Faith Presbyterian Hospice

“Based on record reviews and interviews, the Hospice Agency failed to ensure the patient had the right to voice grievances regarding treatment or care that is or fails to be furnished for 1 (Patient 1) of 8 active and discharged records reviewed. The failure of the Hospice Agency to address, document and investigate the complaint received by family members of Patient 1 potentially resulted in a delay in hospice services, interventions and treatments which placed the patient at risk for increased pain, discomfort and emotional distress. Findings:Review of the Health and Human Services Commission Complaint and Incident Intake in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed intake 1053563 received on 12/02/2025. The intake documented the complainant’s statement that on 11/27/2025 (Thanksgiving Day) Patient 1 who was actively dying was transported from the hospital to the patient’s home around 3:30pm and the complainant had been informed a Hospice Admission Nurse would arrive at 4:45pm. The complainant reported that no one showed up to the patient’s home and around 8 pm on 11/27/2025 the complainant received a call from the agency that there was a miscommunication, and an admission nurse would be at the home on 11/28/2025 at 8:25am. The complainant reported on 11/28/2025 at 8:25am no one from the agency showed up at the home and the complainant called the agency multiple times and spoke to an agency Supervisor. The complainant reported that the Hospice Admission nurse arrived to Patient 1’s home on 11/28/2025 at 10:00am and did not submit the medications to the pharmacy until 12:00pm which included Hydromorphone (opioid pain medication used to treat moderate to severe pain) Lorazepam (medication used to treat anxiety), Haloperidol (medication used to treat agitation combative behaviors, nausea and vomiting), Promethazine (medication used to treat nausea), Ondansetron (medication used to treat nausea and vomiting), Acetaminophen (medication used to treat mild pain or fever) and Oxygen (supplemental oxygen that is supplied from oxygen portable tanks or an oxygen concentrator machine) and Patient 1 was in severe pain during that time. The complainant reported that the Admission Nurse told him the medications would arrive in 3 to 5 hours. The complainant reported on 11/28/2025 at 4:45pm he called the agency to ask when the medications would arrive, and the agency transferred him to the Hospice Admission Nurse. The complainant reported that the Admission Nurse stated she would call the office and then call the complainant back. The complainant stated the Admission Nurse never called back. The complainant stated he received a call from an agency supervisor on 11/28/2025 around 5:45pm who stated the doctor did not submit the medication orders and it would take an additional 3 hours for the medications to arrive. The complainant reported Patient 1 died on 11/28/2025 at 7:32pm without any medications or oxygen and the medications arrived on 11/28/2025 at 8:29pm. The complainant reported he was notified by a female nurse that the contracted equipment company would arrive on 12/01/2025 between 12pm and 4pm to pick up the equipment and the equipment company did not show up. The complainant reported he contacted the contracted equipment company directly and they stated the hospice agency never notified them. The complainant stated he arranged equipment pickup for 12/02/2025 between 12pm and 3 pm.An entrance conference was conducted on 12/4/2025 at 11:10am with the Hospice Agency’s Director of Operations, Patient Care Managers (PCM 1 and 2) and the Corporate Compliance Nurse (via phone conference). The DOO stated the agency was actively trying to fill the positions of Administrator, Alternate Administrator and Supervising Nurse after the resignations of the Administrator on 11/24/2024, the Alternate Administrator on 11/21/2025 and the Supervising Nurse on 11/21/2025. The DOO stated effective 12/4/2025 PCM 1 was the interim Administrator, the Corporate Compliance Nurse was the interim Alternate Administrator, PCM 2 was the interim Supervising Nurse, and PCM 3 was the Alternate Supervising Nurse. When asked about the agency’s complaint log binder, the Corporate Compliance Nurse stated that the agency’s complaint logs were located “online” and she would email the surveyor the requested complaint logs. Record review of the undated complaint log spread sheet for 2025 received via email from the Corporate Compliance Nurse on 12/4/2025 at 2:02pm, revealed no documentation of a complaint received for Patient 1. Record review of Patient 1 revealed the “Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment” documents signed on 11/27/2025 (Thanksgiving Day) by the hospice agency’s Clinical Liaison and Patient 1’s Family Member #4. The consents contained a “Date Care will Start” of “11/27/2025.”Record review of Patient 1 in the agency’s EMR system, revealed a plan of care with “Effective Date of 11/28/25.” The POC contained information pulled from the SOC visit dated “11/28/25” and signed by RN A. The POC contained an admitting diagnosis of “Malignant neoplasm (abnormal growth of cells that can form a tumor which can spread to other parts of the body. Tumors can affect the function of the organ by pressing on or destroying healthy tissues resulting in pain and inflammation) of Tongue” and a hospice nurse frequency of “1 visit(s) 1 times.” The POC contained a “Problem” statement of “Initial Plan of Care prior to Service Provision” and a “Goal” of “Admission and Initial Plan of Care will be established within 24 hours.” The POC also contained a “Problem” statement of “Presence of pain, either verbalized or non-verbal indicators assessed…” and a “Goal” of “Patient will remain free of non-verbal signs of pain, such as moaning/grimacing, within 24 hours of medication administration.” The POC contained orders for “Fentanyl (powerful opioid medication to treat moderate to severe pain), Hydrocodone (opioid medication used for moderate to severe pain) / Acetaminophen, Haloperidol, Lorazepam, Gabapentin (medication that calms over active nerves and is used to treat nerve pain), Bisacodyl (medication used to treat constipation), hydromorphone (powerful opioid used to treat moderate to severe pain), Hyoscyamine Sulfate (medication used to dry up excessive oral secretions and mucus to help keep the dying patient more