Cardinal Hospice

“Based on record review and interview, the agency failed to report that verified violations are reported to the State within 24 hours of becoming aware of the violation in that: The agency became aware that CNA A had neglected 2 of 7 (Pt #7 and Pt #8) patients by not providing scheduled visits whose charts that were reviewed. This failure had the potential to delay regulatory oversight and the implementation of actions necessary to protect patients from neglect. Findings included: Review of TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self- reported incidents on home health agencies for the State of Texas) on 6/15/2026, revealed no self-reported incidents regarding Pt #7 or Pt #8 were received by the date of entrance survey on 6/16/2026. Record review of CNA A, employee file contained a hire date 6/12/2025. NAR/EMR and background checks were completed on 6/10/2025. Further review of the employee file revealed a form titled “Counseling Form” dated 6/4/2026. Included in this form was a section titled “Identified area needing improvement and/or incident/problem area including time:”. The description under this section included the following details: “On 5/11/2026 concerns were raised regarding the completion of scheduled [Pt #7] visits after a family chose to transfer services due to reports that the hospice aide may have not been present as scheduled…”. “On 5/29/2026, additional concerns were reported [by facility staff] regarding the appearance of [Pt #8] at [facility name]. A review of facility sign-in logs again revealed non-compliance with required sign in procedures. Pt #8 was scheduled to receive five visits per week, but records indicated that the aide had not signed in since 5/26/2026”. Review of Pt #7 clinical record revealed a plan of care date 12/12/2025 and a diagnosis of dementia (a brain problem that causes decline in memory, thinking, and reasoning). The client was ordered to receive 1 skilled nursing visit per week and 6 hospice aide visits per week. Tasks assigned to the hospice aide included: clothing assist, complete bed bath, foot care, nail care, oral care, partial bed bath, perineal care, shampoo, shower, and skin care. Review of Pt #8 clinical record revealed a plan of care date 12/28/2025 and diagnosis of vascular dementia (a decline in thinking and memory caused by blocked or reduced blood flow to the brain). The patient was ordered to receive 1 skilled nursing visit per week and 2 hospice aide visits per week. Tasks assigned to the hospice aide included: clothing assist, complete bed bath, denture care, foot care, nail care, oral care, shampoo, show, skin care. A phone interview was conducted with CNA A on 6/22/2026 at 12:41 PM. CNA A was asked what she remembered about the incidents listed in her employee file. Per CNA A, she was counseled on the policy regarding signing in and out of the agency during client visits. CNA A stated that for Pt #7, she was unable to locate and sign the book designated by the facility because it was locked away and she was unable to obtain it. For Pt #8, she stated that she didn’t have a pen available to sign the book. CNA A stated that she completed all the visits but could not document the visits per the agency policy. An interview was conducted with DON on 6/22/2026 at 1:15 PM. DON was asked about the incident listed in CNA A’s personnel file. DON stated that CNA A had been with the agency since it opened and that she did not believe that CNA A was missing visits but that she just forgot to sign in to the visits for Pt #7 and Pt #8. Surveyor asked what the agency did to investigate the complaints made by family members for Pt #7 and facility staff for Pt #8. DON stated that they spoke with CNA A and counseled her on signing in and out of her visits on the facility logs. DON stated that some patients have cameras in their room so they would know for sure if their staff was not attending the required visits. Surveyor asked DON if either of the patients listed on the disciplinary documents in the employee file had cameras that they reviewed. DON stated that neither Pt #7 or Pt #8 had a camera in their room. A joint conference with Admin and DON was conducted on 6/22/2026 at 2:15 PM. Surveyor asked why the incidents listed in CNA A’s employee file were not called into the state when the agency became aware of the complaint regarding missed visits. DON stated that she did not believe that the visits were being missed and that it was an issue with the log not being signed. Admin stated that he did not know it was something that should have been called into the state. Both DON and Admin stated that an internal investigation was completed and CNA A was issued a final written warning after the complaint regarding the conditions of patients’s clothing was made by facility staff regarding Pt #8. Admin admitted responsibility for calling in complaints to the state and verbalized understanding of the requirement to report any suspicion of potential abuse, neglect, or exploitation. Review of agency policy titled “Abuse, Neglect, and Exploitation” last reviewed 02/22/2024, read in part, “…hospice management will... report if there is cause to believe abuse, neglect, or exploitation of a patient has occurred by a staff member, immediately… cause to believe is defined as a Hospice or individual knows or suspects, or receives an allegation regarding abuse, neglect, or exploitation…Report all alleged ANE to Complaint Intake and Investigation (a formal process agencies use to receive, evaluate, and resolve grievances).”

