Every finding on record at Trinity Hospice of Texas, LLC

Upon patient record review, 2 of 19 (Patient #2,#3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#2:Upon home visit observation, it was identified that lorazepam 0.5mg was listed as active medications on the agency medication profile. There was no evidence of this medication on the facility profile. Patient#3: Upon home visit observation, it was identified that the medication atropine 0.75 place 2 drops under tongue every 2 hours PRN for secretions was present in the home. There is no evidence of this medication on the agency medication profile.

Upon patient record review, 1 of 19 (Patient #8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#8: Upon review of record, there was documentation indicating the person to be a moderate risk on 10/21/25. No evidence that a follow-up was completed or that anything was done to start supporting the person at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the persons needs. There is documentation that prior to 10/21 a mock survey was completed on 10/02/25 and a plan of correction was put in place on 10/02.

Upon patient record review, 1 of 19 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient#2: The medical record contained nursing documentation identifying patient required daily use of c-collar. There is no evidence of orders for DME/Supplies that included this item in plan of care.

Upon client record review, 3 of 19 (Patient #3,#11,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#3: The skilled nurse frequency is ordered at 2 times per week. On the week of 1/7/26 there is only evidence of 1 visit completed. There was no evidence of missed visits. Patient#11: The skilled nurse frequency is ordered at 2 times per week. On the week of 01/01/26 there is only evidence of 1 visit being completed. There was no evidence of missed visits. Patient#13: The skilled nurse frequency is ordered at 2 times per week. On the week of 12/04/25 there is only evidence of 1 visit being completed. There was no evidence of missed visits.

Upon patient record review 1 of 19 (Patient #8) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#8: There was documentation indicating the person to be a moderate risk on 10/21/25. No evidence that a follow-up was completed or that anything was done to start supporting the person at the time that the need was identified. No evidence that the bereavement care plan was updated to reflect the persons needs. There is documentation that prior to 10/21 a mock survey was completed on 10/02/25 and a plan of correction was put in place on 10/02.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient#14:There was documentation in the chaplain visit on 12/15/25 stating that a non-facility vascular nurse was giving the patient an IV infusion. There is no evidence in the record that this was coordinated between the facility and the hospice agency. Upon the administrator inquiring about this occurrence, the facility indicated that this infusion was scheduled prior to the hospice admit and they did not cancel nor communicate it with the hospice.

Upon patient record review 5 of 19 (Patient #1,#2,#5,#6,#14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient#1: The Plan of Care indicates aide frequency is ordered at 3 times per week. On the week of 1/27/26 only 1 in person visit is documented. There was no evidence of missed visits. Patient#2: The Plan of Care indicates aide frequency is ordered at 3 times per week. On the week of 11/23/25 only 1 in person visit is documented. There was no evidence of missed visits. Patient#5: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 01/19/26 only 2 in person visits are documented. There was no evidence of missed visits. Patient#6: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 11/25/25 only 2 in person visits are documented. There was no evidence of missed visits. Patient#14: The Plan of Care indicates aide frequency is ordered at 5 times per week. On the week of 12/01/25 only 1 in person visit is documented. There was no evidence of missed visits.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The 2024 volunteer utilization was 4.63%. The 2025 volunteer utilization was 4.84%. The agency has a PIP in place which started on 9/15/25.

Upon client record review, 1 of 19 (Patient #14) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient#14: The skilled nurse frequency is ordered at 2 times per week. On the week of 12/11/25 there is only evidence of 1 visit being completed. There was no evidence of missed visits.

Upon patient record review 1 of 11 (Patient #9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #9 The patient was admitted on 5/5/21, the spiritual assessment was completed on 5/17/21.

Upon patient record review, 2 of 11 (Patient #1, 8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1 The medication profile for Eye itch relief drops 0.025% does not specify which eyes, or eye to administer. (Corrected on site) Patient #8 The medication entered on 6/18/22 for Brimonidine 0.2% eye drop does not specify which eye/s to instill drops into. The medication entered on 6/18/22 for Latanoprost 0.005% eye drops does not specify which eye/s to instill the drops into. (Corrected on site)

Upon patient record review, 1 of 11 (Patient #9) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes 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 is considered in the bereavement plan of care. Patient #9 The patient was admitted on 5/5/21, there bereavement assessment was completed on 6/23/22.

Upon patient record review, 2 of 11 (Patient #1, 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1 The medication order on 4/26/22 for Eye Itch Relief 0.025% 1 drop daily for seasonal allergies, the order does not contain the specified site/sites for administration. (Corrected on site) Patient #8 The medication order on 6/18/22 for Brimonidine 0.2% eye drops 1 every 8 hours does not contain the specified eye/s for use. The medication order for Latanoprost 0.005% 1 drop every PM does not specify the eye/s to be instilled for use. (Corrected on site)

Upon patient record review, 2 of 11 (Patient #5, 6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5 The patient was started on antibiotics on 1/26/23 for a UTI (Bactrim DS 1 PO BID x 10 days) the plan of care was not updated to include a problem statement with interventions and goals for treatment. Patient #6 The patient was treated for a skin tear to the left forearm on 12/27/22, the plan of care is not updated to include a problem statement for skin integrity or wound with interventions or goals. The patient was prescribed and treated for a UTI on 11/27/22 with Cephalexin 500mg x 6 days, the plan of care was not updated to reflect a problem statement with interventions or goals.

Upon client record review, 1 of 13 (Patient #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #13 Per the nursing note on 11/11/22, the RN placed an indwelling foley catheter for patient comfort with no MD order.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1 During the home visit with the RN, it was witnessed that the RN utilized the bedside table of the patient to place her assessment tools, she did not wipe the table before use. The RN used a paper towel as a barrier on the bedside table for her clean tools, then placed her used assessment tools directly onto the bedside table. The nursing bag being utilized by the RN is single pocket bag made of cloth, it can not be wiped or sanitized between each patient visit. The RN placed all nursing items inside the bag along with notebook and other paper items that can not be sanitized, and did not keep dirty items separated from clean items.