Every finding on record at Texas Home Health Hospice LP

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 following: 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 measures 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and OTC drugs. CLINICAL RECORD 1/HOME VISIT 1: The patient elected hospice care on 06/16/2025 with a diagnosis of hypertensive heart disease and chronic kidney disease. The skilled nursing (SN) visit note dated 07/11/2025 documented, "This writer educated patient on need to use O2 prn due to dyspnea...." The hospice medication profile did not document the oxygen noted in the clinical note. During the home visit with the Licensed Vocational Nurse (LVN) on 08/05/2025, the patient's son stated the oxygen has been in the home since admission and, "She uses the oxygen two to three times a day." Oxygen was observed in the home. The patient's son stated that the patient's daughter was in charge of the medications. The hospice medication profile did not document the oxygen noted in the clinical note and observed during the home visit. CLINICAL RECORD 6: The patient elected hospice care on 04/16/2025 with a diagnosis of atherosclerotic heart disease. The SN visit note dated 06/30/2025 documented, "The patient is in the bathroom. He is in there for about 5-10 minutes. He later shares that he has been having a harder time having bowel movements. He has been taking Colace and MiraLAX." The hospice medication profile did not document the Colace and MiraLAX noted in the SN visit note. During a joint record review and interview on 08/06/2025, the Executive Director confirmed that the medications were not documented on the medication profiles for clinical record 1 and clinical record 6.

It is required that each patient’s individualized written plan of care: reflects patient, and family goals; [and] 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 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care reflected patient and family goals and identified planned interventions based on problems identified in the comprehensive assessments. CLINICAL RECORD 7: The patient elected hospice care on 05/28/2025 with a diagnosis of alcoholic cirrhosis of the liver. On 07/7/2025, the physician ordered, "Keflex 500 mg po bid x 7 days for skin infection." The skilled nursing (SN) visit dated 07/10/2025 documented, "Pt continues with antibiotic treatment for skin lesions on neck, pt frequently scratches them, SN cleansed skin applied bandage to prevent infection. Instructed on skin integrity measures and keeping skin clean and dry." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports 07/15/2025 did not document patient and family goals, and planned interventions for the identified skin infection. CLINICAL RECORD 9: The patient elected hospice care on 04/23/2025 with a diagnosis of Alzheimer's Disease. On 05/16/2025, the physician ordered, "Macrobid 100mg PO BID x 7 days for urinary tract infection (UTI)." The Hospice IDG Comprehensive Assessment and Plan of Care Update Reports 05/20/2025 did not document patient and family goals, and planned interventions for the identified urinary tract infection. During a joint record review and interview on 08/06/2025, the Executive Director [Personnel Record 7] confirmed that the Hospice IDG Comprehensive Assessment and Plan of Care Update Reports did not include updated goals and planned interventions for clinical record 7 and clinical record 9.

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. Agency policy/protocol #4003 "Hand Hygiene" (revised 06/09/2021) read in part "Decontaminate the hands using an alcohol-based hand rub, or wash hands with antimicrobial soap and water when the hands are not visibly soiled in the following circumstances: g. when performing patient care and moving from a contaminated body site to a clean-body site." In 1 of 4 (25%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. HOME VISIT 4: The patient elected hospice care on 07/16/2024 with a diagnosis of hypertensive heart disease and chronic kidney disease. The Hospice Aide (HA) [Personnel Record 4] provided peri care during the home visit on 08/06/2025. During the patient's shower, the HA provided peri care, rinsed the patient, toweled off the patient, and dressed the patient. Once all tasks were completed, the HA removed their gloves and washed their hands. The HA did not perform hand hygiene when moving from a contaminated to a clean body site during patient care, as per the policy. During an interview on 08/06/2025, the Executive Director confirmed the finding and the agency policy that hand hygiene should be performed during patient care when moving from a contaminated body site to a clean-body site

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 was equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the agency's "Hospice Volunteer Requirement Report" with the Administrator [Personnel Record 7] and Volunteer Coordinator [Personnel Record 5] on 08/05/2025 revealed that volunteer utilization was 2.29% for the calendar year 2024 and 2.57% from January 2025 through July 2025. During an interview and a joint review of the report on 08/05/2025, the Administrator confirmed that volunteer utilization was below the required 5% and stated, "We have a PIP [performance improvement plan] in place; it's been challenging as we grow." Review of volunteer documents revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that was equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.

