Vitas Healthcare of Texas LP

“Based on record review and interview the hospice agency failed to ensure the right of a patient to receive effective pain management and symptom control for conditions related to the terminal illness, in that the patient did not have the Morphine (pain medication), as ordered by the physician, available for the patient when the patient’s pain had increased for 1 (#2) of 3 discharged patient records reviewed. The failure resulted in Patient #2 having ineffective pain management. Patient #2:Record review of Patient #2’s clinical record revealed a Plan of Care dated 4/27/2025. The Plan of Care listed Multiple Myeloma (type of cancer affecting plasma cells, a type of white blood cell, that multiplies uncontrollably within bone marrow leading to bone damage, pain, and increased risk of fractures and may also affect other organs) not having Achieved remission (stability) as the terminal diagnosis. The Plan of Care listed Roxanol (Morphine Sulfate- used to treat pain), 20 milligrams per milliliter, take 0.25 milliliters (5 milligrams) every 3 hours as needed for pain as a medication related to the terminal condition. The Plan of Care indicated that the start date for the Roxanol (Morphine) was 4/27/2025. Patient #2’s clinical record contained a Hospice initial Certification of Terminal Illness that indicated that hospice services began on 4/27/2025. Patient #2’s clinical record contained a document titled “Pre-Admit Evaluation” dated 4/27/2025. Registered Nurse D conducted the evaluation and documented that Patient #2 did not have current pain. Registered Nurse D documented that what mattered most to Patient #2 and Patient #2’s family was comfort care. Registered Nurse C conducted a visit on 4/27/2025. Registered Nurse C documented that pain was assessed and no changes were needed on the care plan. Registered Nurse C documented that Patient #2 had Tylenol 500 milligrams (used to treat mild to moderate pain) and could take 1 tablet every 6 hours as needed for pain. Registered Nurse C documented that Patient #2 had a moderate shortness of breath with exertion of standing. Registered Nurse E conducted an Initial Start of Care Comprehensive Assessment on 4/28/2025. Registered Nurse E documented that Patient #2 had a Pain level of 1 on a pain scale of 0-10. Registered Nurse E documented that it was a generalized aching pain that affected Patient #2’s sleep. Registered Nurse E documented that an order was obtained for Roxanol (Morphine) 20 milligrams/milliliter and that Patient #2 could take 0.25 milliliters (5 milligrams) by mouth every 3 hours as needed for pain. Registered Nurse F conducted a skilled nurse visit on 4/29/2025. Registered Nurse F documented Patient #2’s pain as 3 on a pain scale of 0-10. Registered Nurse F described Patient #2’s pain as aching and affecting sleep. Registered Nurse F called the physician to get an increase in Roxanol (Morphine dosage). Registered Nurse F received an order to increase the dosage of Roxanol (Morphine) to 1 milliliter (20 milligrams) every 2 hours as needed for pain and shortness of breath. Registered Nurse H conducted a skilled nurse visit on 4/29/2025 and pronounced Patient #2’s death on 4/29/2025 at 8:15 p.m. Hospice documentation of the calls between Family Member #2 and the hospice:4/29/2025 6:44 p.m. Call received that (Patient #2) was struggling to breathe; Family had given (Patient #2) a 2nd dose of Morphine after the first dose; Oxygen was put on (Patient #2) nose; phone was passed from Family Member #1 to Family Member #2; Family Member #2 agreed to hold for a supervisor. 6:54 p.m. call connected. (Family Member #2) stated (Patient #2) was in pain, asked for medications and nurse to come out each day. Offered to get a nurse on the line to review medications; call physician; and send out a nurse. (Family Member #2) agreed to the plan. (Family Member #2) had indicated that it took 45 minutes for morphine to arrive. Apology given and advised Team will follow up. 7:00 - 7:09 p.m. See EMR (electronic medical record). The clinical record documentation indicated that Patient #2’s severity level was 10 on a scale of 0-10. Family Member #2 was very upset and wanted pain medication increased. Please send a nurse to assess respiratory distress, clarify oxygen orders with physician, no orders. Physician called and increased Morphine concentrate 20milligram/milliliter to 1.5 milliliters by mouth every 2 hours as needed for shortness of breath or pain and to give a dose now; advise family to consider sending patient to unit. Call to Registered Nurse H, on-call nurse. Family Member #2 was called twice to notify of new orders, sent to voice mail. Message left that the nurse would try again due to generic voice mail. 7:15 p.m. Family Member #2 was called to notify of new orders, sent to voice mail.7:24 p.m. (Family Member #2) called, (Patient #2) had passed. Review of documentation regarding the medications ordered from the mail order pharmacy indicated that Roxanol/Morphine, 100 milligrams/5 milliliters, 15 milliliters was dispensed on 4/28/2025, with a shipped Priority of “Next Day PM,” with a ship date of 4/28/2025, and a delivery date of 4/29/2025. Review of documentation regarding the medications ordered from Pharmacy X, local pharmacy, indicated that Roxanol/Morphine, 100 milligrams/5 milliliters, 30 milliliters had a dispense date of 4/28/2025. During an interview on 8/18/2025 at 4:34 p.m. with Family Member #2, the surveyor was informed; that Patient #2 had a diagnosis of cancer; Patient #2 decided that Patient #2 wanted to go home, was tired of fighting (the cancer); A nurse came out to the home at 9:00 p.m. the first night (4/27/2025) and asked for Patient #2 medications; Patient #2 only had Lorazepam (used for anxiety) and Benadryl (used to treat allergy symptoms) as medications; Family Member #2 had informed the nurse that Patient #2 would need a stronger pain medication, Patient #2 would need Morphine; Family was told that we would receive the Morphine in the morning (4/28/2025); On (4/28/2025) the family was expecting the Morphine and did not receive it; Patient #2 had a hard night on 4/27/2025, wanting to walk, urinate; Family Member #2 informed the surveyor that Family Member #2 called the hospice agency and was passed from one person to another, on average it was 4 different people, “it was like nobody knew”; Family Member #2 had told the hospice that Patient #2 needed a nurse to come out and that the Morphine had not arrived; Family Member #2 was told that the hospice would find out about the medication; Family Member #2 told the hospice that Patient #2 was in pain; The next morning, (4/29/2025), no Morphine had been received; Patient #2 was screaming out in pain; Patient #2 was fully cognitive (related to process of thinking); Registered Nurse F arrived on 4/29/2025; Patient #2 was in so much pain; Registered Nurse F asked about the Morphine; Patient #2 did not have any Morphine; Registered Nurse F made phone calls, more Morphine was ordered; Registered Nurse F had informed Patient #2’s family that someone would have to go get the Morphine; Family Member #3 and Family Member #4 went to get the Morphine; a Company Y Delivery Truck arrived with Morphine and Registered Nurse F received the Morphine; Registered Nurse F gave Patient #2 Morphine; Patient #2 died while Family Members #3 and #4 were out of the home getting the Morphine; and Family Member #2 informed the surveyor that Patient #2 “didn’t deserve to die that way.” During an interview on 8/18/2025 at 5:21 p.m. with Family Member #1 the surveyor was informed; On Monday (4/28/2025) that Patient #2 was exhibiting like Patient #2 was uncomfortable, wiggling, not resting soundly; On Tuesday (4/29/2025), Patient #2 was in pain asking for pain medication; No Morphine was in the home, only Tylenol and Benadryl; the Family had been told that the condition that Patient #2 was in, Patient #2 would have someone here 24 hours; and Patient #2 “suffered” at the end. During an interview on 8/18/2025 at 5:37 p.m. with Family Member #3 the surveyor was informed; Family Member #3 was under the impression that Patient #2 was going to have somebody there full time; on Monday, Patient #2 was very restless, like Patient #2 needed some pain medication; On Tuesday (4/29/2025), Patient #2 was really in pain; Family Member #2 had called the hospice about the Morphine, it was supposed to be delivered on Monday but it wasn’t, the Morphine arrived later on 4/29/2025; Registered Nurse F made a visit, the Morphine arrived from Company Y Delivery Truck while the nurse was at the home; the nurse had told the family that Patient #2 needed more Morphine, that there was not enough; Family Member #3 went to three different pharmacies before Family Member #3 was able to obtain the Morphine at a local pharmacy; Patient #2 died while Family Member #3 was in line at a pharmacy getting the Morphine; Patient #2 had been screaming, ‘help, medicine’; and Patient #2 suffered, Patient #2 was in pain. During an interview on 8/21/2025 at 9:52 a.m. with the Alternate Administrator/Supervising Nurse, the surveyor asked about the order for Roxanol (Morphine) that was listed with a start date of 4/27/2025 and asked who had obtained that order. The Alternate Administrator/Supervising Nurse informed the surveyor that Registered Nurse C had obtained the physician order on 4/27/2025 and ordered the Roxanol (Morphine) for next day delivery because Patient #2 was comfortable. The Alternate Administrator/Supervising Nurse stated, “Briefly, nurse went out to see (Patient #2) and then family called having crisis. A nurse was sent out, (Registered Nurse F). Patient #2 had a lot more pain, but the Roxanol (Morphine) had not arrived. (Company Y Delivery Truck) arrived with Roxanol (Morphine) while (Registered Nurse F) was in the home. The original order for Roxanol (Morphine) was a low dose order. (Registered Nurse F) got (Patient #2) comfortable and gave a bath.” (Registered Nurse F) ordered mor Morphine locally. (Registered Nurse F) stayed with the family while other family members went to get the Roxanol (Morphine). The surveyor asked who was responsible to ensure medications were available to patients. The Alternate Administrator/Supervising Nurse stated, “The case manager.” During an interview on 8/21/2025 at 12:20 p.m. with the Administrator, Alternate Administrator/Supervising Nurse, the surveyor was informed that Registered Nurse C had told them that Patient #2 denied pain; Roxanol (Morphine) was ordered next day and local; and that Patient #2’s Family Member was going to pick it up at the local pharmacy; the Administrator pointed out that Registered Nurse E documented return demonstration of Roxanol (Morphine) by caregiver, they were not out of Morphine; and Patient #2 was on a minimal dose of Roxanol (Morphine). The surveyor asked if Registered Nurse F had an interaction with a delivery from Company Y Delivery Truck during the visit on 4/29/2025. The Alternate Administrator/Supervising Nurse informed the surveyor that Company Y Delivery Truck package was the Roxanol (Morphine) ordered by Registered Nurse C on 4/27/2025. The surveyor asked about phone calls made to the agency from Patient #2’s family. The surveyor was given documents titled “Telecare call.” The documents referenced phone calls from Patient #2’s Family Member 2 to the hospice agency on 4/29/2025. The surveyor discussed that Patient #2’s family had called the agency on 4/28/2025 but no reference to phone calls made on 4/28/2025 were noted in Patient #2’s clinical record. The Alternate Administrator/Supervising Nurse asked if these calls had been made during agency operating hours, if so “there would be no way to track that.” During an interview on 8/21/2025 at 12:54 p.m. with Registered Nurse F, the surveyor asked about Patient #2 and Registered Nurse F’s interaction with Patient #2 and Patient #2’s family during the skilled nurse visit on 4/29/2025. Registered Nurse F informed the surveyor that Registered Nurse F was an after-hour nurse. Registered Nurse stated, “The patient didn’t look comfortable. (Patient #2) was in some distress, Patient #2 had pain medication but was unable to swallow” (Tylenol Extra Strength 500 milligram, 1 tablet every 6 hours as needed for pain). Registered Nurse F stated, “Morphine was pending delivery. It was verified it was going to get there, it was on the way. I looked at the order and saw that it started with 0.25 milliliters (5 milligrams), a baby dose. I stepped out to call the doctor asking if the dose could be increased. The physician increased the dosage. (Company Y Delivery Truck) pulled up; I took it (Roxanol/Morphine) right away to give a dose.” Registered Nurse F informed the surveyor that Registered Nurse F conferenced with the family, Registered Nurse F had explained Patient #2 was imminent (final stage of dying). Registered Nurse F informed the surveyor that a pharmacy was found locally that had Morphine and a family member of Patient #2 was going to pick it up. The surveyor asked if there was Roxanol (Morphine) at Patient #2’s home when Registered Nurse F had arrived at the home. Registered Nurse F stated, “No, there was no Morphine in the home.” During an interview on 8/21/2025 at 1:09 p.m. with Registered Nurse C, the surveyor asked what occurred at the skilled nurse visit Registered Nurse C conducted on 8/27/2025 and was Patient #2 in pain during the visit. Registered Nurse C informed the surveyor that Registered Nurse C had pulled Patient #2 up in the bed and Patient #2 did not complain or wince. Registered Nurse C stated, I asked if (Patient #2) needed anything. Patient #2 wanted to have stronger pain medication. I ordered it mail order and the local pharmacy (Pharmacy X).” Registered Nurse C informed the surveyor that Patient #2’s Family Member 2 was going to pick it (Roxanol/Morphine) up. Registered Nurse C had documented on 4/27/2025, “Pain - Assessed, no changes needed on the care plan.” During an interview on 8/21/2025 at 1:20 p.m. with Chaplain G, the surveyor asked about the visit Chaplain G made to Patient #2 on 4/28/2025. Chaplain G informed the surveyor that Chaplain G did not recall if Patient #2 had discomfort. Chaplain G stated, “I asked for a nurse to come because they (the family) had concerns about medications.” During an interview on 8/21/2025 at 1:38 p.m. with Registered Nurse E, the surveyor asked about the visit Registered Nurse E conducted on 4/28/2025 to Patient #2. Registered Nurse E informed the surveyor that Registered Nurse E had told the family that Patient #2 was imminent, and a nurse would come tomorrow to assess for medication adjustments. Registered Nurse E informed the surveyor that Registered Nurse E thought that Patient #2 needed crisis care. The surveyor asked if Registered Nurse E had talked with anyone at the agency regarding this concern. Registered Nurse E stated, “I talked to the MD (medical doctor). I talked to the family about the inpatient unit. The family refused.” The surveyor asked if Patient #2 had discomfort. Registered Nurse F informed the surveyor that Patient #2 was restless, did not want to lie in the hospital bed.” The surveyor asked if Patient #2 had Morphine in the home. Registered Nurse F stated, “I am not sure. I asked if (Patient #2) had pain and (Patient #2) had said no.” (Registered Nurse E had documented that Patient #2 had pain of 1 on a pain scale 0-10 during the visit conducted on 4/28/2025). During an interview on 8/21/2025 at 1:53 p.m. with Family Member #2, the surveyor asked if Family Member #2 had been instructed to pick up the Morphine that had been ordered by the nurse on 4/27/2025 at a local pharmacy. Family Member #2 stated, “No, we were told that the Morphine was to be delivered the next day.” Family Member #2 stated, “If we had been told that than we would have gone to pick it up. We had plenty of family here.” Family Member #2 added that they (family) had done that on Tuesday when the nurse (Registered Nurse F) had ordered some more. During an interview on 8/21/2025 at 2:13 p.m. with Pharmacy X, Local Pharmacy Staff Member, the surveyor was informed that Roxanol/Morphine for (Patient #2) was picked up on April 29, 2025. Local Pharmacy Staff Member informed the surveyor that Roxanol/Morphine was not ordered for Patient #2 prior to 4/27/2025. Local Pharmacy Staff Member informed the surveyor that the Local Pharmacy Staff Member could only do a two-year look back on Patient #2’s medications and that the Morphine that was picked up on 4/29/2025 was the only Morphine that had been picked up. During an interview on 8/26/2025 with Family Member #5, the surveyor was informed that Patient #2 died in excruciating pain. Family Member #5 stated, “On the second day (4/29/2025), (Patient #2) squeezed my hand so hard, and said ‘pain.’ The surveyor asked if the family had been told to pick up Morphine prior to 4/29/2025. Family Member #5 stated, No, the first Morphine that came, came in a (Company Y Delivery Truck) truck (4/29/2025).” Review of the agency’s complaint investigation documentation on a document titled “Service Opportunity Form.” The form was dated 4/29/2025 indicated that a complaint had been received regarding Patient #2 on 4/29/2025. The complaint had a final review on 5/12/2025 by the Alternate Administrator/Supervising Nurse. The classification category was Medication issue, other- Medication not ordered. The document read in part; “(Family Member 2) had stated patient was in pain and (Hospice) was not providing comfort care. (Family Member #2) had informed the hospice that (Patient #2) was in pain and having a hard time breathing. (Family Member #2) stated that (Family Member #2) had call the agency three times on Monday 4/28/2025 to get low dose Morphine and it took 45 minutes for it to arrive. According to (Family Member #2) (Registered Nurse E) had stated ‘We are going to send someone out here to be with (Patient #2)...Telecare apologized for patient having pain. Advised would contact MD for medication order and would send nurse out as soon as possible...Team lead apologized to (Family Member #2) for uncontrolled pain and shortness of breath. (Family Member #2) had said the hospice was called 3 times on Monday 4/28/2025 to get Morphine for (Patient #2) and that the hospice was not providing comfort care...On 4/27/2025 after reviewing the chart order was obtained from the MD (medical doctor) Sunday to the weekend nurse, (Registered Nurse C). Medication found to be not ordered. The next day follow up, 4/28/2025, Nurse visited (Patient #2) was refusing medications from (Registered Nurse E) and Family Member #2. Patient #2 was alert, no distress noted, medication was ordered from mail order instead of a local fill for next day delivery. Follow up visit schedule for patient to be visited today. Upon nurse arrival (Patient #2) was leaning over with discomfort. Placed back in bed with family help and nurse along with providing ADL (activities of daily living) care. During visit medication arrived via (Company Y Delivery Truck) during nurse visit delivered on hand Morphine concentrate 15 ml. The family insisted to order more Morphine to have on hand. (Patient #2) was medicated during visit and (Patient #2) started settling down, became very comfortable. Staff nurse explained to the family (Patient #2) condition was not good, (Patient #2) could pass at any time. The nurse ordered additional medication from (pharmacy) as the Family Member #3 left along with another family member to pick up meds. the family went to two different locations for medication, became aggravated looking for meds (medication) Reported from (F amily Member #2) no call placed back to the office for clarification as the locations for pick up was provided per (Registered Nurse F). (Patient #2 passed away a few hours later before (Family Member #3) returned back home. On 4/27 Weekend staff nurse educated if you obtain and order medication should be ordered right away for patient. Reinforce to the follow up visit the next day 4/28/2025 ordered medication via mail delivery instead of local fill to assure medication on profile are in the home on hand due the patient terminal diagnosis medication need to be on hand...” Review of documentation received from Family Member #2 that was a list with dates and times of phone activity of Family Member #2 phone. The list included the phone number for the hospice (phone number as listed in the Texas Unified Licensing Information Portal - last 4 digits 5600) that listed phone calls between Family Member #2 and the hospice agency on 4/28/2025 at 9:37 a.m., 2:28 p.m., and 5:40 p.m. The hospice did not have a record of the phone calls between Family Member #2 and the hospice on 4/28/2025. The physician ordered Morphine for Patient #2 on 4/27/2025. Patient #2 did not receive Morphine until 4/29/2025. Morphine was not available for Patient #2 when Patient #2’s pain increased. Review of the agency’s policy titled “Symptom Management” that was updated 6/2/2022 read in part; “Purpose The patient has a right to the following; Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness...””

“Based on record review and interview, the hospice failed to develop and maintain a system of communication and integration within its policies and procedures that ensured that care and services were provided in accordance with the plan of care, in that the patient did not have Roxanol/Morphine (used to treat pain) available as needed for pain, in accordance with the Plan of Care, when the patient had increased pain for 1 (#2) of 3 discharged records reviewed. The failure resulted in Patient #2 did not have Roxanol/Morphine available when Patient #2’s pain increased. Review of the agency’s policy titled “VS Supervision Delegation and Coordination,” updated 7/15/2019 read in part; “Purpose 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section that, in consultation with the patient’s attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. 1. Standard: Approach to service delivery 1. The hospice must designate an interdisciplinary group or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety must supervise the the care and services. The hospice must designate a registered nurse that is a member of the interdisciplinary group to provide coordination of care and to ensure continuous assessment of each patient’s and family’s needs and implementation of the interdisciplinary plan of care...” Patient #2:Record review of Patient #2’s clinical record revealed a Plan of Care dated 4/27/2025. The Plan of Care listed Multiple Myeloma (type of cancer affecting plasma cells, a type of white blood cell, that multiplies uncontrollably within bone marrow leading to bone damage, pain, and increased risk of fractures and may also affect other organs) not having achieved remission (stability) as the terminal diagnosis. The Plan of Care listed Roxanol (Morphine Sulfate- used to treat pain), 20 milligrams per milliliter, take 0.25 milliliters (5 milligrams) every 3 hours as needed for pain as a medication related to the terminal condition. The Plan of Care indicated that the start date for the Roxanol (Morphine) was 4/27/2025. Patient #2’s clinical record contained a Hospice Initial Certification of Terminal Illness that indicated that hospice services began on 4/27/2025. Patient #2’s clinical record contained a document titled “Pre-Admit Evaluation” dated 4/27/2025. Registered Nurse D conducted the evaluation and documented that Patient #2 did not have current pain. Registered Nurse D documented that what mattered most to Patient #2 and Patient #2’s family was comfort care. Registered Nurse C conducted a visit on 4/27/2025. Registered Nurse C documented that pain was assessed and no changes were needed on the care plan. Registered Nurse C documented that Patient #2 had Tylenol 500 milligrams (used to treat mild to moderate pain) and could take 1 tablet every 6 hours as needed for pain. Registered Nurse C documented that Patient #2 had a moderate shortness of breath with exertion of standing. Review of documentation regarding the medications ordered from the pharmacy indicated that Roxanol/Morphine, 100 milligrams/5 milliliters, 15 milliliters was dispensed on 4/28/2025, with a shipped Priority of “Next Day PM,” with a ship date of 4/28/2025, and a delivery date of 4/29/2025. Review of documentation regarding the medications ordered from Pharmacy X, local pharmacy, indicated that Roxanol/Morphine, 100 milligrams/5 milliliters, 30 milliliters had a dispense date of 4/28/2025. During an interview on 8/18/2025 at 4:34 p.m. with Family Member #2, the surveyor was informed; that Patient #2 had a diagnosis of cancer; Patient #2 decided that Patient #2 wanted to go home, was tired of fighting (the cancer); A nurse came out to the home at 9:00 p.m. the first night (4/27/2025) and asked for Patient #2 medications; Patient #2 only had Lorazepam (used for anxiety) and Benadryl (used to treat allergy symptoms) as medications; Family Member #2 had informed the nurse that Patient #2 would need a stronger pain medication, Patient #2 would need Morphine; Family was told that Patient #2 would receive the Morphine in the morning (4/28/2025); On (4/28/2025) the family was expecting the Morphine and did not receive it; Patient #2 had a hard night on 4/27/2025, Patient #2 wanted to walk, urinate; Family Member #2 informed the surveyor that Family Member #2 called the hospice agency (4/28/2025) and was passed from one person to another, on average it was 4 different people, “it was like nobody knew”; Family Member #2 had told the hospice that Patient #2 needed a nurse to come out and that the Morphine had not arrived; Family Member #2 was told that the hospice would find out about the medication; Family Member #2 told the hospice that Patient #2 was in pain; The next morning, (4/29/2025), the Morphine had not been received; Patient #2 was screaming out in