comfortable)” and “Oxygen.”Record review of Patient 1 in the agency’s EMR system, revealed a SOC admission completed by RN A on 11/28/2025 with a visit start time of 10:00 AM and out time of 1:00 PM. RN A documented in the SOC visit that Patient 1’s pain was “Severe” with a pain level of “8” out of 10. RN A documented Patient 1’s pain location as “Generalized,” severity “Severe,” character “Aching,” duration “Constant,” frequency “Constant,” pain relieved by “Opioids,” pain is worsened by “Movement,” and effect on function/quality of life “Yes.” RN A documented that Patient 1’s “Shortness of breath” was “Severe” with a shortness of breath level of “9” out of 10. RN A documented that treatment for shortness of breath was initiated on “11/28/25” which included “Opioids” and “Oxygen.” RN A documented in the nurse summary notes that Patient 1 was “currently taking only sips of water,” pain was poorly controlled and he received IV (a small tube is inserted into a vein in which medication can be administered directly into the bloodstream) Morphine (opioid pain medication given for moderate to severe pain) at the hospital. RN A documented at home Patient 1 had been taking Hydrocodone (opioid pain medication used to treat moderate to severe pain)/Acetaminophen (medication used to treat mild pain and fever) liquid and used a Fentanyl patch (an adhesive patch that is applied to the skin that delivers the powerful opioid pain medication through the skin into the bloodstream) …He has a PEG (a flexible feeding tube inserted through the abdominal wall directly into the stomach for long term delivery of food, fluids and medications) tube in place but is currently refusing tube feedings.” Under the patient/family teaching and learning section of the SOC visit, RN A checked the boxes for pain management techniques, oxygen use and safety, comfort measures, comfort kit usage, hospice program, levels of hospice care, plan of care, call hospice for condition change and how and when to call the hospice nurse.Record review of Patient 1 revealed a coordination note dated 11/27/2025 with a “time of event” of “11:32 AM” signed by the triage nurse (a registered nurse who addresses the hospice agency’s after hour incoming calls and patient needs) RN B. The RN documented that the DME (reusable medical devices or equipment prescribed by the doctor for patients’ home use) company called to request Patient 1’s “oxygen liter flow (the rate at which supplemental oxygen is delivered to the patient)” RN B documented that she spoke to PCM 2 and was “notified to order a 2–5-liter flow for PRN oxygen.” RN B documented that the employee of the DME company stated, “Someone ordered a 10-liter concentrator (medical device that provides concentrated oxygen to the patient), shall we still send that concentrator?” RN B documented that the DME company employee was informed to send the 10-liter concentrator.” Further review of the agency’s EMR system did not contain any additional coordination notes or documentation explaining the reason why Patient 1 was not admitted onto Hospice on 11/27/2025 upon discharge from the hospital. Record review of Patient 1 revealed a visit note dated 11/28/2025 with a visit time of 8:25pm signed by RN C. The RN documented “Visit made to pronounce death. Family at the bedside. All grieving appropriately.” The visit note did not contain any additional information. Record review of the agency’s answering service call logs provided by the interim Adm on 12/5/2025 revealed the first call regarding Patient 1 was received from the DME company on 11/27/2025 at 11:23 AM regarding the oxygen liter flow. The second call received for Patient 1 was received from Family Member #4 on 11/27/2025 at 4:35 PM. The documentation of the call read “Need help setting up all his (Patient 1’s) equipment and oxygen ASAP. Please call me (Family Member #4) back with ETA for when the nurse will be here (Patient 1’s home).” The answering service documented that a text message was sent to the triage nurse RN B on 11/27/2025 at 4:33 PM and 4:52 PM with no response. The answering service documented a text message was sent to on call nurse RN D at 5:12 PM and 5:31 PM. The answering service documented that Family Member #4 confirmed a return call from one of the agency’s RNs at 5:47 PM. The third call documented by the answering service was received from Family Member #5 on 11/28/2025 at 5:25pm which read ““He (Patient 1) went on hospice at 3pm, no one ever showed up. Someone was supposed to be here at 8:15am and they instead came at 10am. I was told the meds would be here today within 3-5 hours from the time the order was placed, which was at 12pm. I called at 4:45pm and spoke with” RN A “and she said she would call us back to give an ETA for the meds, but no one has called us back yet.” The answering service documented that they texted RN C at 5:25 PM and 5:44 PM. The answering service documented at 6:23 PM Family Member #5 confirmed he received a call back from one of the agency’s nurses. The next call received by the answering service on Patient 1 was received from Family Member #6 on 11/28/2025 at 7:36 PM that Patient 1 “passed (died).” The answering service texted RN C at 7:36 PM and confirmed a call back from the agency nurse to Family Member #6 at 7:56 PM. Record review of the triage on call report for date 11/27/2025 received via email from the interim Adm on 12/08/2025 contained triage nurse RN B’s documentation of the calls for Patient 1 on 11/27/2025. The on-call report documented a call at 11:32 AM from the DME company regarding the “oxygen flow rate,” and a call received at 4:47 PM which stated Patient 1’s “referral. Need assistance with setting up equipment and oxygen ASAP. Admission department will need to follow up with this please.” The email was sent to the agency’s “Clinical Teammates” group on 11/27/2025 at 6:07pm. Record review of the triage on call report for date 11/28/2025 received via email from the interim Adm on 12/08/2025 contained triage nurse RN C’s documentation of the calls received for Patient 1 on 11/28/2025. The on-call report read, Patient 1 at 5:25 PM Family Member #5 “called to inquire about delivery of comfort medications” at 5:27 PM Family Member #7 “called and voiced they have not received medications.” RN C documented in the report that she spoke to Family Member #7 and informed her that RN C would contact PCM 2. RN C documented she followed