Every finding on record at Texas Home Health Hospice, L.P.

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. The agency did not ensure that hospice volunteers provided 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. A joint review of the Volunteer Program documents and an interview on July 24, 2025, with the Executive Director, the Area Manager of Volunteer Services (AMVS), and the Volunteer Coordinator revealed that the average volunteer percentage rate for the calendar year 2024 was 1.67%. The Executive Director, the Area Manager of Volunteer Services (AMVS), and the Volunteer Coordinator confirmed that this falls below the targeted 5% volunteer requirement, which prompted the initiation of a Performance Improvement Project on January 3, 2025. As of June 2025, the year-to-date volunteer contribution was 2.4%, with June’s percentage increasing to 3.4%. During the review of the Volunteer Program documents and an interview with the Executive Director (ED - Personnel Record 2), the Area Manager of Volunteer Services (AMVS - a Corporate employee), and the Volunteer Coordinator (VC - Personnel Record 7) on July 24, 2025, it was determined that the average volunteer percentage rate for 2024 was 1.67%. This falls below the targeted 5% volunteer requirement, which prompted the initiation of a Performance Improvement Project on January 3, 2025. The ED and VC hold bi-weekly meetings, which include the AMVS monthly, to review ongoing activities and progress toward the volunteer engagement goal. Documented recruitment strategies include outreach through presentations at churches, universities, colleges, the Veterans of Foreign Wars (VFW), and the Chamber of Commerce, as well as distributing flyers. There is consistent engagement with current volunteers, a yearly volunteer gathering, activities during Volunteer Appreciation Month, and regular invitations to employee events. As of June 2025, the year-to-date volunteer contribution was 2.4%, with June’s percentage increasing to 3.4%.

It is required that nursing care and services are provided by or under the supervision of a Registered Nurse and per the patient Plan of Care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) clinical records of patients with wound care, revealed the agency Skilled Nurse had failed to provide evidence of “Standards of Practice” having been met; documentation regarding patient information and evaluation of findings consistent with a nursing comprehensive assessment were not in evidence. Clinical Record 23: The initial certification began 8/16/2022. The patient's family member revoked hospice services on 8/18/2022 as the patient was hospitalized (NOTE: the patient was readmitted to hospice on 8/21/2022). The patient's initial diagnoses included Encephalopathy, Sepsis, Patient with Stage 4 Pressure Injury to the Sacrococcygeal area, DTI (deep tissue injury) to the Bilateral heels. This is a 74-year-old female, residing in a LTCF (long-term care facility) after an admission to an acute care facility. Padded boots were applied to her feet. She is also bedbound. Included in the nurse notes is notation regarding a device that "Could not be removed on the Sacral/Coccyx wound” This device was not defined in terms of its function, or the orders relating to its maintenance or initial application or purpose. Skin care ordered was to be continued from the hospital, and was reflected in the physician's History and Physical, and continued as ordered by the Discharging Physician from the acute care facility. This read: “Care to the Sacrum (STG 4), dressing changes once a day by Nursing. Cleanse the wound with Vashe and gauze, apply liquid skin barrier to the peri wound area. Pack wound with Vashe wet and DRAWTEX. Cover with dry DRAWTEX and three ABD, Secure with tape. Apply No-string Skin Prep to dried areas of the sacrococcygeal and perineum. Allow to dry to help protect the skin. Apply the Venelex topically to the Bilateral Heels and Bilateral posterior abductors, once per shift. Upon initial admission, 8/16/2022, the RN documented “Sacral Area infected so bad, area so infected. They decided to choose Hospice to help them manage pain and comfort at the nursing home. Patient has wound to Sacral Coccyx area that is covered with clean dressing and order written to have Treatment Nurse evaluate and treat at facility.” There was no order for the Treatment Nurse, or Hospice Nurse, to evaluate the bilateral heels. On 8/17/2022, the RN documented, under the integumentary section “Wound assessed: No, not ordered this visit, [and] Wound Care not provided this visit.” This appears to be a flaw in the transcription capabilities of the documentation program used by this agency. On 8/18/2022, it was documented ”The family revokes services for hospital care on 8/18/2022. There was no evidence documented as to whether the admitting hospice nurse had undertaken