Every finding on record at Txcardref, Inc

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure physician orders were obtain for services rendered. Clinical Record 1: The patient elected the hospice benefit 12/11/2022 with a terminal diagnosis of Alzheimer's disease. Clinical record review revealed the Chaplain provided a visit to the patient dated 08/30/2023. The hospice plan of care dated 08/08/2023 did not include orders for chaplain services. The 08/15/2023 and 08/29/2023 interdisciplinary team meetings and the associated hospice plan of care/comprehensive assessment updates did not include orders for chaplain services. During an interview on 09/12/2023, the Administrator stated the patient had initially declined services and then requested chaplain services for 08/30/2023 and an order had been obtained but had inadvertently been omitted from the electronic medical record and had since been corrected.

It is required that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with 418.24. This standard was not met as evidenced by a review of clinical records. 1 of 11 (9%) records reviewed revealed the agency did not ensure that the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. Clinical Record 2: The patient elected hospice care on 3/04/2022. The record did not include evidence of a spiritual assessment completed no later than 5 calendar days after the election of hospice care. The initial spiritual assessment was completed on 4/11/2022, with 38 days outstanding.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, and includes all services necessary for the palliation and management of the terminal illness. This standard was not met as evidenced by a review of clinical records and interviews. 6 of 11 (55%) records reviewed revealed that the agency did not ensure that the plan of care (POC) identified planned interventions based on problems identified in the comprehensive assessment. Clinical Record 9: The initial social work assessment completed on 04/12/2022 identified the patient's several psycho-social and support needs and a problem living with his father and brother. The plan of care ordered social work visits "once a month." The POC dated 04/08/2022 and subsequent plans of care through 5/19/2022 did not include evidence of interventions and goals addressing the identified psychosocial and support needs as documented in the comprehensive assessment. Clinical Record 2: The initial social work assessment was completed on 03/08/2022. The plan of care ordered social work visits "once a month." The POC did not include evidence of problems identified during the comprehensive assessment or evidence of goals and interventions addressing the problems. Clinical Record 1: The initial social work assessment was completed on 06/13/2022. The plan of care ordered social work visits "once a month." The POC did not include evidence of problems identified during the comprehensive assessment or evidence of goals and interventions addressing the problems. Clinical Record 4: The initial social work assessment was completed on 08/29/2022. The plan of care ordered social work visits "once a month." The POC did not include evidence of problems identified during the comprehensive assessment or evidence of goals and interventions addressing the problems. Clinical Record 8: The initial social work assessment was completed on 05/08/2022. The plan of care ordered social work visits "once a month." The POC did not include evidence of problems identified during the comprehensive assessment or evidence of goals and interventions addressing the problems. Clinical Record 11: The initial social work assessment was completed on 10/27/2022. The plan of care ordered social work visits "once a month." The POC did not include evidence of problems identified during the comprehensive assessment or evidence of goals and interventions addressing the problems.

It is required that the hospice must use the data collected to do the following: monitor the effectiveness and safety of services and quality of care; and identify opportunities and priorities for improvement. This standard was not met as evidenced by a review of document review and interview. A review of the agency's performance improvement program for the years 2020, 2021, and 2022 revealed no evidence that the agency used data collected to monitor the effectiveness and safety of services and quality of care; and identify opportunities and priorities for improvement. During an interview on 11/8/2022, the Alternate Administrator stated he had collected the data on the problems that were found, and they talked about them in their IDG meetings, but an analysis of the data had not occurred. A review of the Agency's performance improvement process revealed that the agency did not ensure that data had been analyzed for the purpose of performance improvement. A review of the agency's performance improvement program for the years 2020, 2021, and 2022 lacked evidence that the agency had analyzed the data collected. The Alternate Administrator was interviewed on 11/08/2011 and he stated he had collected the data on the problems that were found, and they talked about them in their IDG meetings, but an analysis of the data had not occurred.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by a review of document reviews and observations. 2 of 3 (67%) home visits observed revealed that the agency did not ensure hand hygiene as per agency policy. The agency's policy "Hand Hygiene" stated in part, "hand hygiene with an alcohol-based hand rub will be used after contact with inanimate objects (including medical equipment in the immediate vicinity of the patient) before having direct contact with the patient and, after removing gloves." Home Visit 2: A home visit was conducted on 11/08/22 with the agency's chaplain. During the visit the chaplain was observed shaking the patient's hand without first sanitizing his hands. Home Visit 1: A home visit was conducted on 11/08/22 with the agency's Registered Nurse (RN). During the visit the RN used his personal cell phone and then returned to patient care without sanitizing his hands. In addition, the RN did not sanitize his hands after doffing gloves. During an interview on 11/09/22 , the administrator confirmed the finding and stated she was aware of what the policy states on hand hygiene and had reviewed it with staff.

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 a review of clinical records, observation, and interview. 1 of 11 (9%) records reviewed revealed the hospice did not ensure that orders were received prior to services being provided. Clinical Record 2: A home visit was conducted with the agency chaplain on 11/08/2022. A review of the clinical record and the POC revealed no physician order for chaplain services. There was no evidence of communication with the physician or a physician's order to add chaplain services to the POC. The chaplain stated in an interview the administrator asked him to make a visit with the surveyor.

It is required that if the care of a patient is transferred to another Medicare/Medicaid-certified facility, the hospice must forward, to the receiving facility, a copy of the hospice discharge summary; and the patient's clinical record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 1 (100%) record reviewed for a patient transferred from hospice services to another Medicare certified agency, revealed that the agency did not ensure a transfer summary was forwarded to the receiving agency. Clinical Record 9: The patient was transferred to another hospice's service on 5/19/22. The record lacked evidence of a written transfer summary and lacked evidence that a transfer summary had been forwarded to the receiving hospice. The Administrator was interviewed on 11/09/2022, she confirmed the finding and stated the agency had the documents, but they were not uploaded. The agency was provided additional time to present the discharge summary, this information was not presented as of the exit conference.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) records reviewed for patients discharged from the agency revealed the agency did not ensure that a copy of the discharge summary was forwarded to the attending physician. Clinical Record 9: The patient was discharged on 5/19/2022. The record lacked evidence that a discharge summary was completed and forwarded to the attending physician. Clinical Record 10: The patient was discharged on 10/07/2022. The record lacked evidence that the discharge summary was forwarded to the attending physician. During an interview and a joint review of the clinical records on 11/9/2022, the Administrator confirmed the finding and stated that the records were completed but not uploaded into the chart. The agency was offered more time to present documentation confirming the completion of the summary. No further documentation was provided.