Every finding on record at Texas Home Health Hospice LP

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 the patient's initial comprehensive assessment within five (5) calendar days after the election of hospice care. CLINICAL RECORD 16: The patient elected the hospice benefit on 01/07/2025 with diagnoses of chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. The plan of care dated 01/07/2025 through 03/07/2025 ordered "Chaplain 1wk1." A clinical record review on 09/02/2025 revealed a Chaplain visit dated 01/23/2025, 16 days after the patient's election of the hospice benefit. There was no documentation explaining why the chaplain visit was not completed within the 5-day timeframe. During a joint record review on 09/02/2025, the Director of Clinical Operations confirmed the finding and stated, "There is no coordination note in the chart to tell why the visit was not completed."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide provided services as ordered in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 04/13/2024, with a terminal diagnosis of senile degeneration of the brain. The HA care plan, created by the Registered Nurse (RN) on 08/06/2024, assigned the HA the relevant tasks of: a shampoo and changing linens to be provided at every visit. The HA visit notes dated 08/16/2024 and 08/19/2024 did not document that a shampoo was completed. The HA did not document a reason for not providing a shampoo during every visit, as indicated in the HA care plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/13/2025, with a terminal diagnosis of Unspecified Cerebral Infarction. The HA care plan, created by the RN on 03/13/2025, assigned the HA the relevant task of providing oral care at every visit. The HA visit notes dated 03/18/2025, 03/19/2025, 03/27/2025, 03/28/2025, 04/01/2025, 04/10/2025, 04/18/2025, 05/07/2025, 05/20/2025, 06/18/2025, 06/30/2025, 07/08/2025, and 08/19/2025 did not include documentation that oral care was provided. The HA did not document a reason for not providing oral care during every visit, as indicated in the HA care plan. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/16/2024, with a terminal diagnosis of malignant neoplasm of the stomach. The HA care plan, created by the RN on 12/16/2024, assigned the HA the relevant task of: a shampoo to be provided at every visit. The HA visit notes dated 01/16/2025, 01/30/2025, 02/13/2025, 02/18/2025, and 02/20/2025 did not include documentation that a shampoo was provided. The HA did not document a reason for not providing a shampoo during every visit, as indicated in the HA care plan. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/18/2025, with a terminal diagnosis of unspecified sequelae of unspecified cerebrovascular disease. The HA care plan, created by the RN on 02/18/2025, assigned the HA the relevant task of: a shampoo to be provided at every visit. The HA visit note dated 02/27/2025 did not include documentation that a shampoo was provided. The HA did not document a reason for not providing a shampoo during every visit, as indicated in the HA care plan. CLINICAL RECORD 14: The patient elected the hospice benefit on 06/18/2025, with a terminal diagnosis of senile degeneration of the brain. The HA care plan, created by the RN on 06/18/2025, assigned the HA the relevant tasks: shampoo, oral care, nail care, emptying trash, and changing linens to be provided at every visit. The HA visit notes dated 07/18/2025 and 07/22/2025 did not include documentation that the assigned tasks: shampoo, oral care, nail care, emptying trash, and changing linens were provided. The HA did not document a reason for not providing the tasks assigned in the HA care plan. These findings were reviewed with the leadership team on 09/04/2025. During an interview on 09/04/2025, the Director of Clinical Operations stated, "They did have some issues with aide care plans in the past and have put new processes in place within the last two months to fix the problems and will continue to monitor this issue."