pain; Patient #2 was fully cognitive (related to process of thinking); Registered Nurse F arrived on 4/29/2025; Patient #2 was in so much pain; Registered Nurse F asked about the Morphine; Patient #2 did not have any Morphine; Registered Nurse F made phone calls, more Morphine was ordered; Registered Nurse F had informed Patient #2’s family that someone would have to go get the Morphine; Family Member #3 and Family Member #4 went to get the Morphine; a (Company Y Deliver Truck) arrived (4/29/2025) with Morphine while Registered Nurse F was at the home; Registered Nurse F received the Morphine; Registered Nurse F gave Patient #2 Morphine; Patient #2 died while Family Members #3 and #4 were out of the home getting the Morphine; and Family Member #2 informed the surveyor that Patient #2 “didn’t deserve to die that way.” During an interview on 8/18/2025 at 5:21 p.m. with Family Member #1 the surveyor was informed; On Monday (4/28/2025) that Patient #2 was exhibiting like Patient #2 was uncomfortable, wiggling, not resting soundly; On Tuesday (4/29/2025), Patient #2 was in pain asking for pain medication; No Morphine was in the home, only Tylenol and Benadryl; the Family had been told that the condition that Patient #2 was in, Patient #2 would have someone here 24 hours; and Patient #2 “suffered” at the end. During an interview on 8/18/2025 at 5:37 p.m. with Family Member #3 the surveyor was informed; Family Member #3 was under the impression that Patient #2 was going to have somebody there full time; on Monday, Patient #2 was very restless, like Patient #2 needed some pain medication; On Tuesday (4/29/2025), Patient #2 was really in pain; Family Member #2 had called the hospice about the Morphine, it was supposed to be delivered on Monday but it wasn’t, the Morphine arrived later on 4/29/2025; Registered Nurse F made a visit, the Morphine arrived from Company Y Delivery Truck while the nurse was at the home; the nurse had told the family that Patient #2 needed more Morphine, that there was not enough; Family Member #3 went to three different pharmacies before Family Member #3 was able to obtain the Morphine at a local pharmacy; Patient #2 died while Family Member #3 was in line at a pharmacy getting the Morphine; Patient #2 had been screaming, ‘help, medicine’; and Patient #2 suffered, Patient #2 was in pain. During an interview on 8/21/2025 at 9:52 a.m. with the Alternate Administrator/Supervising Nurse, the surveyor asked about the order for Roxanol (Morphine) that was listed on the Plan of Care with a start date of 4/27/2025 and asked who had obtained that order. The Alternate Administrator/Supervising Nurse informed the surveyor that Registered Nurse C had obtained the physician order on 4/27/2025 and ordered the Roxanol (Morphine) for next day delivery because Patient #2 was comfortable. The Alternate Administrator/Supervising Nurse stated, “Briefly, nurse went out to see (Patient #2) and then family called having crisis. A nurse was sent out, (Registered Nurse F). Patient #2 had a lot more pain but the Roxanol (Morphine) had not arrived. (Registered Nurse F) ordered locally. (Registered Nurse F) stayed with the family while other family members went to get the Roxanol (Morphine). (Company Y Delivery Truck) arrived with Roxanol (Morphine) while (Registered Nurse F) was in the home. The original order for Roxanol (Morphine) was a low dose order. (Registered Nurse F) got (Patient #2) comfortable and gave a bath.” The Alternate Administrator/Supervising Nurse was in agreement that there was a physician order for Roxanol (Morphine) that had a start date of 4/27/2025. During an interview on 8/21/2025 at 12:20 p.m. with the Administrator and Alternate Administrator/Supervising Nurse, the surveyor was informed that Registered Nurse C had told the Administrator and Alternate Administrator/Supervising Nurse that Patient #2 denied pain; Roxanol (Morphine) was ordered next day and local; and that Patient #2’s Family Member was going to pick it up at the local pharmacy; the Administrator informed the surveyor that Registered Nurse E documented, on 4/28/2025, returned demonstration of Roxanol (Morphine) by caregiver, they were not out of Morphine; and Patient #2 was on a minimal dose of Roxanol (Morphine). The surveyor asked if Registered Nurse F had an interaction with Company Y Delivery Truck during the visit on 4/29/2025. The Alternate Administrator/Supervising Nurse informed the surveyor that the Company Y Delivery Truck package was the Roxanol (Morphine) ordered by Registered Nurse C on 4/27/2025. The surveyor asked about phone calls made to the agency from Patient #2’s family. The surveyor was given documents titled “Telecare call.” The document referenced phone calls between Patient #2’s Family Member #2 and the hospice agency on 4/29/2025. The surveyor discussed that Patient #2’s family had called the agency on 4/28/2025 but there were no references to the phone calls on 4/28/2025, nothing was documented in Patient #2’s clinical record. The Alternate Administrator/Supervising Nurse asked if these calls had been made during agency operating hours, if so “there would be no way to track that.” During an interview on 8/21/2025 at 12:54 p.m. with Registered Nurse F, the surveyor asked about Patient #2 and Registered Nurse F’s interaction with Patient #2 and Patient #2’s family during the skilled nurse visit on 4/29/2025. Registered Nurse F informed the survey that Registered Nurse F was an after-hour nurse. Registered Nurse stated, “The patient didn’t look comfortable. (Patient #2) was in some distress, Patient #2 had pain medication but was unable to swallow” (Tylenol Extra Strength 500 milligram, 1 tablet every 6 hours as needed for pain). Registered Nurse F stated, “Morphine was pending delivery. It was verified it was going to get there, it was on the way. I looked at the order and saw that it started with 0.25 milliliters (5 milligrams), a baby dose. I stepped out to call the doctor asking if the dose could be increased. The physician increased the dosage. (Company Y Delivery Truck) pulled up; I took it (Roxanol/Morphine) right away to give a dose.” Registered Nurse F informed the surveyor that Registered Nurse F conferenced with the family, Registered Nurse F had explained Patient #2 was imminent (final stage of dying). Registered Nurse F informed the surveyor that a pharmacy was found locally that had Morphine and a family member of Patient #2 was going to pick it up. The surveyor asked if there was Roxanol (Morphine) at Patient #2’s home when Registered Nurse F had arrived at the home. Registered Nurse F stated, “No, there was no Morphine in the home.” During an interview on 8/21/2025 at 1:09 p.m. with Registered Nurse C, the surveyor asked what occurred at the skilled nurse visit Registered Nurse C conducted on 8/27/2025 and was Patient #2 in pain during the visit. Registered Nurse C informed the surveyor that Registered Nurse C had pulled Patient #2 up in the bed and Patient #2 did not complain or wince. Registered Nurse C stated, “I asked if (Patient #2) needed anything. Patient #2 wanted to have stronger pain medication. I ordered it mail order and the local pharmacy (Pharmacy X).” Registered Nurse C informed the surveyor that Patient #2’s Family Member 2 was going to pick it (Roxanol/Morphine) up. Registered Nurse C had documented on 4/28/2025, “Pain assessed- no change to care plan.” Registered Nurse C was asked what the process for obtaining medication for a patient was. Registered Nurse C informed the surveyor that Registered Nurse C would get an order from the physician, the order would be put in the system. The physician signs it and that would push it out -order goes to the pharmacy. The patient or family would pick the medication up unless actively hurting, then staff will pick it up. During an interview on 8/21/2025 at 1:20 p.m. with Chaplain G, the surveyor asked about the visit Chaplain G made to Patient #2 on 4/28/2025. Chaplain G informed the surveyor that Chaplain G did not recall if Patient #2 had discomfort. Chaplain G stated, “I asked for a nurse to come because they (the family) had concerns about medications.” During an interview on 8/21/2025 at 1:38 p.m. with Registered Nurse E, the surveyor asked about the visit Registered Nurse E conducted on 4/28/2025 to Patient #2. Registered Nurse E informed the surveyor that Registered Nurse E had told the family that Patient #2 was imminent, and a nurse would come tomorrow to assess for medication adjustments. Registered Nurse E informed the surveyor that Registered Nurse E thought that Patient #2 needed crisis care. The surveyor asked if Registered Nurse E had