA) printing the necessary consents, plan of care, certifications, and Interdisciplinary Group Notes for the nurse to deliver to the facility within 24-48 hours after admission, ideally during the follow-up visit or the next scheduled IDG meeting. The DCO acknowledged that this process did not function as intended in this instance.

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures addres development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment. The documented discussion of the plan provided to the patient/family, and maintained by the hospice. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 13 (15%) clinical records reviewed, the emergency plan did not include documentation of discussion or development of a plan with the patient and family about evacuation plans. Clinical Record 3: The patient elected the hospice benefit on 4/6/2018. There was no evacuation plan developed or discussed documented in the clinical record. Clinical Record 11: The patient elected the hospice benefit on 1/30/2023. There was no evacuation plan developed or discussed documented in the clinical record. The Executive Director was interviewed on 2/9/2023 and agreed that no evacuation plan was documented on these records.

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 a review of clinical records and interviews. In 1 of 13 (8%) clinical records reviewed, the comprehensive assessment was not completed within the first five days after the election of hospice care. Clinical Record 6: The patient elected the hospice benefit on 1/27/2023. The initial nursing assessment identified that the patient/family accepted chaplain services. There was no documentation that the chaplain completed an initial spiritual assessment. The Executive a spiritual initial evaluation/2023 and agreed that there was no initial chaplain assessment completed.

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 and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 2 (50%) clinical records reviewed of patients who were live discharges, the agency did not document that the discharge summary was forwarded to the attending physician. Clinical Record 12: The patient elected the hospice benefit on 11/14/2022 and revoked the hospice benefit on 12/19/2022 to seek aggressive treatment. There was no documentation that the discharge summary was forwarded to the patients attending physician. The Executive Director was interviewed on 2/9/2023 and agreed that there was no documentation that the discharge summary was forwarded to the patients attending physician.

It is required that Hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. This standard was not met as evidenced by document review and interview which revealed identified problems not included in the official hospice plan of care problems located in the EMR. These problems included 1) "Nutrition/Hydration: Diet-G-Tube feedings as per MD Orders; NFS will assess the patient for nausea and/or vomiting; NFS will assess for complications of enteral/parenteral/IV nutrition/hydration; NF will call hospice if the patient experiences nausea/vomiting; NSF will call hospice to report complications of enteral/parenteral/IV nutrition/hydration residuals over 20ml. Goals/Outcomes: SNF Nurse to report each visit: Patient and family/caregiver will understand the impact of disease progression on metabolism, appetite, and need for food and hydration; " Patient will tolerate diet that is consistent with disease progression. Residuals less than 20ml." 2) "High Risk for Falls: NSF will notify hospice of any patient falls; Safety interventions currently include: Bolsters and Concave mattress. Goals/Outcomes: SNF will report any falls immediately; Patient will not experience any falls; Patient will not sustain any injury from falls; SNF to report NO falls or injuries each visit." The Executive Director was interviewed on 2/9/2023 and agreed that these problems were not present in the official hospice plan of care.