Every finding on record at Texas Total Care Inc

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 3 of 4 (75%) clinical records reviewed revealed the agency did not ensure the plan of cares (POCs) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The POC dated 12/13/2023 stated the social worker was visiting the patient 1 time per month. The same POC lacked goal(s) and intervention(s) that address the patient's psychosocial needs. Also, the medication list dated 12/13/2023 included oxygen 2-5 liters per minute via nasal cannula, as needed for increased shortness of breath (SOB), and Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) micrograms/ACT, 2 inhalation every 6 hours, as needed for SOB. The POC dated 12/13/2023 lacked interventions that included the specific details of the ordered oxygen and albuterol treatment. The physician certification of terminal illness dated 12/12/2023 stated the patient has urinary incontinence. The POC dated 12/13/2023 lacked goal(s) and intervention(s) for urinary incontinence. Clinical Record 3: The POC dated 01/20/2024 stated the social worker and the chaplain were visiting the patient 1 time per month. The POC lacked goal(s) and intervention(s) that address the patient's psychosocial and spiritual needs. Clinical Record 4: The certification of terminal illness dated 10/11/2023 stated the patient had a 3 by 3 centimeters pressure ulcer on the inner right buttock. The POC dated 10/11/2023 included a goal for skin integrity but lacked intervention(s) that included the specific wound care orders to be performed on the pressure ulcer. The Alternate Administrator/Alternate Director of Nursing stated in an interview while completing joint clinical record reviews on 02/07/2024 that the agency did not ensure the POCs reflected patient and family goals and interventions based on problems identified in the initial and 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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical records reviewed for patients that elected hospice aide services revealed the agency did not ensure the hospice aide care plan prepared by the registered nurse (RN) included the specifics for the aide tasks ordered. THIS IS A CONTINUED REQUIRED ACTION Clinical Record 1: The hospice aide care plan dated 02/06/2024 had a task list: "Shampoo Hair: Per request". The patient has a comorbid diagnosis of dementia. The record lacked the RN writing a specific intervention for how many times per week the aide should shampoo hair. Also, on the same aide care plan in the "Additional Comment" area, the RN stated, "If the patient is deemed a fall risk, HA must use a gait belt for transfers to the shower." The record lacked the RN assessing and writing a specific intervention for when the aide was required to use a gait belt. Clinical Record 4: The hospice aide care plan dated 10/11/2023 had the following "Bath tasks" listed: "Complete Bed Bath; Partial Bath/Shower; Complete Shower: Per request." The record lacked the RN writing a specific "Bath type". Also, on the same aide care plan in the "Additional Comment" area, the RN stated, "If the patient is deemed a fall risk, HA must use a gait belt for transfers to the shower." The record lacked the RN assessing and writing a specific intervention for when the aide was required to use a gait belt. The Alternate Administrator/Alternate Director of Nursing stated in an interview while completing joint clinical record reviews on 02/07/2024 that the agency did not ensure the hospice aide care plan prepared by the registered nurse (RN) included the specifics for the aide tasks ordered. THIS IS A CONTINUED REQUIRED ACTION

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 1 of 3 (33%) clinical records reviewed in which the patient elected hospice aide services revealed the agency did not ensure the hospice aide reported changes in the patient's medical needs to the registered nurse (RN) as the changes related to the plan of care (POC). Clinical Record 1: The aide care plan dated 12/13/2023 ordered the tasks: "Change linen and make bed". The aide visit notes dated 12/27/2023 and 01/26/2024 stated the aide did not complete either task - noted as a "D"; a "C" means "Completed". The record lacked evidence that the aide reported changes to the RN as the changes related to the aide POC. The Alternate Administrator/Alternate Director of Nursing stated in an interview while completing joint clinical record reviews on 02/07/2024 that the agency did not ensure the hospice aide reported changes in the patient's medical needs to the RN as the changes related to the aide's POC.

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. 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 clinical record review and interview. In 1 of 1 (100%) clinical record reviewed for a patient that was receiving hospice services in a Skilled Nursing Facility (SNF) revealed the agency did not ensure that the plan of care (POC) specified which provider was responsible for performing the functions that were agreed upon based on the needs of the patient. Clinical Record 3: The patient elected the hospice benefit on 01/20/2024. The patient was receiving hospice services at home, and then was transferred to a SNF on 01/30/2024. The record lacked evidence of which provider was responsible for performing the care and services that were included in the patient's POC. The Alternate Administrator/Alternate Director of Nursing stated in an interview while completing joint clinical record reviews on 02/07/2024 that the agency did not ensure that the POC for the SNF patient specified which provider was responsible for performing the functions that were agreed upon based on the needs of the patient.

