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

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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment within five (5) days after the election of hospice care. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/14/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). The Registered Nurse (RN) completed a comprehensive assessment on 02/14/2025. A clinical record review revealed no evidence that the Social Worker (SW) or Chaplain (SC) completed an assessment within five days of the patient's election of hospice care, made contact with the patient to perform an assessment, or documented evidence that the patient declined the services at admission. In a joint record review and interview on 08/27/2025, the Director of Clinical Operations confirmed that the record lacked evidence of the required services or evidence that the patient declined the required services, stating, "Our normal process is for the admission nurse to include in her admission note if the patient declines social work or chaplain services, and this record it was not done."

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 volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the 2024 Hospice Volunteer Requirement Report revealed the volunteer percentage of hours worked for January 2024 through December 2024 was 0.0%. During an interview on 08/28/2025, the Administrator stated, "They currently have an opening and are actively recruiting for a volunteer coordinator, and are getting more volunteer hours, and the percentage is up to 2.0% in 2025." The review of the Hospice Volunteer Requirement Report revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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, and ensure the implementation of the interdisciplinary plan of care. 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. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) clinical records reviewed revealed that the agency did not ensure that care and services provided to the patient followed the plan of care. Clinical Record 8: Plan of care orders dated 9/25/2022 read, SN 1 wk 14 3 PRN for symptom management. The order written on 10/15/2022 read "D/T patient's change in condition to unresponsive and actively dying, increase SN /HHA to daily, SCC(Chaplain)/MSW to weekly.” Skilled nurse visits were completed on 10/15/2022 and 10/16/2022 but no further skilled nursing visits were documented in the clinical chart as of 10/20/2022. In an interview on 10/19/2022 Executive Director stated that she was aware of the patient and would notify the nurse to download visits. In an interview on 10/20/22 Executive Director reported that the nurse's tablet had had problems which are now resolved and the visits have been downloaded. Visits after 10/16/2022 are not in the patient record. 1 of 13 (7%) of clinical records reveal that agency did not ensure that care and services provided to the patient followed the plan of care.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (7%) reviewed revealed that the agency did not ensure that the plan of care included services necessary to meet the needs of the patient. Clinical Record 11: Election of Hospice 8/29/20222, with a primary diagnosis of Heart Disease. The patient resides in a Skilled Nursing Facility. The initial Skilled Nursing assessment dated 8/29/2022 noted in part, “an unstageable wound to right coccyx that includes multiple wounds in a cluster. Facility using calcium alginate for wound care daily and PRN. The patient has a wound to the right hip, hydrogel being used with adhesive dressing, and stage 2 pressure wounds to the right inner thigh from the catheter impression staying in the same position. Hydrogel applied and adhesive dressing…Facility providing wound care.” The Hospice Plan of Care effective 8/29/2022 included orders to provide instruction related to prevention /management of skin breakdown. The Hospice Plan of care did not include any specific orders for wound care being provided by the facility staff. In an interview on 10/19/22, the Executive Director stated, "I understand why it should be on the care plan." 1 of 13 (7%) reviewed revealed that the agency did not ensure that the plan of care included services necessary to meet the needs of the patient.

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 a review of clinical records and interviews. 1 of 9 (11%) clinical records reviewed for patients receiving aide services revealed that the agency did not ensure that the aide care plan was updated to ensure that the patient needs were met and the aide could function within the scope of practice. Clinical Record 10: Patient elected hospice on 8/18/22. The patient was admitted 8/18/2022 with an aide care plan initiated on 8/18/2022. New orders were received on 8/19/2022 for RN to insert a Foley catheter. The Aide care plan was not updated to include Foley catheter care. Interview on 10/19/2022, Executive Director finished the site visitor's sentence when describing new orders and stated, "the nurse forgot to update the aide care plan." 1 of 9 (11%) of records reviewed for patients receiving aide services revealed that the agency did not ensure that the aide care plan was updated to ensure that the patient needs were met and the aide could function within the scope of practice.