talked with anyone at the agency regarding this concern. Registered Nurse E stated, “I talked to the MD (medical doctor). I talked to the family about the inpatient unit. The family refused.” The surveyor asked if Patient #2 had discomfort. Registered Nurse F informed the surveyor that Patient #2 was restless, did not want to lie in the hospital bed.” The surveyor asked if Patient #2 had Morphine in the home. Registered Nurse F stated, “I am not sure. I asked if (Patient #2) had pain and (Patient #2) had said no.” (Registered Nurse E had documented that Patient #2 had pain of 1 on a pain scale 0-10 during the visit conducted on 4/28/2025). During an interview on 8/21/2025 at 1:53 p.m. with Family Member #2, the surveyor asked if Family Member #2 had been instructed to pick up the Morphine that had been ordered by the nurse on 4/27/2025 at a local pharmacy. Family Member #2 stated, “No, we were told that the Morphine was to be delivered the next day.” Family Member #2 stated, “If we had been told that than we would have gone to pick it up. We had plenty of family here.” Family Member #2 added that they (family) had done that on Tuesday when the nurse (Registered Nurse F) had ordered some more Morphine. During an interview on 8/21/2025 at 2:13 p.m. with Pharmacy X, Local Pharmacy Staff Member, the surveyor was informed that Roxanol/Morphine for (Patient #2) was picked up on April 29, 2025. Local Pharmacy Staff Member informed the surveyor that Roxanol/Morphine was not ordered for Patient #2 prior to 4/27/2025. Local Pharmacy Staff Member informed the surveyor that the Local Pharmacy Staff Member could only do a two-year look back on Patient #2’s medications and that the Morphine that was picked up on 4/29/2025 was the only Morphine that had been picked up. Local Pharmacy Staff Member informed the surveyor that the pharmacy did not deliver medication. During an interview on 8/21/2025 at 2:25 p.m. with the Alternate Administrator/Supervising Nurse. The Hospice did not have a record of the calls made. Patient #2’s family had been told that Morphine would be delivered the next day (4/28/2025). The Morphine was not delivered. Patient #2’s family was not instructed to pick up Morphine at local pharmacy. The local pharmacy staff said that the Morphine was not be picked up until 4/29/2025 (after Registered Nurse F had gotten more ordered). The local pharmacy did not deliver medication. The Alternate Administrator/Supervising Nurse did not state how it could affect the patients. During an interview on 8/26/2025 with Family Member #5, the surveyor was informed that Patient #2 died in excruciating pain. Family Member #5 stated, “On the second day (4/29/2025), (Patient #2) squeezed my hand so hard, and said ‘pain.’ The surveyor asked if the family had been instructed to pick up Morphine prior to 4/29/2025. Family Member #5 stated, “No, the first Morphine that came, came in a (Company Y Delivery Truck) (4/29/2025).” Family Member #5 had informed the surveyor that Family Member #5 had been at Patient #2’s house from 9:00 a.m. to around 11:00 p.m. on 4/28/2025 and was at Patient #2’s home the 2nd day from 9:00 a.m. to “well not as long because he passed.” Family Member #5 informed the surveyor that there was terrible communication from the hospice. Review of documentation received from Family Member #2 that listed activity of Family Member #2’s phone. The documentation listed the phone number of the hospice (phone number as listed in the Texas Unified Licensing Information Portal - last 4 digits 5600) of calls between Family Member #2 and the hospice agency on 4/28/2025 at 9:37 a.m., 2:28 p.m., and 5:40 p.m. The hospice did not have a record of the phone calls between Family Member #2 and the hospice on 4/28/2025. The physician ordered Morphine for Patient #2 on 4/27/2025. Patient #2 did not receive Morphine until 4/29/2025. Review of Patient #2’s clinical record did not contain evidence that the hospice had communicated with Patient #2’s family that the family would need to pick up the Morphine that was ordered on 4/27/2025 at a local pharmacy. Patient #2 Family Member #2 had informed the surveyor that no one from the hospice had told the family that Morphine could be picked up at the local pharmacy. Morphine was not available, as ordered in the Plan of Care, for Patient #2 when Patient #2’s pain increased.”

“It is required that the hospice has a written Patient Bill of Rights and Responsibilities (Bill of Rights). The patient has the right to be informed of his or her rights and responsibilities, and the hospice defines, protects, and promotes the exercise of these rights. This is a CMS CONDITION LEVEL DEFIENCY that was not met, resulting in Immediate Jeopardy determination as evidenced by a review of clinical records, personnel records, documents, and an interview with the Administrator, Patient Care Administrator, and other hospice team members, which revealed the hospice: Failed to ensure that the patient was free from mistreatment, neglect, or mental, sexual and physical abuse, injuries unknown source, misappropriate of property (L517), Failed to report alleged violations immediately (L508), Failed to immediately investigate/prevent further violations (L509), Failed to take appropriate corrective action for verified violations (L510), Failed to report verified violations to the State and local bodies and Certification Agency (L511). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.52: Patient Rights. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program reflects the complexity of the hospice and services, involves all hospice services, including those provided under contract or arrangement, focuses on indicators related to improved palliative outcomes, includes investigation and analysis of sentinel and adverse events, has evidence of action taken that results in improvement in hospice performance. The hospice must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS. This is a CMS CONDITION LEVEL DEFIENCY that was not met, resulting in Immediate Jeopardy determination as evidenced by a review of clinical records, personnel records, documents, and an interview with the Administrator, Patient Care Administrator, and other hospice team members, which revealed the hospice: Failed to ensure the agency measured/analyzed/tracked quality indicators (L562), Failed to ensure tracking/analysis of adverse events/implement preventative actions (L569), Failed to ensure priorities were addressed and evaluated for effectiveness (L575). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.58: Quality assessment and performance improvement. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice has a defined process to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source or misappropriation of patient/family property by anyone furnishing services on behalf of the hospice, are reported immediately: by the hospice employee to the hospice administrator. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “(Agency name) Management Standard” Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a … employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” In 1 of 1 (100%) clinical record review in which a complaint of alleged abuse was identified, the agency did not ensure adherence to its policies and procedures regarding reporting alleged violations to the agency’s Administrator. Clinical Record 2: The patient transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” On 07/09/2024, the Patient Care Administrator (PCA) [Personnel record 16] confirmed knowledge of the complaint and stated, “This family has been through multiple hospices, and this is probably the fourth aide change she has requested in two months.” When asked for the investigation, the PCA stated, “The RN and aide were sent out for a joint visit, and the RN did not see any problems.” During an interview, the PCA was asked if that was the full extent of the investigation and if there was any written documentation regarding the investigation. The agency presented a document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the Administrator was notified of the alleged abuse. During an interview on 07/09/2024, the Senior Patient Care Administrator [Personnel record 16] and General Manager/Administrator [Personnel Record 21] reported that the complaint from 06/01/2024 was not reported to them per the policy and thus, further investigation was not completed. The policy titled “(Agency name) Management Standard (policy was not numbered nor dated); Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a (agency) employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.””