up with PCM 2” to inquire if the medications had been ordered for delivery as none were listed” in the agency’s EMR system. RN C documented a call was received at 7:36pm from Family Member #6 that Patient 1 “expired (died).” RN C documented she went to Patient 1’s home and pronounced the time of death at 8:29 PM. RN C documented “Family request equipment be picked up on Monday (12/1/2025) afternoon.” The email was sent to the agency’s “Clinical Teammates” group on 11/29/2025 at 7:59 AM. Record review of an email dated 12/1/2025 at 12:32pm received from the Clinical Liaison on 12/10/2025 read in part “Subject” Patient 1’s “equipment pick up and feedback. Please verify equipment pick up today. Last night they (Patient 1’s family) were told equipment would be picked up by noon today (12/1/2025). No one (from the DME company) has called or come out. Family is upset and said “we (Patient 1’s family) have not been happy about our (the agency’s) service”. It would be nice if someone in management can call and speak with” Family Member #5.Record review of the emailed text messages dated 12/1/2025 at 1:22pm received from the Clinical Liaison on 12/10/2025 contained Family Member #5’s phone number as the recipient of the text messages. The message from the Clinical Liaison to Family Member #5 read “I have called my supervisor, and she is calling the equipment company and calling you with an answer.” Response from Family Member #5 “Thank you.” Response from the Clinical Liaison “You are very welcome. I am sorry for the bad experience with my company.” Response from Family Member #5 “Thank you-you were great but unfortunately the nurse never showed up on Thursday (11/27/2025)/ then her supervisor contacted us and said she (the admission nurse) would arrive at 8:15 (am) but she arrived at 10 (am). She (RN A) ordered the medications at noon and said 3-5 hours. Medicine never showed up. I called at 4:45 (pm) and she (RN A) said she would check on it (ordered medications). Never heard back. Called back at 5:15 (pm) and got the answering service. Finally got a call at 6 (pm) from on call nurse and said meds were just ordered and would arrive within 3 hours. He (Patient 1) died at 7:32 (pm). Thank god we had some extra hydrocodone, or he (Patient 1) would have had nothing. It was an epic failure on your company’s part. However- you (Clinical Liaison) were great. I just heard from” the Director of Business Development “Thank you for helping me.”Record review of a text message showed to the surveyor on 12/9/2025 by PCM #3 revealed a text message from RN D dated 11/27/2025 at 5:52pm which read “Spoke with” Family Member #4 “Equipment (oxygen equipment) sorted. She would rather have someone come in the morning” to complete Patient 1’s Hospice admission.An interview was conducted on 12/5/2025 at 11:48 am with the interim Adm. When asked about the agency’s triaging of after hour calls regarding the agency’s patients, The Adm stated the agency’s contracted answering service received the after-hour calls and text messaged the triage or on call nurses. When asked about the number of on call nurses available after hours, the interim Adm stated “Monday through Friday there are two on call nurses. One takes the calls, and one goes out for visits. Sometimes we will have an extra staff nurse available.” When asked about the agency’s policy and procedures on the coordination for a patient discharge from the hospital and admission to hospice. The interim Adm stated the agency tried “to schedule the time (of a patient discharge) with the hospital, so we (agency nurses) can be there when the patient arrives home. There were times when the hospital does not notify us (the agency) that the patient is discharged or that transport has been arranged. In that instance we (agency nurses) have to adjust our schedules.” When asked about the agency’s process of scheduling DME and comfort medications (medications for pain, anxiety, nausea/vomiting, increased secretions, fever and constipation) on a rapidly declining patient prior to discharging from the hospital. The interim Adm stated, one of the agency’s “admission team” staff (clinical liaison, social worker or admission nurse) meets with the patient and patient’s family at the hospital to “complete consents (Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment).” The interim Adm stated once the consents are completed the agency orders the “DME (medical equipment)” and can also order a comfort kit to be delivered to the patient’s home prior to discharge. When asked about the physician on call rotation to authorize controlled pain medications (opioid pain medications with a high potential for abuse, dependence, or addiction that is regulated by the government) through the agency’s electronic prescribing system. The interim Adm stated the agency had 3 doctors that were in the on-call rotation that sent the authorizations for controlled pain medications. The interim Adm stated one of the doctors left employment with the agency on 11/30/2025. When asked about the agency’s contracted pharmacy services. The interim Adm stated medication orders were sent to Pharmacy Contractor #8 who primarily used Pharmacy #9 to fill the patients’ medications. The interim Adm stated Pharmacy #9 delivered the medications to the patient’s home and “sometimes the family will pick it (the medication) up” from the pharmacy upon the patient’s or patient’s family’s request. The interim Adm stated the agency nurses called Pharmacy Contractor #8 “directly” to order patients’ medications or ordered the medications “online.” The interim Adm stated Pharmacy Contractor #8 then sent the medication request to a Pharmacy #9 located near the patient’s home. The interim Adm stated if the local Pharmacy #9 does not have the medication available, Pharmacy Contractor #8 sends the medication order to another local contracted pharmacy. The interim Adm stated Pharmacy Contractor #8 had a mail order service in which new medications or urgent orders are delivered “next day” and “refills in 2-3 days.” When asked if medications can be ordered “STAT (immediately).” The interim Adm stated “Yes” and STAT order delivery time frames were “3 to 4 hours.” When asked about the process of doctor notification when the electronic prescription authorization for controlled pain medications had not been received by the doctor. The interim Adm stated, Pharmacy Contractor #8 