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 3 of 19 (16%) clinical records reviewed, the agency did not ensure the patient's clinical record contained physician orders for the care and services provided. CLINICAL RECORD 1/HOME VISIT 1: The patient elected hospice care on 06/16/2025 with a diagnosis of hypertensive heart disease and chronic kidney disease. The skilled nursing (SN) visit note dated 07/11/2025 documented, "This writer educated patient on need to use O2 prn due to dyspnea. This writer educated on Zofran use for NV." During the home visit with the Licensed Vocational Nurse (LVN) on 08/05/2025, the patient's son stated the oxygen has been in the home since admission and, "She uses the oxygen two to three times a day." Oxygen was observed in the home. The patient's son provided a medication bottle of Zofran that was his prescription, stating he gave it to the patient for nausea and vomiting. The patient's son stated that the patient's daughter was in charge of the medications. The patient's Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 07/16/2025 and 07/30/2025 did not document Zofran and oxygen. There was no evidence of a physician's order for the patient for oxygen or Zofran. CLINICAL RECORD 6: The patient elected hospice care on 04/16/2025 with a diagnosis of atherosclerotic heart disease. The SN visit note dated 06/30/2025 documented, "The patient is in the bathroom. He is in there for about 5-10 minutes. He later shares that he has been having a harder time having bowel movements. He has been taking Colace and MiraLAX." The hospice medication profile did not document the Colace and MiraLAX noted in the SN visit note. The patient's Hospice IDG Comprehensive Assessment and Plan of Care Update Reports dated 07/09/2025 and 07/23/2025 did not document Colace and MiraLAX. A clinical record review revealed no evidence of a physician's order for Colace or MiraLAX. CLINICAL RECORD 7: The patient elected hospice care on 05/28/2025 with a diagnosis of alcoholic cirrhosis of the liver. On 07/07/2025, the physician ordered, "Keflex 500 mg po bid x 7 days for skin infection." The skilled nursing (SN) visit note dated 07/10/2025 documented, "Pt continues with antibiotic treatment for skin lesions on neck, pt frequently scratches them, SN cleansed skin, applied bandage to prevent infection. Instructed on skin integrity measures and keeping skin clean and dry." The patient's Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 07/15/2025 did not document the wound care (treatment) provided to the patient. A clinical record review revealed no evidence of a physician's order for the wound care provided. During a joint record review and interview on 08/08/2028, the Executive Director confirmed the findings and stated in part, "We should have orders in the record for wound care and medications."

Based on record review and interview, the agency failed to comply with the provisions of the Texas Human Resources Cod, Chapter102 for 1 of 3 active patients (Patient #3), whose records were reviewed in that the patient received services that was refused. This failure placed the agency's patients at risk for their rights being violated when the patient refuse services from the agency. --- Findings include: Record Review of the State of Texas regulation titled, ";Texas Human Resource Code § 102.003 Section 102.003 - Rights of the Elderly," revealed ";(b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: (1) has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits, and services;" During a record review of Patient #3s clinical records revealed a start of care date of 1/17/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (a condition that causes difficulty breathing). Further review of the Patient #3s clinical records further reveal Patient #3 lived in a skilled nursing facility and received hospice nurse visits once weekly, hospice aide visits twice weekly, and chaplain services once monthly. During a record review of Patient #3s clinical records from HHA A, the clinical records dated 11/21/2024 revealed, ";I saw [Patient #1] ...the facility wanted her cleaned up because they were going to get her up for their Thanksgiving Dinner. She was so mad and fighting but I did manage to complete my assignment. Just in case she tells her family..." During a record review of Patient #3s clinical records from HHA A, the clinical records dated 11/26/2024 revealed, ";I saw [Patient #3] ...today, and she was very agitated and mean. She told me she didnt like me. She deliberately held on to the rails when I am trying to turn her. She told me that in front of the nurse. She said she doesnt not like the baths. She got a small skin tear on her left arm from holding the rails while I was trying to turn her...she is only like that when its bath time. I also informed the nurse." During an interview with Patient #3 on 2/6/2025 at 1:45 p.m., Patient #3 stated she never liked HHA A and she didnt like the way she bathed her. Patient #3 stated that the last time HHA A bathed her, she caused bruises on her arms. During an interview on 1/30/2025 at 3:00 p.m. with HHA A, HHA A stated," When I went to bathe [Patient #3], she already stated that she didnt like me, and she didnt like my bathing, but I kept bathing her. She kept saying she doesnt like me. No, I never asked her why she didnt like me. Then I got the [nursing facility] nurse to assist me . The nurse tried to talk to her. She kept saying that she didnt like me, and I dont know why. It was my fourth time seeing her. She had refused me bathing her twice before. The other time, the nurse had to assist me." HHA A further stated that HHA A was wearing a bracelet while bathing Patient #3 that cause bruises on Patient #3 arms. During an interview on 2/10/2025 at 5:00 p.m., with the Alternate Administrator, the Alternate Administrator was asked why HHA A was not reassigned due to Patient #3s consistent refusal of services from HHA A, the Alternate Administrator stated, ";No, I didnt know this. We usually try to accommodate the patient." During an interview on 2/10/2025 at 5:00 p.m., with the Administrator, the Administrator was asked why HHA A was not reassigned due to Patient #3s consistent refusal of services from HHA A, the Administrator stated that the failure was a result of her not being aware of the previous refusals of services. Review of the agencys policy, no date, titled ";Consent and Education for Hospice Care," revealed ";Sec 102.003 Rights of the Elderly...the elderly individual: has the right to make the individuals own choices regarding the individuals personal affairs, care, benefits, and services...2. Acknowledges that the individual clearly understands the consequences of refusing treatment..."