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 11 of 19 (57%) clinical records reviewed it was revealed that the agency did not ensure that a bereavement assessment was completed as part of the comprehensive assessment within five calendar days after the election of hospice care. Record 2: The patient elected the hospice benefit on 3/2/23 with a diagnosis of Alzheimer's disease. The bereavement assessment was documented as completed on 5/4/23. There was no documented evidence that an initial bereavement assessment was completed by another hospice clinician within 5 days of the patient's hospice election. Record 3: The patient elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. The bereavement assessment was documented as completed on 10/16/22. There was no documented evidence that an initial bereavement assessment was completed by another hospice clinician within 5 days of the patient's hospice election. Record 4: The patient elected the hospice benefit on 11/9/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. At the time of the site visit review conducted from 6/13/23 - 6/15/23, there was no documented evidence that an initial bereavement assessment was completed. Record 5: The patient elected the hospice benefit on 2/16/23 with a diagnosis of Cerebral Infarction. At the time of the site visit review conducted from 6/13/23 - 6/15/23, there was no documented evidence that an initial bereavement assessment was completed. Record 6: The patient elected the hospice benefit on 9/15/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. At the time of the site visit review conducted from 6/13/23 - 6/15/23, there was no documented evidence that an initial bereavement assessment was completed. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. The bereavement assessment was documented as completed on 6/1/23. There was no documented evidence that an initial bereavement assessment was completed by another hospice clinician within 5 days of the patient's hospice election. Record 9: The patient elected the hospice benefit on 3/22/23 with a diagnosis of Alcohol use unspecified. At the time of the site visit review conducted from 6/13/23 - 6/15/23, there was no documented evidence that an initial bereavement assessment was completed. Record 10: The patient elected the hospice benefit on 12/22/22 with a diagnosis of End Stage Renal Disease and the initial bereavement assessment was documented as completed on 12/31/22, which was 4 days past due. . Record 11: The patient elected the hospice benefit on 4/21/21 with a diagnosis of Multiple Sclerosis and the bereavement assessment was documented as completed on 5/10/21, which was 15 days past due. Record 12: The patient elected the hospice benefit on 3/17/21 with a diagnosis of Neoplasm of the Brain. At the time of the site visit review conducted from 6/13/23 - 6/15/23, there was no documented evidence that an initial bereavement assessment was completed. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. Documentation in the record revealed there was no evidence of an initial bereavement assessment completed until after the patient's death on 4/3/23. During an interview on 6/15/23, the Assistant Administrator stated that the bereavement assessments had not been completed timely, and if the patient refused the chaplain, who was also the bereavement coordinator, the assessments should have been completed by another discipline. This standard is not met as evidenced by a review of the following clinical records that revealed that the bereavement assessment was either obtained beyond the five day timeframe or missing completely from the record. Record 2: The patient elected the hospice benefit on3/2/23 with a diagnosis of Alzheimer's disease. Bereavement (BV) assessment completed on 5/4/20. Record 3: The patient elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. BV assessment completed 10/16/22. Record 4: The patient elected the hospice benefit on 11/9 22 with a diagnosis of Chronic Obstructive Pulmonary Disease. No BV assessment completed. Record 5: The patient elected the hospice benefit on 2/16/23 with a diagnosis of Cerebral Infarction. No BV assessment completed. Record 6: The patient elected the hospice benefit on 9/15/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. No BV assessment completed. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. BV assessment completed on 6/1/23. Record 9: The patient elected the hospice benefit on 3/22/23 with a diagnosis of Alcohol use unspecified. No BV assessment completed. Record 10: The patient elected the hospice benefit on 12/22/22 with a diagnosis of End Stage Renal Disease. BV assessment completed 12/31/22. Record 11: The patient elected the hospice benefit on 4/21/21 with a diagnosis of Multiple Sclerosis. BV assessment completed 5/10/21. Record 12: The patient elected the hospice benefit on 3/17/21 with a diagnosis of Neoplasm of the brain. No BV assessment completed. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. No Initial BV assessment completed. Was completed post death on 4/3/23. Record 16: The patient elected the hospice benefit on 11/4/22 with a diagnosis of Hypertensive Heart Disease. Initial BV assessment completed but not dated. Record 18: The patient elected the hospice benefit on 9/21/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Initial BV assessment completed but not dated. Record 19: The patient elected the hospice benefit on 4/7/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Initial BV assessment completed but not dated.