“It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by immediately investigating all alleged violations and taking immediate action to prevent further potential violations while the alleged violation is being verified. This standard was not met as evidenced by clinical record review, document review, observation, and interview. The Agency policy “(Agency name) Management Standard” Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a … employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” In 1 of 1 (100%) clinical record review in which a complaint of alleged abuse was identified, the agency did not ensure adherence to the agency policies and procedures regarding investigating and taking immediate actions. Document 5: The agency presented a document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the Administrator was notified of the alleged abuse or that an investigation regarding the alleged abuse was completed. Clinical Record 2/Home Visit 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” On 07/09/2024, the Patient Care Administrator (PCA) [Personnel record 16] confirmed knowledge of the complaint and stated, “This family has been through multiple hospices, and this is probably the fourth aide change she has requested in two months.” When asked for the investigation, the PCA stated, “The RN and aide were sent out for a joint visit, and the RN did not see any problems.” During an interview, the PCA was asked if that was the full extent of the investigation and if there was any written documentation regarding the investigation. The agency provided the “Telehealth on-call logs” documenting that on 05/31/2024, the RN informed the Team Manager on-call that the daughter was requesting a new aide, that the Team Manager changed the aide assignment, and a different aide made the visit on 06/01/2024 and moving forward. The documentation presented did not include the daughter’s concerns about the aide being rude and allegedly causing injuries to the patient. A home visit observation was conducted on 07/10/2024 from 1400 to 1500. Due to the patient’s condition, the patient was not able to participate in an interview, but the patient’s daughter (the complainant) and granddaughter participated. During an interview, the daughter stated that she reported the incident on 05/31/2024 to the RN in the evening following a joint aide and RN visit. The daughter presented the text message and pictures (with time stamp, dated 05/31/2024) to show what was sent to the RN the evening of 05/31/2024 (the text message thread no longer contained the time sent, only the date). The text message notification documented concerns about the aide being verbally rude and physically abusive while providing direct care to the point of causing bruises and cuts. The notification included pictures of the injuries. On 07/09/2024, the Senior Patient Care Administrator [Personnel Record 17] and the General Manager/Administrator [Personnel Record 21] were informed that clinical record 2 would be reviewed and that a home visit observation was requested. The Senior Patient Care Administrator presented a summary of the events as documented by the Team Manager: 05/30/2024 the RN case manager [Personnel Record 5] reported the daughter would like a different hospice aide. The Team Manager (TM), on 05/31/2024, scheduled the RN case manager and the new hospice aide [Personnel Record 22] to make a joint visit so that the RN could help introduce the new aide and supervise care for that first visit. Then, on 05/31/2024, the TM on-call was informed by the RN case manager that the daughter wanted a different aide and was okay with the aide that had been coming before the joint visit on 05/31/2024, but she did not want the aide from the joint visit [Personnel Record 22] to return. The Senior Patient Care Administrator stated that until now (07/09/2024) the TM [Personnel Record 1] and the Patient Care Administrator [Personnel Record 16] were the only members of leadership that had reviewed the service comment regarding this incident. On 07/11/2024, during an interview, the General Manager/ Administrator and the Senior Patient Care Administrator verbalized that they were not informed of the alleged abuse (as stated in agency policy) and since they were not notified, a formal investigation had not occurred, and the event was not reported to the state agency. The policy titled “(Agency name) Management Standard (policy was not numbered nor dated); Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a (agency) employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.””

“It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by taking appropriate corrective action in accordance with state law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction, such as the state survey agency or local law enforcement agency. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “(Agency name) Management Standard” Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a … employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” In 1 of 1 (100%) clinical records reviewed in which a complaint of alleged abuse was identified, the agency did not ensure adherence to policies and procedures in regard to investigation and verification of the allegations by the Administrator. Document 5: . The agency presented the document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” Clinical Record 2: The patient transferred into this agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit documented on 05/15/2024 revealed the patient was 102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds. Upon review of the agency complaint logs this patient was listed in a complaint filed on 06/01/2024 which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” On 07/09/2024, the PCA (patient care administrator; personnel record #16) confirmed knowledge of the complaint and stated, “this family has been through multiple hospices, and this is the probably the fourth aide change she has requested in two months.” When asked for the investigation the PCA stated, “the RN and aide were sent out for a joint visit and the RN did not see any problems.” This site visitor questioned if that was the full extent of the investigation and if there was any written documentation regarding the investigation. On 07/09/2024, the Senior Patient Care Administrator [Personnel Record 17] and the General Manager/Administrator [Personnel Record 21] were informed that clinical record 2 would be reviewed and that a home visit observation was requested. The Senior Patient Care Administrator presented a summary of the events as documented by the Team Manager: 05/30/2024 the RN case manager [Personnel Record 5] reported the daughter would like a different hospice aide. The Team Manager (TM), on 05/31/2024, scheduled the RN case manager and the new hospice aide [Personnel Record 22] to make a joint visit so that the RN could help introduce the new aide and supervise care for that first visit. Then, on 05/31/2024, the TM on-call was informed by the RN case manager that the daughter wanted a different aide and was okay with the aide that had been coming before the joint visit on 05/31/2024, but she did not want the aide from the joint visit [Personnel Record 22] to return. The Senior Patient Care Administrator stated that until now (07/09/2024) the TM [Personnel Record 1] and the Patient Care Administrator [Personnel Record 16] were the only members of leadership that had reviewed the service comment regarding this incident. On 07/11/2024, during an interview, the General Manager/ Administrator and the Senior Patient Care Administrator verbalized that they were not informed of the alleged abuse (as stated in agency policy) and since they were not notified, a formal investigation had not occurred, and the event was not reported to the state agency. The policy titled “(Agency name) Management Standard (policy was not numbered nor dated); Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a (agency) employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.””