notified the nurse when the authorization had not been received by the doctor. The interim Adm stated the agency nurses then followed up with the doctor on the electronic prescription authorization.An interview was conducted with Family Members #4 and #5 during a home visit on 12/5/2025 at 3:35 PM. When asked about the incident that occurred on 11/27/2025, Family Member #4 stated that the agency’s Clinical Liaison met with her at the hospital “around 10 AM” on 11/27/2025 and Family Member #4 signed the Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment for Patient 1. Family Member #4 stated the Clinical Liaison had informed her that a nurse from the agency “would be here (at patient’s home) at 4pm.” Family Member #5 stated he was not at the hospital when the consents were signed. Family Member #4 stated the equipment had arrived “around 2:30 pm on Thanksgiving day (11/27/2025)” prior to the patient’s discharge from the hospital. Family Member #4 stated she was told by the hospital that the patient “needed 15 liters of oxygen.” Family Member #4 stated the DME company notified the hospice of the need for an additional oxygen concentrator which was provided by the DME company. Family Member #4 stated Patient 1 was discharged from the hospital at approximately “3pm” and arrived home at approximately “3:45pm.” Family Member #4 stated she called the hospice agency after 4pm and asked for assistance on setting up the patient’s oxygen equipment and inquired on the ETA of the admission nurse. Family Member #5 stated “no one (from the agency) called back after the first call.” Family Member #5 stated the answering service called “every 15 to 20 minutes” to follow up on a call back from the hospice agency’s on call staff. Family Member #5 stated they received a call “from a supervisor” at approximately “6:30pm.” When asked for the name of the supervisor, Family Member #5 stated “He refused to tell me his name.” Family Member #5 stated the supervisor told him “There was a mix up in the scheduling and a nurse would not be able to come out until 8:30 am the next morning (11/28/2025).” Family Member #5 stated, RN A “did not show up until 10am.” Family Member #4 stated RN A was at the home for approximately “3 hours.” When asked about the pain medications Patient 1 was receiving prior to the hospice admission, Family Member #4 stated “he (Patient 1) was receiving 2 to 4 milligrams of morphine (opioid pain medication for moderate to severe pain) in the hospital in addition to the fentanyl patch the hospital put on him that day and it wasn’t touching his pain.” Family Member #4 stated RN A told her Hydromorphone was ordered and would take “3 to 5 hours to arrive.” When asked when RN A ordered the medications. Family Member #5 stated around “noon” on 11/28/2025 while RN A was present at the patient’s home. When asked if RN A provided any education to the family on the pain medications ordered and educated the family on pain management and interventions. Family Member #4 stated, “she (RN A) knew I was a nurse and only told me that she was ordering” Hydromorphone. When asked if Patient 1 received any pain medications prior to his death, Family Member #4 stated Patient 1 was given Hydrocodone/ Acetaminophen liquid for pain. Family Member #5 stated when he called to follow up on the ETA of the pain medication after 5pm on 11/28/2025, he received a call from “the supervisor (the supervisor’s name provided by Family Member #5 was not on the agency’s active employee roster).” Family Member #5 stated the supervisor told him that there was a “mix up” and the “doctor had not signed off on the medication.” Family Member #5 stated he was told that the medication would take an additional “2 to 3 hours” to arrive. Family Member #4 stated Patient 1 “passed at 7:32pm” and the medication arrived at “8:35pm.” When asked if the family was given the option to pick up the medication from the pharmacy. Family Member #5 stated “we asked if we could pick it (the medications) up.” Family Member #5 stated RN A told the family the medication had to be ordered from “compounding pharmacies (pharmacies that customize medications, turning pills into liquids, creams or gels)” and picking up the medication was not an option. Family Member #5 stated “we were surprised when the medication was delivered from” Pharmacy #9. We could have picked it up.” Family Member #5 stated the hospice services received by the agency “was a complete failure. They (the hospice agency) are supposed to provide comfort” to the patient. A phone interview was conducted with the Corporate Compliance Officer for Pharmacy Contractor #8 on 12/5/2025 at 4:07pm. When asked about the date and time the medication orders were received for Patient 1. The Corporate Compliance Officer stated, “All that I can tell you is” Pharmacy Contractor #8 received the medication orders for Patient 1 at “4:43pm central time” on 11/28/2025 and the patient “received the medication at 8:31pm.” When asked about the medication ordering process, the Corporate Compliance Officer stated that the nurse entered the physician ordered medications into the agency’s EMR system and the medication orders were sent to Pharmacy Contractor #8. The Corporate Compliance Officer stated for controlled medications, authorizations were sent by the hospice doctor through “an electronic prescribing system.” The Corporate Compliance Officer stated once the order is received “our system helps the agency locate a local pharmacy that delivers the medication to the patient.” The Corporate Compliance Officer stated any additional information that the surveyor needed would have to be obtained from the agency’s Administrator. A phone interview was conducted with RN A on 12/9/2025 at 12:37pm. When asked about the agency’s policy and processes on hospice admissions RN A stated, “I or a clinical liaison or community liaison will do their (the patient’s) DC planning and consents while the patient was in the hospital. When they’re (the patients are) discharged home our supervisor or the admissions manager will schedule one of us to meet them (the patient/family) at the home. About an hour after discharge, we meet them (patient and family) at home and that’s when we start the home admission. “When asked about the patient/family education and patient interventions provided during the admission process. RN A stated, “I will go over the admission packet. I will