Based on record review and interviews, the agency failed to ensure the effective exchange of information, reporting, and coordination of patient services of 1 of 1 discharged patient (Patient #1), who live in an assisted living facility and whose records were reviewed. This failure could place the agency's patients at risk of inadequate care and a delay in care due to ineffective communication among providers and staff. --- The findings included: Record Review of Patient #1 clinical records reveal a start of care date of 7/6/2024, with Patient #1 receiving the following hospice services: skilled nursing services three times weekly, Chaplain services one visit monthly, Social Worker services one visit monthly, and home health aide services twice weekly. Patient#1 was living in an assisted living facility and had a terminal diagnosis of Parkinsons Disease (A disorder of the brain that affects movement and causes tremors.) Further record review revealed that on 11/08/2024 at 1:45 a.m., Patient #1 fell off the bed on the floor. RN A (on call nurse) visited Patient #1 to assess for injury at approximately 2:30 a.m. RN A gave Patient #1 pain medication for pain and discussed with staff regarding ordering a right and left hip x-ray. RN A did not write an order for a x-ray. LVN A visited Patient #1 to perform a follow up reassessment 11/8/2024 at approx. 10:00 a.m. During the visit, LVN A asked the assisted living staff about a right and left hip x-ray to which the assisted living staff stated a right and left hip x-ray was ordered. Further record review revealed that on 11/10/2024, the family member of Patient #1 inquired why the right and left hip x-ray to Patient #1s hips were not done, and the agency call center informed the family member of Patient #1 that RN B will visit Patient #1. On 11/11/2025 RN B assessed Patient #1 and to order the right and left hip x-ray. Record review revealed Patient #1 RN A had hip fracture because of the fall on 11/8/2024. During an interview on 2/6/2025 at 7:00 p.m., with RN A, it was revealed that RN A was assigned to Patient #1s home on 11/8/2024 at 2:30 a.m for the assessment after Patient #1s fall. RN A stated, ";I dont know I would assume the day shift staff at the assisted living facility notified the doctor. I notified the doctor after my visit a little before 8 am. I texted the Doctor, but the family member of Patient #1 stated she didnt want [Patient #1] to go to the hospital. I informed the family member of the fall after my visit. I assumed that the the family member was aware of the option of the mobile x-ray." During an interview on 2/6/2025 at 7:45 p.m., with LVN A, LVN A stated that she was assigned to Patient #1s home on 11/8/2024 at 10:00 a.m., for the an additional assessment after Patient #1s fall. LVN A stated, ";the assisted living facility staff medicated Patient #1 before I arrived. He was grimacing and the facility medicated him. The Facility representative stated that the mobile x- ray was ordered. I relayed the information about the mobile x-ray to the hospice office staff." During an interview on 2/7/2025 at 3:00 p.m., with the family member of Patient #1, the family member stated the delay in the ordering of the x-ray was a result of a, ";miscommunication between the facility and the hospice agency." During an interview on 2/6/2025 at 7:45 p.m., with RN B, RN B stated he was assigned to visit Patient #1s home on 11/11/2024 for a follow up on the family members phone call. RN B stated, ";I went there that Monday and realized that the x-ray was not done so I arranged for the x-ray to be done after receiving an order. I spoke with the family member of Patient #1 about it." During an interview on 2/6/2025 at 5:00 p.m., with the Administrator, the Administrator, stated that the failure was a result from the lack of follow up of the x-ray being ordered by RN A or LVN A was due to miscommunication from the assisted living facility. The Administrator also revealed that RN A was the on-call nurse at the time of Patient #1s fall and should have assured that the x-ray was completed. Record review of an agency policy titled, "Triage," dated 11/21/2024, read in part, ";The call center receives a call from patient...or facility regarding situations...request for new, non-routine diagnostic studies/tests etc..."When a fall is reported by a family, patient or facility, it is considered a significant event and requires an in-person hospice assessment including evaluation of patient status....any need for diagnostic x-rays..." Record review of an agency policy titled, "Interdisciplinary group Coordination of Care," dated 10/31/2024, read in part, ";The interdisciplinary group...is responsible for...i. Monitor continually of care and implement plans across all settings, including residence and inpatient facilities..." Record review of an agency policy titled, "Adverse Event Reports," dated 5/22/2023, read in part, ";...Event Management: The process for multidisciplinary, coordinated response to sentinel events and significant patient quality outcomes. The process includes points of escalation, coordination, reporting, and planning by the site level, region team members and national roles. The process is applied to a significant event that require oversight..."