It is required that the 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. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (7%) reviewed revealed that the agency did not ensure that the Hospice Plan of Care identified which provider is responsible for performing functions that were agreed upon. Clinical Record 11: Election of Hospice 8/29/20222, with a primary diagnosis of Heart Disease. The patient resides in a Skilled Nursing Facility. The Skilled Nurse initial assessment dated 8/29/2022 noted in part, “an unstageable wound to right coccyx that includes multiple wounds in a cluster. Facility using calcium alginate for wound care daily and PRN. The patient has a wound to the right hip, hydrogel being used with adhesive dressing, and stage 2 pressure wounds to the right inner thigh from the catheter impression staying in the same position. Hydrogel applied and adhesive dressing…Facility providing wound care.” The written Hospice Plan of Care did not identify which provider is responsible for performing wound care. In an interview on 10/19/22 the Executive Director stated, "I understand why it should be on the care plan."

Based on record review and interview, the agency failed to conduct and document a patient specific comprehensive assessment that identified the physical needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process for one of five hospice patients (Patient #1) whose clinical records were reviewed in that: The hospice SN failed to include information from the comprehensive assessment to establish and monitor a plan of care to assess Patient #1's Mediport (implanted port with a flexible tube placed into a vein in the chest) and receive orders from the physician on the care and treatment of the site. This failure may have led to the emergency room visit of Patient #1 and placed all patients at risk of unidentified infections resulting in hospitalizations. Findings included: Review of a "Client Coordination Note Report" dated 04/14/22 indicated Patient #1's family member called the agency and reported Patient #1's right chest port (mediport) was red, and patient was complaining of pain at the port. The note indicated Patient #1's family member reported the port had not been flushed since hospice admission. Review of a "Client Coordination Note Report" dated 04/15/22 indicated Patient #1's family member reported Patient #1 was taken to the emergency room on 04/14/22 and patient was being treated for infection of the port (mediport). Review of a hospital emergency room visit note for Patient #1 dated 04/14/22 indicated Patient #1's family member took patient to the emergency room with complaints of erythema (redness of the skin) over right chest port (mediport) site that had been present for two to three days. The note indicated a diagnosis of severe sepsis. Review of a POC dated 08/11/21 - 11/08/21 for Patient #1 indicated a SOC date 08/11/21 and diagnoses including malignant neoplasm (cancerous tumor) of lower lobe, right bronchus or lung, secondary malignant neoplasm of bone, secondary malignant neoplasm of brain, secondary malignant neoplasm of other specified sites, and neoplasm related pain. The POC indicated Patient #1 was to receive SN visits three times a week for one week, twice a week for one week, three times a week for eleven weeks, and one time a week for one week. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care the with physician. The POC indicated goals: A nursing plan of care will be established that meets the patient's needs. The POC did not include orders to assess the patients mediport access site, nor did it address the location, safety measures, or care interventions for the protection of the access site. Review of a SOC comprehensive assessment visit note report for Patient #1 dated 08/11/21 indicated "yes" to "does the patient have an IV access". The note also indicated IV access/flushed under integumentary assessment findings. The note did not address the location or type of access site the patient had. Review of a Hospice Recertification Plan of Care update Order for Patient #1 dated 04/06/22 for certification period 04/08/22 - 06/06/22 indicated Patient #1 was to receive SN once every two weeks for two weeks, then once a week for eight weeks. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care with the physician. The POC did not include orders to assess the patient's mediport access site or care interventions for the protection of the access site. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report for Patient #1 dated 08/26/21, 09/09/21, 09/23/21,10/07/21, 10/21/21, 11/04/21, 11/17/21,12/01/21,12/15/21, 12/29/21, 01/12/22, 01/26/22,02/09/22, 02/23/22,03/09/22, 03/23/22, and 04/06/22 did not indicate the patient had a mediport. Review of SN visits for Patient #1 for the certification period of 02/07/22 - 04/07/22 and 04/08/22 until discharge on 04/21/22 did not reveal documentation of assessment for Patient #1's mediport access site or the location of the site. A SN recertification visit dated 03/21/22 prior to hospitalization did not include an assessment of Patient #1's mediport. During an interview on 07/18/22 at 12:10 a.m., the RN Administrator said the agency did not typically mess with/flush mediports in the hospice environment unless the patient was receiving something through it because of the risk for introducing infection. She said the SN should assess a patient's mediport as part of their skin assessment. During an interview on 07/18/22 at 1:05 p.m., the RN Administrator said she did not know if the nurses were assessing Patient #1's mediport because she was not there. During an interview on 07/18/22 at 1:37 p.m., the RN Administrator, who was part of the IDG/meetings, said she admitted Patient #1 and knew he had a mediport. During an interview on 07/18/22 at 1:56 p.m., the RN Administrator said the nurse of a patient with a mediport was expected to assess the skin/site. She said if the doctor ordered flushes of the port or IV medications the nurse would put an order in for a flush. She said that if a patient's port was subdermal (located or placed beneath the skin) it would be noted on the POC as a wound area to assess. The Administrator said the POC was updated a minimum of every 15 days and with changes. She said a patient's skin was assessed once every 15 days or weekly if the patient had an existing wound. She said a mediport should be documented on subsequent assessments after the SOC and there was no reason for it not to be. The Administrator said the importance of assessing a mediport was problems could be determined at the skin level such as heat and redness (signs of infection). She said by not assessing a mediport a patient could have an infection that may not be caught. The Administrator said Patient #1 went to the hospital on 04/14/22 and was released on 04/20/22. She said the family member reported Patient #1 had sepsis and the patient was treated with IV antibiotics and had the port (mediport) removed. Attempted to call the medical director of the agency for interview on 07/18/22 at 1:50 p.m. and left voicemail but he did not return surveyor's call. Attempted to call RN D, who provided care for Patient #1, for an interview on 07/18/22 at 1:52 p.m. and left voicemail but she did not return surveyor's call. Review of a Comprehensive Assessment policy revised on 02/15/22 indicated "This comprehensive assessment identifies the physical, psychological, emotional, and spiritual needs related to the terminal illness to promote the hospice patients' well-being, comfort, and dignity throughout the dying process ... 4. During the comprehensive patient assessment, all baseline data, and other relevant information shall be documented in the patient's clinical record, including at least the following information and assessments, as relevant ... F. A physical assessment ... I. Complications and risk factors that affect care planning ... 5. The comprehensive assessment shall determine: A. Patient problems and needs related to the terminal illness ..." Review of an Ongoing Nursing Assessment policy revised on 02/15/22 indicated " ...Elements assessed and documented shall include: G. Skin integrity ... 3. Based on assessments, the care plan- including problems, needs, goals, and outcomes shall be reviewed and updated by the interdisciplinary group members responsible for the case ..." Review of a Hospice Nursing Care policy revised on 02/15/22 indicated " ...3. A hospice registered nurse shall be assigned as the case manager for each patient and family/caregiver, and their duties shall be enumerated in a job description. Duties shall include ... B. Coordination of care and fostering communication between the patient and the interdisciplinary group. C. Participating in developing and implementing the plan of care ... G. Recommending revisions or changes in the plan of care as necessary ..." Review of a Plan of Care policy revised on 02/15/22 indicated " ...1. A written individualized plan of care will be established and maintained for each individual admitted to the hospice program ... 5. The Case Manager (or admitting registered nurse) will notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, identifying patient needs and the recommended services to meet those needs. The plan of care will be reviewed before care is delivered ... 16. The written plan of care will contain, but will not be limited to, the following ... B. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling ... F. Safety measures to protect against abuse, injury, infection, or infectious disease, as appropriate ... Q. drugs and treatments ..." Review of About Your Implanted Port dated 05/10/21 and accessed at https://www.mskcc.org/cancer-care/patient-education/your-implanted-port indicated "...Your implanted port will need to be flushed by a nurse every 4 weeks when it's not being used. This is done to make sure the catheter doesn't become blocked. If it becomes blocked, it may not work anymore and it may have to be removed ...Call Your Interventional Radiologist if You: have new or increased pain at the site of your port, have swelling or a growing bruise at the site of your port, Have pus or fluid coming from your incision(s), notice your incision(s) are hot, tender, red, or irritated ..."