explain what Hospice is… I go over the medications and call the medications into the pharmacy… I also go over the equipment with them and what they need. I go ahead and order the DME needed. By the time I’m leaving the house they (patients and families) know what to expect from us (the hospice agency). When asked if pain medications or a comfort kit was ordered and delivered prior to a patient’s discharge from the hospital, if the patient is experiencing pain or is declining rapidly. RN A stated “we try to coordinate medication delivery. We want them (patients) not to be in pain.” RN A stated pain medication orders can be sent to the pharmacy and delivered prior to a patient’s discharge if a hospice nurse completed the admission consents in the hospital. RN A stated, “I have had circumstances with ordering the medication (prior to the patient’s discharge from the hospital) and it was delivered late by the pharmacy because of a delay in authorization from” Pharmacy Contractor #8. RN A stated “Sometimes ordering medication for a patient before they are admitted to hospice works, sometimes it does not work. In that case we order the medication during the admission when the patient is home.” When asked if the patient’s family were given the option to pick up the medication if it is urgently needed, RN A stated, “yes that’s an option we (the agency nurses) give them (patients/families). We have a contract with “Pharmacy #9.” Most of the patients request that the medication be brought by a carrier. We tell the family that after we put in the orders the doctor had to sign it (authorization for controlled pain medications through the electronic prescribing system) and it takes four to six hours for the medication to be delivered depending on when the doctor’s signature is received. That is for STAT orders. But in some instances, if it’s (electronic prescription) not signed on time or maybe the medication is not available at the pharmacy of choice then it (medication delivery) might be longer than the six hours. I always leave my number with them (patients and families) if there is issues with the delivery of the medication. They’re (the patients and families are) good at calling us (hospice agency) to let us know the medication is not there yet.” When asked about the interventions to address Patient 1’s pain during RN A’s admission visit on 11/28/2025. RN A stated, Patient 1 had “Hydrocodone liquid and Fentanyl patches” at the home. RN A stated Family Member #4 gave the patient Hydrocodone liquid while she was there and the patient “seemed to calm down.” RN A stated “I also ordered the comfort kit and told them (patient’s family) as soon as the doctor signs it, the medication should take four to six hours to be delivered, and the expected delivery would be around 5:00 PM. Unfortunately, it was signed a little later by the doctor.” RN A stated she ordered the medication STAT. When asked if Patient 1’s family was informed of the option to pick up the medication from the pharmacy, RN A stated, Family Member #4 “was home alone with the patient when I ordered the medication. She preferred the carrier to drop it (medication) off (to the patient’s home).” When asked about the time the pain medication was ordered, RN A stated, “I ordered those medications at the patient’s home around 11:30am (11/28/29).” RN A stated, Family Member #5 “reached out to me” to ask about the ETA of the medication “I immediately called the pharmacy to see why there was a hold and they told me the doctor had not signed. I reached out to the doctor and sent the doctor a message that there’s a medication needing a signature. I called the pharmacy to let them know that the doctors said everything had been sent. The pharmacy told me they had received it (doctor’s electronic prescribing authorization) and we’ve (the pharmacy) already sent out the medication. I went ahead and called” Family Member #4 “to let her know.” When asked about Patient 1’s pain level before RN A left the patient’s home. RN A stated the hydrocodone liquid was effective in reducing Patient 1’s pain “I did not see him moaning or in any distress.” When asked about the education on pain management provided to Patient 1’s family, RN A stated teaching was provided to Family Member #4 and Family Member #5 and the other family members did not arrive to the home until the “last 30 minutes of my visit.” RN A stated, “I educated her (Family Member #4) on how to use the comfort kit and how to relieve the pain and if that did not work to call our (Hospice Agency’s) 24/7 number.” RN A stated she educated Family Member #4 that the agency had “on call nurses they can come anytime they call that number.” RN A stated she discussed the option of the agency’s inpatient unit for IV pain medications to manage the patient’s pain and that oral pain medications would not be as effective as the IV pain medications. RN A stated Family Member #4 wanted Patient 1 to remain at home. When asked about the agency’s policy on pain and symptom management, RN A stated, the agency nurses “order the pain medication if they’re (the patients are) having pain and put in a care plan for pain. In 24 hours, a nurse follow up is done to see how they (the patients) are doing... The nurse (Hospice RN or LVN) assigned (to the patient) follow ups and checks the pain level and communicates with the provider if it’s (the pain medication is) therapeutic or not, The provider changes the medication orders if they’re (patients) having severe pain.” When asked about the potential negative outcome for delays in the delivery of patients’ pain medications RN A stated, “patient’s pain is not going to be controlled effectively.” A phone interview was attempted on 12/08/2025 at 1:16pm with the Hospice Physician scheduled to work on 11/28/2025. The Hospice Physician was unavailable for an interview.A phone interview was conducted with PCM #3 on 12/9/2025 at 1:45pm. When asked about the agency’s policy, procedure and time frames on hospice admissions regarding patients that are discharged from the hospital. PCM 3 stated, “We (the hospice agency) would coordinate with the case manager at the hospital to either request transport or sometimes we arrange the transport for them (the patients) through a transport service… Our (the agency’s) Admission Scheduling Department makes sure we (the agency) have someone available to do the admission. Our (the agency’s) goal