Based on observation, record review and interview, the agency failed enforce written policies addressing infection control including the prevention of the spread of infectious and communicable disease, that: No handwashing was observed before and after patient care to Patient #4 by 1 of 2 employees (RN D) observed. This failure placed the agency's clients at risk for an infection. --- Findings include: During an observation on 2/7/2025 at 1:30 pm, the surveyor was observing the bathing of Patient #4 with HHA A and RN D. Further observation revealed that RN D, prior to touching Patient #4, walked to her medical bag, and proceeded to obtain and don rubber gloves. Further observation revealed RN D, assisted HHA A with patient care of Patient #4, removed her gloves and disposed the gloves in the trash. Further observation revealed no hand sanitizer was used or handwashing performed prior to or after care was provided. During an interview on 2/7/2025 at 2:00 p.m. with RN D, RN D was informed of the observation findings. When asked the reason of the lack of hand washing before and after patient care, RN D responded, ";I forgot." During an interview on 2/7/2025 at 5:00 p.m. with the Administrator, the Administrator was informed of the above findings. The Alternate Administrator stated that RN was a new nurse that may require education. Record review of an agency policy titled, "Hand Hygiene," dated 6/9/2021, read in part, ";To prevent cross-contamination and the transmission of healthcare-associated infections...guidelines for hand hygiene...2. Decontaminate the hands using an alcohol-based hand rub, or wash hands with antimicrobial soap and water when the hands are not visibly soiled in the following circumstances: a. Before having direct contact with patients. b. After removing gloves..."