the effort to assess any of the lesions as there is no evidence the lesions had been measured. This is pivotal in the IDG’s ability to formulate a Plan of Care. In addition, there was no documented evidence that the Hospice admitting nurse had evaluated the lesions this client presented upon Hospice admission or consulted with the Treatment Nurse at the LTCF pertaining to the sacral wound or evaluation of wounds that may have been present under the heel protectors applied to the bilateral heels. This situation persisted since admission on 8/16/2022, and 8/17/2022 until the family had revoked services on 8/18/2022.Though this patient’s admission was of short duration, at no point in time is there any evidence of wound measurements having been taken from admission to revocation of services. During an interview on 9/9/2022, the Administrator, in response to the question, "Why is there no evidence in the documentation ensuring measurements of wounds are undertaken on admission and on a weekly basis? The Administrator stated that the RNs are aware of the requirement to provide documentation of wound measurements on admission and weekly, and that the corrective process to ensure compliance has been initiated.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group, included in the plan of care, and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interview. 1 of 5 (20%) clinical records of patients receiving Hospice Aide services revealed hospice aide services was not consistently documented as having been completed in accordance with the orders for assigned tasks on the Aide Plan of Care. Clinical Record 9: For the start of care benefit period beginning 6/13/2022 through 9/10/2022, of a 74-year-old female, residing at home, with diagnoses including Alzheimer’s, Weakness, Fatigue, Multiple Falls, and Incontinent of Bowel and Bladder, the Aide Care Plan, dated 8/7/2022, assigned the aide to visit three times a week. The assignment directed the aide to provide “Perineal care every visit, and Barrier Cream to Buttock.” The Aide visits on 8/8/2022, 8/10/2022, 8/12/2022, 8/15/2022, 8/17/2022, 8/18/2022, 8/24/2022, 8/26/2022, 8/29/2022, 8/30/2022, 8/31/2022, 9/1/2022, 9/2/2022, 9/6/2022, and 9/7/2022 were reviewed. There were no documented instances of barrier cream being applied to the patient's buttock. The aide services were not consistent with the Plan of Care. The “Comments/Special Instructions” entry that should have documented the application of the ordered Barrier Cream was left blank. In interviews with the Administrator on 9/08/2022, and 9/09/2022, it was stated that the aide should have been consistent with the plan of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: physician certification and recertification of the terminal illness. This standard was not met as evidenced by a review of clinical records, observation on home visits and interviews. 1 of 1 (100%) record present at the Long-Term Care Facility (LTCF) during an observed home visit revealed the agency had failed to provide the Physician Recertification of Terminal Illness documentation. Clinical Record 25: The patient is an 89-year-old female residing at an LTCF. This patient began Hospice services on 8/21/2020 for the 12th benefit period, beginning 8/11/2022 through 10/19/2022. Diagnoses include Malignant Neoplasm of Endometrium, Chronic Kidney Disease Stage 4, Osteoarthritis, and Dependent on Supplemental Oxygen. The hospice patient records located at the LTCF did not evidence the Physician Certification of the Terminal Illness or the Recertification of the Terminal Illness forms. During the observed visit to the LTCF with the RN at the facility, the hospice patient records were reviewed with the LTCF facility nursing representative. The LTCF staff stated that they could not find the Certification of Terminal Illness upon admission, or the Recertification Physician Certification of Terminal Illness in the hospice "book." Hospice patient information is present in the form of a binder in the nurse station. In interviews with the Administrator on 9/08/2022 and 9/09/2022, it was stated that the patient had moved to the facility on 8/18/2022 and the Nurse Practitioner had seen the patient on 7/29/2022, but relevant forms had not been delivered to the LTCF.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by a review of documents and interview. 1 of 5 (20%) contracts reviewed revealed that the Hospital/GIP contract did not include the clause, in writing, between the contractor/contracted, for the provision that requires criminal background checks. An interview was conducted on 9/9/2022, with the Administrator, who stated that this organization ”Will provide an addendum to ensure compliance” for the requirement that all contractors who either have access to patient records, provide direct patient care, or both, have had criminal background checks.