is (for the admission nurse) to be there when the patient arrives or a little bit sooner. There are times when the patient arrives early before the admission nurse is there. In a situation where they (patient or patient’s family) need a nurse there (patient’s home) immediately right away, we’ll make sure that our nurses are scheduled to be there earlier than later.” When asked about the agency’s process of ordering a comfort kit to be delivered before the patient arrives home from the hospital, PCM #3 stated, ““It depends on the situation and the doctor ordering the medication. A physician may want to avoid some situation of ordering medication and having the patient changed their mind on hospice services.” When asked about the agency’s Patient/Client Rights policy regarding patient/family complaints and who was responsible for documenting and investigating the complaint. The PCM #3 stated, “if a complaint is received it is escalated to the manager on duty who initiates the investigation.” When asked where would the manager document the complaints and investigation? PCM #3 stated “It dependent on the severity of the complaint. If you don’t mind, I want to consult the other managers. I don’t want to mislead you, and they will give you a full complete answer.” When asked if PCM #3 was the on-call manager the evening of Thanksgiving day (11/27/2025), PCM #3 stated “Yes for a short time.” When asked if he had been notified of any issues regarding Patient 1 while on call or spoke to Patient 1’s family, PCM #3 stated “No.” When asked if PCM #3 had knowledge on why Patient 1 was not admitted to hospice on 11/27/2025, PCM #3 stated, “I would have to find someone who has that answer and follow up.” PCM #3 further stated that, “I think the best people are going to be the intake scheduling department.” At 2pm PCM #3 requested to briefly pause the interview.An interview was conducted with PCM #3 on 12/9/2025 at 3:05pm. When asked about the delay in Patient 1’s admission to Hospice. PCM #3 stated, he believed the Admissions Manager or Admission’s Coordinator “that was working on Thanksgiving (11/27/2025), scheduled the admission and the admission nurse (RN E) was running behind or something, so the admission ended up being later.” PCM #3 stated he reviewed the text message received on 11/27/2025 from the on-call nurse RN D. PCM #3 stated, RN D “was sorting through the equipment delivery or something with our equipment (oxygen equipment set up) so he was going to reach out to them (Patient 1’s family) after 5:00. He (RN D) talked to me for a little bit. He (RN D) then texted me that he spoke to” Family Member #4 “and she rather have someone (admission nurse) come in the morning.” PCM #3 then showed the surveyor a text message from RN D. The Surveyor attempted an interview with the Admission Coordinator on 12/9/2025 at 3:40pm. The Admission Coordinator was unavailable for an interview. An interview was conducted with the Admission’s Manager on 12/9/2025 at 3:42pm. When asked about the planned hospice admission for Patient 1 for Thanksgiving Day 11/27/2025. The Admissions Manager stated, the Clinical Liaison “did the discharge planning (for Patient 1) and ordered the DME” on 11/27/2025. The Admissions Manager stated the admission nurse RN E was scheduled to be at Patient 1’s home on 11/27/2025. The Admissions Manager stated the agency’s part time Admission’s Coordinator assigned Patient 1’s admission to RN E’s schedule but did not call RN E to notify her of the scheduled admission. The Admissions Manager stated the nurses scheduled to work holidays were responsible for reading their “emails” and “calendar invites” that contained the scheduled patients’ admissions. The Admissions Manager stated there was a “missed communication” with RN E’s holiday work schedule and the agency “could not get in contact with” RN E on Thanksgiving Day (11/27//25) “So the admission got pushed to on call.” The Admissions Manager stated when the on-call nurse RN D reached out to Family Member #4, he was told that “it was too late” and Family Member #4 “requested a morning admission.”A phone interview was conducted with the Clinical Liaison on 12/10/2025 at 7:15am. When asked about the meeting with Patient 1’s family to sign the Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment. The Clinical Liaison stated, she met with Family Member #4 in the hospital on 11/27/2025 at “10am.” When asked about Patient 1’s health status during her visit with Patient 1 in the hospital, the Clinical Liaison stated Patient 1 “was nonverbal…He was quiet, not moaning and was sleeping while I was there.” The Clinical Liaison stated Family Member #4 told her Patient 1 “had severe pain when he was at home and was receiving liquid” Hydrocodone/Acetaminophen “and a Fentanyl patch.” The Clinical Liaison stated Family Member #4 “was also concerned of the severe neurological (nervous system that includes the brain, spinal cord and nerves that control movement, senses, thinking, and memory) changes he had from the stroke (condition that occurs when the blood flow to the brain is blocked or a blood vessel bursts, causing the brain cells to die). The Clinical Liaison stated “He (Patient 1) was sleeping when I was there and did not appear to be in distress and looked fairly comfortable. The hospital was giving him a minimal amount of pain medications.” When asked about the transportation arrangement for Patient 1 from the hospital to Patient 1’s home. The Clinical Liaison stated she arranged transport with an Ambulance Transporting agency with a pickup time of “around 2pm.” The Clinical Liaison stated, “I always schedule the patient’s pick up a couple of hours before the nurse arrives, so they (the patients) are not home alone for a long period of time and in case transport is late.” When asked about notification and scheduling of the hospice admission after the consents were signed. The Clinical Liaison stated an email was sent on 11/27/2025 at 1:08pm to the Admission Nurse, the Admission Manager and the admissions intake department that Patient 1’s consents had been signed. The Clinical Liaison stated another email was sent at 2:37pm that transport had been arranged for Patient 1. When asked who was scheduled to complete the admission at Patient 1’s home, the Clinical Liaison stated RN E “was scheduled for 4pm.” When asked if the Clinical Liaison contacted RN E to update her on Patient 1 