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. This standard was not met as evidenced by clinical record review and interview. In 8 of 15 (53%) clinical records reviewed where it was documented in the comprehensive nursing assessment that the patient was using supplemental oxygen, it was revealed that the agency did not ensure the drug profile contained documentation of oxygen orders for inclusion in the review of the patient's medication regimen. Record 4: The patient elected the hospice benefit on 11/9 22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 6: The patient elected the hospice benefit on 9/15/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 7: The patient elected the hospice benefit on 1/17/23 with a diagnosis of Acute Respiratory Failure. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 13: The patient elected the hospice benefit on 11/3/21 with a diagnosis of Pulmonary Fibrosis. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. Record 18: The patient elected the hospice benefit on 9/21/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 19: The patient elected the hospice benefit on 4/7/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. During interviews on 6/14/23 and 6/15/23, the Assistant Administrator stated that oxygen was not listed on the medication profiles for these patients, and it should have been documented there. This standard is not met as evidenced by a review of the following records where it was documented in the comprehensive nursing assessment that the patient was on supplemental oxygen, but the patient did not have oxygen documented on the medication profile as required. Record 3: The patient elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. Record 4: The patient elected the hospice benefit on 11/9 22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 5: The patient elected the hospice benefit on 2/16/23 with a diagnosis of Cerebral Infarction. Record 6: The patient elected the hospice benefit on 9/15/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 7: The patient elected the hospice benefit on 1/17/23 with a diagnosis of Acute Respiratory Failure. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 9: The patient elected the hospice benefit on 3/22/23 with a diagnosis of Alcohol use unspecified. Record 10: The patient elected the hospice benefit on 12/22/22 with a diagnosis of End Stage Renal Disease. Record 11: The patient elected the hospice benefit on 4/21/21 with a diagnosis of Multiple Sclerosis. Record 12: The patient elected the hospice benefit on 3/17/21 with a diagnosis of Neoplasm of the brain. Record 13: The patient elected the hospice benefit on 11/3/21 with a diagnosis of Pulmonary Fibrosis. Record 14: The patient elected the hospice benefit on 1/27/23 with a diagnosis of Cerebral Infarction. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. Record 16: The patient elected the hospice benefit on 11/4/22 with a diagnosis of Hypertensive Heart Disease. Record 18: The patient elected the hospice benefit on 9/21/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 19: The patient elected the hospice benefit on 4/7/22 with a diagnosis of Chronic Obstructive Pulmonary Disease.

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 interview and observation. In 2 of 4 (50%) clinical visit observations it was revealed that the agency did not ensure that staff followed agency policies related to the hand hygiene. The agency's policy, "Hand Hygiene Policy No. 7-009", revised November 2021, stated in relevant parts: "3. Hand Decontamination with an alcohol-based hand rub should be performed: A. Before having direct contact with patients F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves." Home Visit 3: The patient (Clinical Record 3) elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. During the home visit, it was observed that the Registered Nurse (Staff 4) did not perform hand hygiene prior to returning the cleaned medical equipment back to their clinical bag. The equipment was returned to the bag while the RN was wearing the contaminated gloves. Home Visit 4: The patient (Clinical Record 4) elected the hospice benefit on 11/9/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. During the home visit, it was observed that the Licensed Vocational Nurse (Staff 3) did not perform hand hygiene prior to returning cleaned medical equipment to their clinical bag. The equipment was returned to the bag while the nurse was wearing the contaminated gloves. In addition, hand hygiene was not performed after the final glove removal. During an interview on 6/13/23, the Assistant Administrator stated that staff had not followed the agency's hand hygiene policy.

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. In 2 of 17 (11%) clinical records reviewed in which the patient received aide services it was revealed that the agency did not ensure that the registered nurse provided specific instructions to the aide regarding assigned tasks to be performed. Clinical Record 1: The patient elected the hospice benefit on 4/20/20 with a diagnosis of Alzheimer's disease. The aide care plan created on 3/2/23 assigned the aide to complete the tasks of a complete bed bath “PRN” and shampoo hair “PRN”. The plan did not include documented guidance for the aide to follow to determine when the bath and shampoo should be completed. Clinical Record 12: The patient elected the hospice benefit on 3/17/23 with a diagnosis of Neoplasm of the Brain. The aide care plan dated 6/9/23 assigned the aide to complete the following tasks "as needed” and did not include documented guidance for the aide to follow to determine which bath to provide and when the tasks should be completed: complete bed bath, foot care, shampoo, complete shower. During interviews on 6/14/23 and 6/15/23, the Assistant Administrator stated that the aide care plans did not contain specific instructions to direct the aide on completion of the assigned tasks.