Based on record review and interview, the agency failed to provide hospice care that optimized comfort and dignity for 1 of 5 patients (Patient #1) for which records were reviewed in that patients pain was not effectively managed. This failure placed the patient at risk of undo suffering, loss of patients dignity and increased emotional stress to the patient's family and caregivers. --- Review of the clinical record for Patient #1 revealed a start of care date of 08/22/2023 with a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease. Review of the plan of care for the time-period 08/22/2023 – 11/19/2023 revealed orders: Hospice nurse to monitor patients pain level and report ineffective pain control to the physician. Hospice nurse to instruct on pain management." Review of a Visit Note Report dated 08/23/2023 read ";Pain: Are you uncomfortable because of pain? Yes, Pain Score- 8, Patient reported pain goal- 3, Frequency of pain- constant, How long does the pain last- constant." Review of a Visit Note Report dated 08/31/2023 read ";Pain: Are you uncomfortable because of pain? Yes, Pain Score- 9, Patient reported pain goal- 2, Frequency of pain- constant, How long does the pain last- constant." Review of a Visit Note Report dated 09/05/2023 read ";Pain: Are you uncomfortable because of pain? Yes, Pain Score- 6, What was the worst level in the last 24 hours for pain- 8, Patient reported pain goal- 4, Frequency of pain- constant, How long does the pain last- constant." The documents were signed by RN #2. The records did not contain documentation regarding interventions, education, or notification of the physician regarding the patients elevated pain levels. An interview was conducted on 10/11/2023 at 2:30 p.m. with the Administrator/Alternate Supervising Nurse. The clinical record for Patient #1 was reviewed. Surveyor asked what the agencys policy was regarding reporting elevated pain levels. Administrator/Alternate Supervising Nurse stated, ";Any pain level above a level 4/10 should be reported to the physician." Administrator/Alternate Supervising Nurse reviewed the Visit Note Reports dated 08/23/2023, 08/31/2023 and 09/05/2023, and acknowledged RN #2 should have notified the RN Case Manager as well as the physician. Surveyor requested contact information for RN #2 to conduct an interview. On 10/12/2023 at 11:15 a.m. RN #2 arrived at the agency for an interview. Surveyor asked RN #2 how long she had been a hospice nurse. RN #2 stated approximately 1 year. Surveyor asked if she received training regarding pain management. RN #2 stated she received pain management training during agency orientation. The clinical record for Patient #1 was reviewed with RN #2. RN #2 confirmed the plan of care orders were to report ineffective pain control to the physician. Visit notes dated 08/22/2023, 08/31/2023 and 09/05/2023 were reviewed. RN #2 indicated the patient didnt want to take her pain medication. Surveyor asked if the physician was notified of the elevated pain levels and noncompliance with oral pain medication. RN #2 stated, ";No". Surveyor asked RN #2 if she understood she was supposed to notify the physician of the ineffective pain management. RN #2 stated, ";Yes. If her (pain) goal was a 3, I should have reported it at a 4". Surveyor asked why she didnt contact the physician to report her findings. RN #2 stated, ";I dont know". Surveyor asked RN if she provided any education to the patient or caregiver regarding compliance with pain medication orders and other comfort measures. RN #2 stated, ";No". Review of the agencys policy titled, ";Pain Management, Effective 04/26/23", read ";Pain will be assessed and documented during every patient visit, contact, and following titration of analgesia or other pertinent treatment changes. For pain rating (greater than or equal to 6) timely follow up is required and must be documented in the EMR (electronic medical record)".