or the transport time. The Clinical Liaison stated the Clinical Liaisons communicated through email and the agency’s staff “are supposed to check their email when they are working.” The Clinical Liaison stated RN E was on the “calendar invite” the Clinical Liaison received, that contained the scheduled time of 4pm for Patient 1’s hospice admission. When asked if the Clinical Liaison had any knowledge on why RN E was not present at Patient 1’s home at 4pm on 11/27/2025. The Clinical Liaison stated she was told RN E “was a no call in, no show (did not notify management that she was not working).” When asked if the Clinical Liaison had any contact with Patient 1’s family after 11/27/2025. The Clinical Liaison stated she spoke to Family Member #5 “for the first time on December 1st. after the patient (Patient 1) had passed” The Clinical Liaison stated Family Member #5 requested pick up of the DME and was not happy with the hospice services Patient 1 received from hospice. The Clinical Liaison stated an email of the complaint was sent to PCM #2, the Admissions Manager, the Director of Business Development and the Admission’s Intake Team to follow up.” The Clinical Liaison stated “only” the Director of Business Development “responded to my email and called” Family Member #5. The surveyor requested the email communication from the Clinical Liaison to the agency’s management team. An interview was conducted with RN E on 12/10/2025 at 10:03am. When asked if RN E was scheduled to work Thanksgiving Day (11/27/2025), RN E stated “I didn’t know I was scheduled to work on Thanksgiving, and I don’t check my phone when I’m not working. I found out the following Monday (12/1/2025) morning when I looked at my phone…” RN E stated “I generally would sign up to work New Year’s Day and New Year’s Eve. I guess that they (management) did the sign-ups when I was on maternity leave... No one (from management) ever talked to me about it (the holiday work schedule) so I didn’t know that I was working Thanksgiving...” When asked when RN E returned back to work from her leave, RN E stated “I came back November 17.” An interview was conducted with the Director of Business Development on 12/10/2025 at 11:35am. When asked about the agency’s Patient Rights Policy and procedures related to the investigation of a patient complaint, the Director of Business Development stated, “The complaint should be put” into the agency’s shared web platform (A central hub used to store, organize, share, and manage digital information) “and I’ve done it (entered a complaint into the agency’s shared web platform).” The Director of Business Development stated the agency’s employees were responsible for documenting the complaints they received. The Director of Business Development stated the agency’s employees were trained “on the link” and “where to go” to navigate the agency’s shared web platform site “to put in the complaint.” The Director of Business Development stated, after the complaint is entered into the agency’s shared web platform site “it goes out to the PCM’s, and I believe our regional nurse.” The Director of Business Development stated, The PCM’’s “follow up on what happened, the situation that occurred, and the staff involved.” When asked about the follow up on the email received from the Clinical Liaison on 12/1/2025 regarding the complaint received from Patient 1’s family. The Director of Business Development stated, “When I reached out (to Family Member #5) the patient had already passed. I gave my condolences. He (Family Member #5) did not voice any concerns and wanted the equipment picked up.” When asked if the follow up with Family Member #5 was documented, the Director of Business Development stated, “I have to go back and look at the e-mail thread. I think I did.” When asked if the agency’s management investigated the reason why Patient 1’s family was not happy with the hospice services that Patient 1 received. The Director of Business Development stated, “I know that we (The Director of Business Development, Admission Manager, and Clinical Liaison) were all involved” with the incident “concerning the scheduling of the Admission Nurse and how that happened. I brought that up with” the Admission Manager. The Director of Business Development stated, “He (Patient 1) did get admitted one day after (11/28/2025). I’m not sure if anyone followed up after the admission.” When asked where the complaint regarding the scheduling of the Admission Nurse was documented, The Director of Business Development stated, “It’s probably in a text message or emails. I have to look at my emails and in the documentation.” When asked who was responsible for investigating the complaints received on Patient 1, the Director of Business Development stated, the Clinical Liaison “did send me the e-mail of the complaint regarding the admission not being done on the day of Thanksgiving Day (11/27/2025) and then the issues with the medications” delivery. The Director of Business Development stated “I know the e-mail went to several individuals in management. The admission aspect (of the complaint) is followed up by” the Admission Manager. The Director of Business Development stated the PCM’s were responsible for investigating “clinical (relating to the direct care, observations, or treatment of patients)” related complaints and were responsible for investigating the complaint related to the delay in the delivery of Patient 1’s medications. When asked why the agency’s policy on Patient Rights related to complaints were not followed, The Director of Business Development stated, “because we’ve (the agency) had a lot of changes in leadership recently and we’ve (the agency staff) definitely have seen some issues with our (the agency’s) processes.” When asked about the potential patients’ outcomes for not documenting and investigating a hospice service-related complaint, the Director of Business Development stated, “complaints should all be documented and investigated, That’s the only way we (agency management) know of service issues, so we (agency management) can improve the process going forward. To fix things if there is an issue on our (the hospice agency’s) side.” A phone interview was attempted on 12/10/2025 at 12:45pm with RN D. RN D was not available for an interview.A phone interview was attempted on 12/10/2025 at 12:47pm with RN C. RN C was not available for an interview.An interview