“It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by: ensuring that verified violations are reported to the state and local bodies having jurisdiction (including the State Survey and Certification Agency) within five (5) working days of becoming aware of the violation. This standard was not met as evidenced by clinical record review, document review, and interview. State policy #2.11... “Administrative Policies Reporting of Abuse, Neglect and Exploitation”(Revised 08/23/2023) stated in relevant part, “State law requires health care practitioners, social workers, and clergy, and in some states, any individuals, to report all suspected or known incidents of abuse, neglect or financial exploitation (“ANE”) of children, dependent adults and elders...Policy...It is the policy of (agency) to report any instances of real or suspected ANE of a child or dependent adult/elder by a (agency) employee, volunteer, contractor, or subcontractor, regardless of payor source, to (State) Health and Human Services Commission (HHSC) at (phone number). If (agency has cause to believe that a patient has been abused, exploited or neglected by an employee of (agency), we will document the occurrence and report it within 24 hours, to the applicable licensing authorities.” In 1 of 1 (100%) clinical records reviewed in which a complaint of alleged abuse was identified, the agency did not ensure adherence to the state law and agency policies and procedures in regard to reporting the alleged violation to the state Health and Human Services Commission. Document 5: . The agency presented the document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the Administrator was notified of the alleged abuse or that an investigation in regard to the alleged abuse was completed. Clinical Record 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” On 07/09/2024, the Patient Care Administrator (PCA) [Personnel record 16] confirmed knowledge of the complaint and stated, “This family has been through multiple hospices, and this is probably the fourth aide change she has requested in two months.” When asked for the investigation, the PCA stated, “The RN and aide were sent out for a joint visit, and the RN did not see any problems.” During an interview, the PCA was asked if that was the full extent of the investigation and if there was any written documentation regarding the investigation. The agency provided the “Telehealth on-call logs” documenting that on 05/31/2024, the RN informed the Team Manager on-call that the daughter was requesting a new aide, that the Team Manager changed the aide assignment, and a different aide made the visit on 06/01/2024 and moving forward. The documentation presented did not include the daughter’s concerns about the aide being rude and allegedly causing injuries to the patient. On 07/09/2024, the Senior Patient Care Administrator [Personnel Record 17] and the General Manager/Administrator [Personnel Record 21] were informed that clinical record 2 would be reviewed and that a home visit observation was requested. The Senior Patient Care Administrator presented a summary of the events as documented by the Team Manager: 05/30/2024 the RN case manager [Personnel Record 5] reported the daughter would like a different hospice aide. The Team Manager (TM), on 05/31/2024, scheduled the RN case manager and the new hospice aide [Personnel Record 22] to make a joint visit so that the RN could help introduce the new aide and supervise care for that first visit. Then, on 05/31/2024, the TM on-call was informed by the RN case manager that the daughter wanted a different aide and was okay with the aide that had been coming before the joint visit on 05/31/2024, but she did not want the aide from the joint visit [Personnel Record 22] to return. The Senior Patient Care Administrator stated that until now (07/09/2024) the TM [Personnel Record 1] and the Patient Care Administrator [Personnel Record 16] were the only members of leadership that had reviewed the service comment regarding this incident. On 07/11/2024, during an interview, the General Manager/ Administrator and the Senior Patient Care Administrator verbalized that they were not informed of the alleged abuse (as stated in agency policy) and since they were not notified, a formal investigation had not occurred, and the event was not reported to the state’s Health and Human Services Commission. A state specific policy titled: “Administrative Policies Reporting of Abuse, Neglect and Exploitation” (Policy Number: 2:11TX, Last Revised 08/23/2023) stated in relevant part, “State law requires health care practitioners, social workers, and clergy, and in some states, any individuals, to report all suspected or known incidents of abuse, neglect or financial exploitation (“ANE”) of children, dependent adults and elders. Policy It is the policy of (agency) to report any instances of real or suspected ANE of a child or dependent adult/elder by a (agency) employee, volunteer, contractor, or subcontractor, regardless of payor source, to (State) Health and Human Services Commission (HHSC) at (phone number). If (agency has cause to believe that a patient has been abused, exploited or neglected by an employee of (agency), we will document the occurrence and report it within 24 hours, to the applicable licensing authorities.””

“It is required that the written Patient Bill of Rights includes the right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. This standards was not met as evidence by clinical record review, document review, and interview. Agency policy “(Agency name) Management Standard” Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a … employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” In 1 of 1 (100%) clinical record review in which a complaint of alleged abuse was identified, the agency did not ensure adherence to the patient’s right to be free from mistreatment, neglect, or verbal, mental, sexual, or physical abuse, including injuries of unknown source and the misappropriation of patient property. Clinical Record 2: The patient transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” An interview with the Patient Care Administrator revealed she received the information from the patient’s daughter.”

“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 33 (3%) clinical records reviewed, the agency did not ensure that the initial psychosocial and spiritual assessments were completed no later than five (5) calendar days after the patient’s election of hospice care. Clinical Record 18: The patient elected the hospice benefit on 02/13/2024 with a diagnosis of congestive heart failure. The initial nursing assessment dated 02/13/2024 documented that the patient was “oriented to person and place, made needs known, and followed directions.” The initial plan of care dated 02/13/2024 ordered the Social Worker (SW) and Chaplain (SC) to evaluate. On 02/15/2024, the SW supplemental interdisciplinary note documented, “SW attempted to contact family; however, no answer. Voicemail left. Initial assessment not completed.” A clinical record review revealed no documentation that the SW made additional attempts to contact the patient or family or that the initial psychosocial assessment was completed within five (5) calendar days of the patient’s election to hospice care. Furthermore, the SC completed the initial spiritual comprehensive assessment on 02/19/2024, with six (6) days outstanding. There was no documented reason that the visit was late. During the Chaplain visit on 02/19/2024, it was reported that the patient and family had strong support and no psychosocial needs; thus, the social work visit orders were changed to PRN (as needed). On 07/12/2024, the Senior Patient Care Administrator confirmed that there was no additional documentation to present explaining why neither the SW nor the SC completed the assessments within the 5-day requirement. The Senior Patient Care Administrator stated, “We missed it.””

“It is required that each patient’s individualized written plan of care 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 1 of 33 (3%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 18: The patient elected the hospice benefit on 02/13/2024 with a diagnosis of congestive heart failure. The nursing comprehensive assessment dated 05/01/2024 documented that the patient had “intermittent confusion, agitation, and combativeness.” The nursing comprehensive assessment dated 06/28/2024 documented the patient’s confusion, agitation, and combativeness. Additionally, the assessment documented, “care plan outcome... manage confusion, manage anxiety.” The plans of care, including the revisions dated 05/01/2024 to the present, did not identify planned interventions and goals related to the problems of confusion, anxiety, agitation, or combativeness as identified in the updated comprehensive assessments. During an interview on 07/10/2024, the Senior Patient Care Administrator reviewed the clinical record and stated, “There were medications, but the nurse did not address them (behaviors) on the care plan.””

“It is required that the hospice measures, analyzes, and tracks quality indicators of performance that enable the assessment of: adverse patient events. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Internal Reporting” stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice...Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints... Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is signed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.” In 1 of 1 (100%) clinical record review in which an adverse event related to patient safety was documented, the agency did not ensure that the patient’s injuries were included in the adverse event analysis and tracking. Document 5: The agency presented a document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024...Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the injuries/injuries of unknown origin were assessed and investigated. Clinical Record 2/Home Visit 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” The comprehensive nursing assessment dated 06/03/2024 documented a “skin tear to right forearm.” There was no bruising documented. A physician order dated 06/03/2024 included orders related to the skin tear. A home visit observation was conducted on 07/10/2024 from 1400 to 1500. Due to the patient’s condition, the patient was not able to participate in an interview, but the patient’s daughter (the complainant) and granddaughter participated. During an interview, the daughter stated that she reported the incident on 05/31/2024 to the RN in the evening following a joint aide and RN visit. The daughter presented the text message and pictures (with time stamp, dated 05/31/2024) to show what was sent to the RN the evening of 05/31/2024 (the text message thread no longer contained the time sent, only the date). The text message notification documented concerns about the aide being verbally rude and physically abusive while providing direct care to the point of causing bruises and cuts. The notification included pictures of the injuries. A review of the photographs revealed bruises to bilateral wrists and a skin tear to the right forearm. At the time of this home visit on 07/10/2024, no bruises or skin tears were visible. On 07/11/2024, the Senior Patient Care Administrator reported that no “Patient/Family/Visitor” form was available to review the documented injuries. The Senior Patient Care Administrator stated, “The RN did not complete one.” This included the injuries first reported to the nurse on 05/31/2024 via text message from the daughter; the alleged injuries of bruises and cuts described by the daughter via the telephone call/complaint reporting on 06/01/2024; and the skin tear documented on the 06/03/2024 nursing visit note. The Senior Patient Care Administrator confirmed that this incident was logged as a complaint and was tracked through QAPI (quality assessment and performance improvement) as such, but since the patient/family/visitor form was not completed related to the injuries, that data was not part of the analysis or quality tracking. Agency policy titled, “Internal Reporting” (policy was not numbered nor dated) stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice.” “Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints.” “5. Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is singed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.”