“Based on observation, record review and interview, the hospice failed to include in the written agreement with the skilled nursing facility, the delineation of the hospice’s responsibilities that included; medical direction and management of the client; nursing, counseling, including spiritual, dietary, and bereavement counseling; social work, medical supplies, durable medical equipment; drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that would be necessary for the care of the patients’ terminal illness and related conditions in that the hospice did not specify the care that the hospice was to provide or the care the facility was to provide for Patient #6, other than administering medications for 1 (Patient #6) of 3 home visits to patients. The failure placed the patients at risk of omission of care or delayed care due to confusion of the facility/hospice’s responsibilities, which could result in poor symptom control. Patient #6:Record review of Patient #6’s clinical record revealed an Interdisciplinary Comprehensive Assessment dated 2/19/2026. The Comprehensive Assessment indicated that Patient #6 started on the hospice’s services on 4/26/2025. The Comprehensive Assessment listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. The Comprehensive Assessment listed Atherosclerotic Heart Disease of Native Coronary Artery (buildup of fat, cholesterol, and calcium inside the arteries, narrowing the arteries and reducing blow flow to the heart muscle), History of Falling, and Unspecified Atrial Fibrillation (abnormal fast and irregular heart rhythm) as secondary diagnoses. The Plan of Care did not identify which provider, hospice or facility, would be responsible for performing functions included in the plan of care except that the facility would administer medications and the “Facility provides care.” Patient #6’s clinical record did not contain a delineation of the hospice responsibilities. Patient #6 lived at Skilled Nursing Facility X. A home visit and concurrent interviews were conducted on 4/9/2026 at 8:30 AM at Skilled Nursing Facility X. The surveyor observed Registered Nurse H conduct a skilled nurse visit with Patient #6. The surveyor observed a skin tear to Patient #6’s left hand. Registered Nurse H and the facility nurse discussed Patient #6’s skin tear. Registered Nurse H told the facility nurse that Registered Nurse H would fax over the physician’s order for the wound care. The surveyor reviewed Patient #6’s hospice record at Skilled Nursing Facility X. Patient #6’s hospice record at the facility did not contain a delineation of hospice responsibilities. The surveyor spoke with Receptionist Y, looking for Skilled Nursing Facility Director of Nursing. Receptionist Y informed the surveyor that the Director of Nursing was in a meeting, but Receptionist Y could text the Director of Nursing. Receptionist Y texted the Director of Nursing that the surveyor was requesting to see the delineation of duties between the hospice and Skilled Nursing Facility. Receptionist Y informed the surveyor that the Director of Nursing texted back. Receptionist Y informed the surveyor that the Director of Nursing had texted back that the delineation of duties would be in the hospice record at the nursing station. Patient #6’s facility hospice record contained a plan of care that did not specify the care that the facility was to provide except for administering medications. During an interview on 4/10/2026 at 10:58 AM with the Administrator and the Alternate Administrator/Supervising Nurse, the surveyor discussed the delineation of duties for Patient #6. The Administrator informed the surveyor that the hospice used the Interdisciplinary Group documentation and care plans for the delineation. The Administrator stated, “We supply wound care supplies. We didn’t know about that (delineation of duties). We have worked in long term care, I haven’t seen one of them.” Patient #6’s Plan of Care did not identify the care and services that were specifically needed and did not identify which provider was responsible for performing the respective functions that had been agreed upon.Review of the agency’s policy titled “Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Intermediate Facility for the Intellectually and Developmentally Disabled) PC. 125,” last reviewed on 11/22/2024, read in part; “Purpose To describe the process for proving hospice care to residents of a Skilled Nursing Facility/Nursing Facility (SNF/NF) or Intermediate Care Facility or Intermediate Facility for the Intellectually and Developmentally Disabled (ICF/IID). Policy I. The Hospice and the facility will have a legally written binding contract/agreement in place defining the provision of hospice services...Procedure...III. A Hospice POC (plan of care) will be developed based on the patient/family’s needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or the family, and the attending physician. A copy of the POC, which includes services furnished, will be provided to the facility. A. The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC...””