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: Signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 16 of 19 (84%) clinical records reviewed it was revealed that the agency did not ensure that the notice of hospice election included documentation of the patients', or applicable patient representatives', acceptance or declination of the "Patient's Right to Request Patient Notification of Hospice Non-Covered Items, Services and Drugs". The agency's document, "Patient Notification of Hospice Non-Covered Items, Services and Drugs", which was signed by the patients, included an area for designating if the patient wished to receive a copy of the hospice covered and noncovered items, services and drugs. However, the area for documenting the patients' decision to receive or decline the form was not completed. Record 1: The patient elected the hospice benefit on 3/2/23 with a diagnosis of Alzheimer's Disease. Record 3: The patient elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. Record 4: The patient elected the hospice benefit on 11/9 22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 5: The patient elected the hospice benefit on 2/16/23 with a diagnosis of Cerebral Infarction. Record 6: The patient elected the hospice benefit on 9/8/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 7: The patient elected the hospice benefit on 1/17/23 with a diagnosis of Acute Respiratory Failure. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 9: The patient elected the hospice benefit on 3/22/23 with a diagnosis of Alcohol use unspecified. Record 10: The patient elected the hospice benefit on 12/22/22 with a diagnosis of End Stage Renal Disease. Record 13: The patient elected the hospice benefit on 11/4/21 with a diagnosis of Pulmonary Fibrosis. Record 14: The patient elected the hospice benefit on 1/27/23 with a diagnosis of Cerebral Infarction. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. Record 16: The patient elected the hospice benefit on 11/4/22 with a diagnosis of Hypertensive Heart Disease. Record 17: The patient elected the hospice benefit on 12/15/22 with a diagnosis of Alzheimer's Disease. Record 18: The patient elected the hospice benefit on 9/21/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 19: The patient elected the hospice benefit on 4/7/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. During an interview on 6/13/23, the Assistant Administrator stated that they had not been answering the question that indicated the patients' and/or representatives' desire to receive the "Patient Notification of Hospice Non-Covered Items, Services, and Drugs" form or decline receipt, and weren't sure when to fill it out. This standard was not met as evidenced by a review of the following clinical records in which the patient's preference for receipt of the "Right to Request Patient Notification of Hospice Non-Covered items, Service & Drugs" was not indicated with a "yes" or "no" answer by the patient or responsible party. The Document "Patient Notification of Hospice Non-Covered Items, Services and drugs was signed by the patient or responsible party and the hospice representative, but the fields for covered and uncovered items were all left blank. Record 1: The patient elected the hospice benefit on 3/2/23 with a diagnosis of Alzheimer's Disease. Record 3: The patient elected the hospice benefit on 9/16/22 with a diagnosis of Hypertensive Heart Disease. Record 4: The patient elected the hospice benefit on 11/9 22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 5: The patient elected the hospice benefit on 2/16/23 with a diagnosis of Cerebral Infarction. Record 6: The patient elected the hospice benefit on 9/8/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 7: The patient elected the hospice benefit on 1/17/23 with a diagnosis of Acute Respiratory Failure. Record 8: The patient elected the hospice benefit on 5/18/23 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 9: The patient elected the hospice benefit on 3/22/23 with a diagnosis of Alcohol use unspecified. Record 10: The patient elected the hospice benefit on 12/22/22 with a diagnosis of End Stage Renal Disease. Record 13: The patient elected the hospice benefit on 11/4/21 with a diagnosis of Pulmonary Fibrosis. Record 14: The patient elected the hospice benefit on 1/27/23 with a diagnosis of Cerebral Infarction. Record 15: The patient elected the hospice benefit on 2/8/23 with a diagnosis of Neoplasm of Lung. Record 16: The patient elected the hospice benefit on 11/4/22 with a diagnosis of Hypertensive Heart Disease. Record 17: The patient elected the hospice benefit on 12/15/22 with a diagnosis of Alzheimer's Disease. Record 18: The patient elected the hospice benefit on 9/21/22 with a diagnosis of Chronic Obstructive Pulmonary Disease. Record 19: The patient elected the hospice benefit on 4/7/22 with a diagnosis of Chronic Obstructive Pulmonary Disease.