“It is required that performance improvement activities: track adverse patient events; [and] analyze the causes; and Implement preventive action and mechanisms that include feedback and learning throughout the hospice. This standard was not met as evidenced by clinical record review, document review, interview, and observation. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Internal Reporting” stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice...Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints... Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is signed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.” In 1 of 1 (100%) clinical record review in which an adverse event related to patient safety was documented, the agency did not ensure that the patient’s injuries were analyzed for cause and tracked through performance improvement activities. Document 5: The agency presented a document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the injuries/injuries of unknown origin were assessed and investigated. Clinical Record 2/Home Visit 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” The comprehensive nursing assessment dated 06/03/2024 documented a “skin tear to right forearm.” There was no bruising documented. A physician order dated 06/03/2024 included orders related to the skin tear. A home visit observation was conducted on 07/10/2024 from 1400 to 1500. Due to the patient’s condition, the patient was not able to participate in an interview, but the patient’s daughter (the complainant) and granddaughter participated. During an interview, the daughter stated that she reported the incident on 05/31/2024 to the RN in the evening following a joint aide and RN visit. The daughter presented the text message and pictures (with time stamp, dated 05/31/2024) to show what was sent to the RN the evening of 05/31/2024 (the text message thread no longer contained the time sent only the date). The text message notification documented concerns about the aide being verbally rude and physically abusive while providing direct care to the point of causing bruises and cuts. The notification included pictures of the injuries. A review of the photographs revealed bruises to bilateral wrists and a skin tear to the right forearm. At the time of this home visit on 07/10/2024, no bruises or skin tears were visible. On 07/11/2024, the Senior Patient Care Administrator reported that no “Patient/Family/Visitor” form was available to review the documented injuries. The Senior Patient Care Administrator stated, “The RN did not complete one.” This included the injuries first reported to the nurse on 05/31/2024 via text message from the daughter; the alleged injuries of bruises and cuts described by the daughter via the telephone call/complaint reporting on 06/01/2024; and the skin tear documented on the 06/03/2024 nursing visit note. The Senior Patient Care Administrator confirmed that this incident was logged as a complaint and was tracked through QAPI (quality assessment and performance improvement) as such, but since the patient/family/visitor form was not completed related to the injuries, that data was not part of the analysis or quality tracking. Agency policy titled, “Internal Reporting” (policy was not numbered nor dated) stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice.” “Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints.” “5. Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is singed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.”

“It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). Addresses efforts and sets priorities for improved quality of care and patient safety, and ensures all improvement actions are evaluated for effectiveness. This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy “Internal Reporting” stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice...Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints... Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is signed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.” In 1 of 1 (100%) clinical record review in which an adverse event related to patient safety was documented, the agency did not ensure an investigation was conducted to determine the cause of the injuries and implement measures to improve quality of care and patient safety. Document 5: The agency presented a document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the injuries/injuries of unknown origin were assessed and investigated. Clinical Record 2/Home Visit 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” The comprehensive nursing assessment dated 06/03/2024 documented a “skin tear to right forearm.” There was no bruising documented. A physician order dated 06/03/2024 included orders related to the skin tear. A home visit observation was conducted on 07/10/2024 from 1400 to 1500. Due to the patient’s condition, the patient was not able to participate in an interview, but the patient’s daughter (the complainant) and granddaughter participated. During an interview, the daughter stated that she reported the incident on 05/31/2024 to the RN in the evening following a joint aide and RN visit. The daughter presented the text message and pictures (with time stamp, dated 05/31/2024) to show what was sent to the RN the evening of 05/31/2024 (the text message thread no longer contained the time sent only the date). The text message notification documented concerns about the aide being verbally rude and physically abusive while providing direct care to the point of causing bruises and cuts. The notification included pictures of the injuries. A review of the photographs revealed bruises to bilateral wrists and a skin tear to the right forearm. At the time of this home visit on 07/10/2024, no bruises or skin tears were visible. On 07/11/2024, the Senior Patient Care Administrator reported that there was no “Patient/Family/Visitor” form available for review of the documented injuries. The Senior Patient Care Administrator stated, “The RN did not complete one.” This included the injuries first reported to the nurse on 05/31/2024 via text message from the daughter to the nurse; the alleged injuries of bruises and cuts described by the daughter via the telephone call/complaint reporting on 06/01/2024; and the skin tear documented on the 06/03/2024 nursing visit note. The Senior Patient Care Administrator confirmed that patient injuries are considered an adverse event, and a form should have been completed. It was also confirmed that the injuries reported on 05/31/2024 were first documented as being assessed on 06/03/2024. Agency policy titled, “Internal Reporting” (policy was not numbered nor dated) stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice.” “Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints.” “5. Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is singed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.”

“It is required that the management and governance of the hospice is responsible to provide care that: optimizes comfort and dignity; [and] is consistent with patient and family needs and goals, with the patient’s needs and goals as priority. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “(Agency name) Management Standard” Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a … employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” Agency policy “Internal Reporting” stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice...Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints... Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is signed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.” In 1 of 1 (100%) clinical record review in which a patient’s safety needs were identified, the agency did not ensure that management followed policies and procedures consistent with meeting the patient’s needs. Document 5: . The agency presented the document titled “Service Comment,” which reported the 06/01/2024 complaint and documented the following: “06/03/2024 Action: Acknowledge (complainant) concerns; she (daughter) accepted apology very pleasant to speak with very thankful of the call. We talked for an extensive time. (Signed by: Home Care Team Manager)….Was the issue resolved in 5 business days? Yes….Issue Resolved Date: 06/03/2024….Complainant verbalized satisfaction with resolution: Yes….Describe: A new aide assigned from the facility family is very pleased with her care….Final review by (Patient Care Administrator) 06/24/2024.” The “Service Comment” document did not include documentation that the injuries/injuries of unknown origin were assessed and investigated. Clinical Record 2: The patient was transferred to this hospice agency on 05/14/2024 with a terminal diagnosis of cerebral atherosclerosis. A face-to-face visit on 05/15/2024 documented that the patient was “102 years old, weighed 100 pounds, and had fragile skin; there were no documented wounds.” A review of the agency’s complaint logs revealed this patient was listed in a complaint filed on 06/01/2024, which stated, “(Daughter) called requesting to switch teams or be reassigned to a different aide. HHA (home health aide) was rough with pt (patient) and not kind to the point where pt sustained bruises and cuts on arms.” The comprehensive nursing assessment dated 06/03/2024 documented a “skin tear to right forearm.” There was no bruising documented. A physician order dated 06/03/2024 included orders related to the skin tear. On 07/11/2024, during an interview, the General Manager/ Administrator and the Senior Patient Care Administrator verbalized that they were not informed of the alleged abuse (as stated in agency policy) and since they were not notified, a formal investigation had not occurred, and the event was not reported to the state agency. The Senior Patient Care Administrator also reported on 07/11/2024 that the Patient/Family/Visitor form related to the injuries was not completed per policy. Thus, members of senior leadership were unable to investigate or track the incident through QAPI. The policy titled “(Agency name) Management Standard (policy was not numbered nor dated); Section 5. Suspected Abuse by (Agency name) Employee” stated in relevant part, “If there are patient complaints and alleged or real violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by a (agency) employee, regulatory requirements include: 1. All patient complaints and alleged or real violations included must be reported immediately to the hospice administrator and should be investigated, resolved and documented. “Immediately” means as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement.” And The agency policy titled, “Internal Reporting” (policy was not numbered nor dated) stated in relevant parts, “418.58 Quality Assessment and Performance Improvement - Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice.” “Considerations: f. All incidents involving employees, patients and families should be reported immediately to the employee’s manager including: iii. injury and non-injury incidents and accidents vi. Patient, family, and provider complaints.” “5. Patient/Family/Visitor incidents a. All patient/family/visitor incidents will be reported and documented i. Reported to employee manager within one hour of knowledge of incident ii. Documented on the Patient/Family/Visitor Report Form within 24 hours of knowledge of the incident 1. The form is singed by the employee and submitted to their manager 2. The manager will review and sign, submit to senior management who will also review and sign.”