Based on record review and interview, the IDG failed to ensure patient-specific needs were identified and assessed in during the updated comprehensive assessments and documented on the updated IDG POCs for one of five patients (Patient #1). This failure may have led to the emergency room visit of Patient #1 and placed all clients at risk of unidentified infections resulting in hospitalizations. Findings included: Review of a "Client Coordination Note Report" dated 04/14/22 indicated Patient #1's family member called the agency and reported Patient #1's right chest port (mediport) was red, and patient was complaining of pain at the port. The note indicated Patient #1's family member reported the port had not been flushed since hospice admission. Review of a "Client Coordination Note Report" dated 04/15/22 indicated Patient #1's family member reported Patient #1 was taken to the emergency room on 04/14/22 and patient was being treated for infection of the port (mediport). Review of a hospital emergency room visit note for Patient #1 dated 04/14/22 indicated Patient #1's family member took patient to the emergency room with complaints of erythema (redness of the skin) over right chest port (mediport) site that had been present for two to three days. The note indicated a diagnosis of severe sepsis. Review of a POC dated 08/11/21 - 11/08/21 for Patient #1 indicated a SOC date 08/11/21 and diagnoses including malignant neoplasm (cancerous tumor) of lower lobe, right bronchus or lung, secondary malignant neoplasm of bone, secondary malignant neoplasm of brain, secondary malignant neoplasm of other specified sites, and neoplasm related pain. The POC indicated Patient #1 was to receive SN visits three times a week for one week, twice a week for one week, three times a week for eleven weeks, and one time a week for one week. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care the with physician. The POC indicated goals: A nursing plan of care will be established that meets the patient's needs. The POC did not include orders to assess the patient's mediport access site, nor did it address the location, safety measures, or care interventions for the protection of the access site. Review of a SOC comprehensive assessment visit note report for Patient #1 dated 08/11/21 indicated "yes" to "does the patient have an IV access". The note also indicated IV access/flushed under integumentary assessment findings. The note did not address the location or type of access site the patient had. Review of a Hospice Recertification Plan of Care update Order for Patient #1 dated 04/06/22 for certification period 04/08/22 - 06/06/22 indicated Patient #1 was to receive SN once every two weeks for two weeks, then once a week for eight weeks. The POC revealed an order for the hospice nurse to evaluate the patient and develop a plan of care with the physician. The POC did not include orders to assess the patient's mediport access site or care interventions for the protection of the access site. Review of Hospice IDG Comprehensive Assessment and Plan of Care Update Report for Patient #1 dated 08/26/21, 09/09/21, 09/23/21,10/07/21, 10/21/21, 11/04/21, 11/17/21,12/01/21,12/15/21, 12/29/21, 01/12/22, 01/26/22,02/09/22, 02/23/22,03/09/22, 03/23/22, and 04/06/22 did not indicate the patient had a mediport. Review of SN visits for Patient #1 for the certification period of 02/07/22 - 04/07/22 and 04/08/22 until discharge on 04/21/22 did not reveal documentation of assessment for Patient #1's mediport access site or the location of the site. A SN recertification visit dated 03/21/22 prior to hospitalization did not include an assessment of Patient #1's mediport. During an interview on 07/18/22 at 12:10 a.m., the RN Administrator said the agency did not typically mess with/flush mediports in the hospice environment unless the patient was receiving something through it because of the risk for introducing infection. She said the SN should assess a patient's mediport as part of their skin assessment. During an interview on 07/18/22 at 1:05 p.m., the RN Administrator said she did not know if the nurses were assessing Patient #1's mediport because she was not there. During an interview on 07/18/22 at 1:37 p.m., the RN Administrator, who was part of the IDG/meetings, said she admitted Patient #1 and knew he had a mediport. During an interview on 07/18/22 at 1:56 p.m., the RN Administrator said the nurse of a patient with a mediport was expected to assess the skin/site. She said if the doctor ordered flushes of the mediport or IV medications the nurse would put an