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 5 of 16 (31%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient's condition or needs related to the plan of care to the Registered Nurse (RN). CLINICAL RECORD 1: The patient elected the hospice benefit on 04/13/2024, with a terminal diagnosis of senile degeneration of the brain. The HA care plan, created by the Registered Nurse (RN) on 08/06/2024, assigned the HA the relevant tasks of: shampoo and changing linens to be provided at every visit. The HA visit notes dated 08/16/2024 and 08/19/2024 did not document that a shampoo was completed. A clinical record review revealed no evidence that the HA notified the Registered Nurse (RN) that they did not perform the tasks assigned in the care plan. CLINICAL RECORD 3: The patient elected the hospice benefit on 03/13/2025, with a terminal diagnosis of unspecified cerebral infarction. The HA care plan, created by the RN on 03/13/2025, assigned the HA the relevant task of providing oral care at every visit. The HA visit notes dated 03/18/2025, 03/19/2025, 03/27/2025, 03/28/2025, 04/01/2025, 04/10/2025, 04/18/2025, 05/07/2025, 05/20/2025, 06/18/2025, 06/30/2025, 07/08/2025, and 08/19/2025 did not include documentation that oral care was provided. A clinical record review revealed no evidence that the HA notified the RN that they did not perform the tasks assigned in the care plan. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/16/2024, with a terminal diagnosis of malignant neoplasm of the stomach. The HA care plan, created by the RN on 12/16/2024, assigned the HA the relevant task of: shampoo to be provided at every visit. The HA visit notes dated 01/16/2025, 01/30/2025, 02/13/2025, 02/18/2025, and 02/20/2025 did not include documentation that a shampoo was provided. A clinical record review revealed no evidence that the HA notified the RN that they did not perform the tasks assigned in the care plan. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/18/2025, with a terminal diagnosis of unspecified sequelae of unspecified cerebrovascular disease. The HA care plan, created by the RN on 02/18/2025, assigned the HA the relevant task of: shampoo to be provided at every visit. The HA visit note dated 02/27/2025 did not include documentation that a shampoo was provided. A clinical record review revealed no evidence that the HA notified the RN that they did not perform the tasks assigned in the care plan. CLINICAL RECORD 14: The patient elected the hospice benefit on 06/18/2025, with a terminal diagnosis of senile degeneration of the brain. The HA care plan, created by the RN on 06/18/2025, assigned the HA the relevant tasks: shampoo, oral care, nail care, emptying trash, and changing linens to be provided at every visit. The HA visit notes dated 07/18/2025 and 07/22/2025 did not include documentation that the assigned tasks: shampoo, oral care, nail care, emptying trash, and changing linens were provided. A clinical record review revealed no evidence that the HA notified the RN that they did not perform the tasks assigned in the care plan. These findings were reviewed with the leadership team on 09/04/2025. During an interview on 09/04/2025, the Director of Clinical Operations stated, "The records do not show that the aide notified the RN casemanager of the tasks not performed."

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 equal to at least 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 that the volunteer percentage of hours worked for January 2024 through December 2024 was 2.00%. The review of the 2025 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked for January 2025 through July 2025 was 2.00%. During an interview on 09/04/2025, the Volunteer Supervisor acknowledged that the 5% minimum was not met for the year 2024, stating, "They currently have an opening for a local volunteer coordinator for this site and are actively recruiting for volunteers."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency policy 203 Bereavement Services states in part, "An initial assessment of the needs of the patient's family and other individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patient's death will be completed by the RN during the initial assessment. The social worker will complete the bereavement risk assessment during the comprehensive assessment." 3 of 13 (23%) clinical records reviewed revealed that the initial bereavement risk assessment was not completed during the comprehensive assessment timeframe. Clinical Record 1: Start of care was 12/29/2021, no documented evidence of an initial bereavement risk assessment during the initial comprehensive assessment. There was documentation of an initial risk bereavement assessment documented in October 2022. Clinical Record 8: The start of care date was 6/21/2021, no documented evidence of an initial bereavement risk assessment during the initial comprehensive assessment. There was documentation of an initial risk bereavement assessment documented on 5/25/2022. Clinical Record 4: The start of care date was 12/27/21, no documented evidence of an initial bereavement risk assessment during the initial comprehensive assessment. There was documentation of an initial bereavement risk documented on 4/21/2022. During an interview with the Clinical Director, it was confirmed that the agency process was to complete an initial bereavement risk assessment by the RN or the Medical Social Worker during their initial comprehensive assessments. Agency policy 203 Bereavement Services states in part "An initial assessment of the needs of the patient's family and other individuals focusing on the social, spiritual and cultural factors that may impact their ability to cope with the patients' death will be completed by the RN during the initial assessment. The social worker will complete the bereavement risk assessment during the comprehensive assessment." During an interview with the Clinical Director, it was confirmed that the agency process was to complete an initial bereavement risk assessment should be completed on the RN and social worker initial assessments.