Based on record review and interview, the agency failed to enforce its written policy to ensure patient care was coordinated among the agency and a licensed facility, group home, foster home or boarding home facility in which a patient resided for 1 of 5 patients (Patient #1) for which records were reviewed. This failure caused confusion between the agency and facility regarding sharing of written orders and responsibility for the care of Patient #1. --- Findings Included: Review of the agencys policy and procedure manual revealed a policy entitled ";HOSPICE PATIENT IN A MEDICAL FACILITY- 2076, Revised: 8/15/22", which read in part ";Purpose: To both assume responsibility for professional management of a residents hospice services and maintain a medical record in medical care facilities where hospice patients reside to provide continuity, coordination and integration of care. 6. The hospice plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care." Review of the clinical record for Patient #1 revealed a start of care date of 10/25/2022. Review of the plan of care revealed diagnosis included: Alzheimers Disease with late onset, Hypertension, Fracture of lower end of right femur, Pleural Effusion, History of Malignant Neoplasm of Large Intestine, Colostomy Status, Anemia. The plan of care did not include a diagnosis related to urinary retention or pressure ulcers. Review of the clinical record revealed no documentation of orders for a Foley catheter. Further review of the clinical record revealed no documentation regarding orthopedic follow-up for management of the patients fractured leg and knee immobilizer. A telephone interview was conducted on 12/22/2022 @ 11:15 AM with RN. Surveyor asked if RN observed a protruding bone under the Pts knee immobilizer. RN stated, ";No. I was told we [hospice] were not to remove it, so I was not able to assess the area." Surveyor asked if a clinician wrote orders for the knee immobilizer. RN stated she did not know. Surveyor asked if patient had a Foley catheter. RN stated ";Yes." Surveyor asked if there were MD orders for the catheter, care and how often the catheter should be changed. ";No. The facility takes care of it." An interview was conducted on 12/22/2022 at 2:30 PM with the Admin. The plan of care was reviewed. Surveyor requested for review documentation of Foley catheter orders and bone fracture/knee immobilizer orders. The Admin acknowledged the plan of care did not include an order for the Foley catheter, care of the catheter, and frequency to change the catheter. Surveyor requested documentation for review of clinician orders regarding bone fracture/knee immobilizer orders since Patient #1 has been admitted to the agency. The Admin stated there were no orders and a referral should have been sent to an orthopedic physician for follow-up care. An interview was conducted on 12/22/2022 at 3:10 PM with the Admin. The Admin provided documentation which she stated was obtained from the SNF. The document read ";Groesbeck LTC [Long Term Care] Nursing & Rehab Medication Review Report, Date: Dec 22, 2022, Time: 14:57. Diagnoses: Retention of Urine. Order Summary: Change Foley catheter Q 30 days and PRN." Surveyor asked for the name of the clinician that wrote the order. Admin stated, ";Someone at the facility". No additional information was provided.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document review, and interviews. Agency Policy on The Plan of Care Policy #H 2-030, "The Plan of Care (Reviewed: 1/5/22)", stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. This plan will focus on identified problems, goals, and interventions." 5 of 13 (38%) clinical records reviewed revealed the patient's individualized written plan of care (POC) failed to reflect patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient was admitted on 1/27/22. There was a physician order dated 10/19/22 that included specific wound care orders for a Stage 2 wound on the left inner thigh crease. The interdisciplinary group (IDG) POC dated 10/19/22 had a "Problem statement: Need for wound care - Hospice; Goal: Patient tolerates wound care with minimal discomfort; Patient/CG demonstrates proper wound care; Intervention: Provide wound care per orders." The IDG POC lacked the specific wound care orders (interventions) for the Stage 2 wound on the left inner thigh crease IDG POC. Clinical Record 1: The patient was admitted on 4/16/22. The certification of terminal illness (CTI) dated 4/16/22 (Certification period 4/16/22 --> 7/14/22) stated the patient had urinary incontinence. The IDG POC dated 4/19/22 lacked a goal and interventions for urinary incontinence. Clinical Record 4: The patient was admitted on 6/10/22. The CTI dated 6/10/22 (Certification period 6/10/22 --> 9/7/22) stated the patient had bowel and bladder incontinence. The IDG POC dated 6/10/22 lacked the goals and interventions for bowel and bladder incontinence. Clinical Record 6: The patient was admitted on 7/22/22. The CTI dated 7/22/22 (Certification period 7/22/22 -->10/19/22) stated the patient was on continuous oxygen 2-4 Liters/minute via nasal cannula. The IDG POC dated 7/22/22 lacked a goal and interventions for respiratory oxygen treatment. Clinical Record 8: The patient was admitted on 10/1/22. The Initial Nursing assessment dated 10/1/22 (Certification period 10/1/22 to 12/29/22) stated the patient had uncontrolled Diabetes Mellites II (DMII). The IDG POC dated 10/1/22 lacked goals and interventions for the uncontrolled DMII. Upon interview on 10/20/22, the Regional Administrator reviewed and agreed with the above findings. Prior to the exit, the Regional Administrator had already started the plan of correction, stating improving the plan of care is a performance improvement project already in progress.

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 for up to one (1) year following the death of the patient. 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, and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, documents, and interviews. Agency Policy on Bereavement Services Policy #H2-008, "Bereavement Services (Reviewed: 1/5/22)", stated in part, "Procedure: 5. The RN will assess the family's response to grief and loss and coping abilities as being Low, Moderate, or High Risk. If the RN ranks bereaved as Moderate, this will trigger the Bereavement Coordinator to do a home visit or call the family prior to the 4-8 week assessment. If the RN assesses the bereaved(s) as being high risk, then the RN will contact the Clinical Director and an appropriate plan which will include, but not be limited to, a referral to an outside agency and/or visit to assess. 6. The IDT will determine whether the bereaved(s) is low risk, moderate risk, or high risk and all information will be referred to the Bereavement Coordinator for follow-up and tracking of bereavement services. 9. A bereavement plan will be developed for the primary bereaved reflecting family needs and frequency of services. Bereavement interventions will be reflective of the family/caregiver's choices regarding Bereavement contact or services will be honored in the bereavement program. Services will be provided in accordance with the bereavement plan of care." 1 of 2 (50%) clinical records of patients that had expired revealed the agency failed to perform a post-death bereavement assessment, and establish a bereavement plan of care that included the types of bereavement services to be offered, and the frequency of service delivery. Clinical Record 5: The patient was admitted on 3/25/22. The date of death was 7/28/22. The record lacked a post-death bereavement assessment of the bereaved and a bereavement plan of care. Upon interview on Thursday 10/20/22, the Regional Administrator and the Bereavement Coordinator reviewed and agreed with the above finding. The Regional Administrator and the Bereavement Coordinator had a meeting prior to exit and already had completed the plan of correction that would be implemented immediately.