order in for a flush. She said that if a patient's mediport was subdermal (located or placed beneath the skin) it would be noted on the POC as a wound area to assess. The Administrator said a POC was updated a minimum of every 15 days and with changes. She said a patient's skin was assessed once every 15 days or weekly if the patient had an existing wound. The Administrator said Patient #1's mediport was not mentioned during IDG meetings until the agency was made aware of the infection. She said that it was normal not to mention a mediport during IDG meetings unless a change had occurred. She said a mediport should be documented on subsequent assessments after the SOC and there was no reason for it not to be. The Administrator said the importance of assessing a mediport was problems could be determined at the skin level such as heat and redness. She said by not assessing a mediport a patient could have an infection that may not be caught. The Administrator said Patient #1 went to the hospital on 04/14/22 and was released on 04/20/22. She said the family member reported Patient #1 had sepsis and the patient was treated with IV antibiotics and had the mediport removed. Attempted to call the medical director of the agency for interview on 07/18/22 at 1:50 p.m. and left voicemail but he did not return surveyor's call. Attempted to call RN D, who provided care for Patient #1, for an interview on 07/18/22 at 1:52 p.m. and left voicemail but she did not return surveyor's call. Review of a Comprehensive Assessment policy revised on 02/15/22 indicated "This comprehensive assessment identifies the physical, psychological, emotional, and spiritual needs related to the terminal illness to promote the hospice patients' well-being, comfort, and dignity throughout the dying process ... 4. During the comprehensive patient assessment, all baseline data, and other relevant information shall be documented in the patient's clinical record, including at least the following information and assessments, as relevant ... F. A physical assessment ... I. Complications and risk factors that affect care planning ... 5. The comprehensive assessment shall determine: A. Patient problems and needs related to the terminal illness ..." Review of an Ongoing Nursing Assessment policy revised on 02/15/22 indicated " ...Elements assessed and documented shall include: G. Skin integrity ... 3. Based on assessments, the care plan- including problems, needs, goals, and outcomes shall be reviewed and updated by the interdisciplinary group members responsible for the case ..." Review of a Hospice Nursing Care policy revised on 02/15/22 indicated " ...3. A hospice registered nurse shall be assigned as the case manager for each patient and family/caregiver, and their duties shall be enumerated in a job description. Duties shall include ... B. Coordination of care and fostering communication between the patient and the interdisciplinary group. C. Participating in developing and implementing the plan of care ... G. Recommending revisions or changes in the plan of care as necessary ..." Review of a Plan of Care policy revised on 02/15/22 indicated " ...1. A written individualized plan of care will be established and maintained for each individual admitted to the hospice program ... 5. The Case Manager (or admitting registered nurse) will notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, identifying patient needs and the recommended services to meet those needs. The plan of care will be reviewed before care is delivered ... 16. The written plan of care will contain, but will not be limited to, the following ... B. Identification of patient and family/caregiver needs, including physical, psychosocial, cognitive, cultural, spiritual, nutritional, functional, educational, and counseling ... F. Safety measures to protect against abuse, injury, infection, or infectious disease, as appropriate ... Q. drugs and treatments ..." Review of About Your Implanted Port dated 05/10/21 and accessed at https://www.mskcc.org/cancer-care/patient-education/your-implanted-port indicated "...Your implanted port will need to be flushed by a nurse every 4 weeks when it's not being used. This is done to make sure the catheter doesn't become blocked. If it becomes blocked, it may not work anymore and it may have to be removed ...Call Your Interventional Radiologist if You: have new or increased pain at the site of your port, have swelling or a growing bruise at the site of your port, Have pus or fluid coming from your incision(s), notice your incision(s) are hot, tender, red, or irritated ..."