was conducted with the interim Adm, PCM #2, and Admission Manager on 12/10/2025 at 1:28pm. When asked about the agency’s Patient Rights Policy and procedures related to the investigation of a patient complaint. The interim Adm stated that the agency’s staff that received the patient related complaint was responsible for entering the complaint into the agency’s shared web platform and was responsible for notifying management of the complaint. The interim Adm stated management (Adm, Alt Adm and PCM’s) was responsible for following up and investigating the complaints and documenting the results of the investigation into the “management portal” of the agency’s shared web platform. The interim Adm stated the agency’s staff notified management of patient related complaints, but “don’t always put the complaints into” the agency’s shared web platform. The surveyor shared the findings of the record reviews and on-call logs for Patient 1, and the interviews with RN A, RN E, PCM #3, the Clinical Liaison, Admission Manager, and the Director of Business Development. The interim Adm stated she was on paid leave on 11/27/2025 and 11/28/2025 and was not aware of the complaint received from Patient 1’s family. PCM #2 stated she was the manager on-call until 5pm 11/27/2025 and was on-call the evening of 11/28/2025. PCM #2 stated the only call she received from RN B on 11/27/2025 regarding Patient 1 was related to the oxygen concentrator delivery and oxygen flow rate setting prior to Patient 1’s discharge from the hospital. PCM #2 stated, she received a call from RN C the evening of 11/28/2025 to inquire on “if medications had been ordered” for Patient 1. PCM #2 stated that RN C was instructed to contact Pharmacy Contractor #8. PCM #2 stated that RN C did not notify her of a complaint received from Patient 1’s family regarding the delay in Patient 1’s hospice admission and medication delivery. The interim Adm stated, RN C “should have put the complaint into” the agency’s shared web platform “and notified the manager (PCM #2).” When asked if the interim Adm and PCM #2 reviewed the answering service call logs, the interim Adm stated “Yes. Usually.” When asked if the interim Adm and PCM #2 reviewed the complaint documented in the answering service call log on 11/28/2025 for Patient 1, the Adm stated “No.” When asked if RN E was notified in advance of the holiday on-call schedule prior to 11/27/2025. The interim Adm stated she scheduled RN E for Thanksgiving Day (11/27/2025) because “she (RN E) was off Thanksgiving last year.” The interim Adm stated she rotated the agency’s on-call scheduling of staff for major Holidays (Thanksgiving, Christmas, New Years) based on if the staff member had worked a major holiday in the current or previous year. The interim Adm stated she emailed the11/27/2025 holiday on-call staff schedule, on 11/21/2025 at 3:57pm. The interim Adm stated “She (RN E) did not read her email.” When asked if the interim Adm had called RN E to notify her of the holiday on-call schedule when the interim Adm had scheduled RN E for Thanksgiving Day (11/27/2025), the interim Adm stated “No.” The Admission Manager stated, “It can get busy during the holidays” the Admission Intake Team “needs to call the nurses directly” to notify the nurses of the scheduled patient admissions. When asked about the email sent by the Clinical Liaison on 12/1/2025 on the complaint received by Family Member #5 regarding the hospice services Patient 1 received. PCM # 2 stated, the Director of Business Development “Is a Manager” and had followed up with Patient 1’s family and told PCM #2 “they (Patient 1’s family) did not have any complaints.” The interim Adm stated, the Director of Business Development “should have put the complaint into” the agency’s shared web platform and “notified us (interim Adm and PCM #2) of the complaint.” When asked about the potential patient outcomes related to the agency’s failure to document and investigate patient related complaints, The interim Adm stated, the patients “don’t get the care they need” which can lead “to them changing agencies.” Review of agency’s policy “Patient’s Rights and Responsibilities” dated “Last Reviewed 10/01/2021,” read in part “During the initial assessment visit and in advance of furnishing care, the Hospice will provide the patient and/or representative with verbal and written notice of the patient’s rights and responsibilities in a language and manner that the patient or representative understands. The Hospice staff and staff under arrangement will receive in-service education regarding patients’ rights and responsibilities on hire and annually thereafter. Procedure The Hospice staff will be responsible for knowing, observing, and implementing the patient’s rights and patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights… Exercise of patients’ rights, the patient has the right: To exercise his or her rights as a patient of the Hospice; To receive effective communication; To be informed of anticipated outcomes of care and of any barriers in outcome achievement; To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the Hospice; To have all grievances, complaints and concerns investigated, and the investigation and resolution shared and documented. The Hospice will attempt to resolve all patient grievances and/or complaints as defined in policies and state regulations; To receive effective pain management and symptom control from the Hospice for conditions related to the terminal illness.”

“Based on interviews and record reviews, the agency failed to ensure the patient was free from neglect, in that LVN F failed to ensure proper placement of a patient’s indwelling urinary catheter (a thin flexible tube that is inserted through the urinary opening of the body into the bladder to drain urine) before inflating the catheter’s balloon for 1 (Patient 2) of 4 active patient record reviews. The failure of LVN F to verify the indwelling urinary catheter was properly placed resulted in Patient 1’s Emergency Department visit on 11/14/2025 for bleeding and indwelling catheter replacement. Findings: Review of the Health and Human Services Commission Complaint and Incident Intake in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed the agency’s self-reported incident 1050872 received on 11/18/2025 from the agency’s interim Administrator with an allegation of Patient Neglect from alleged perpetrator LVN F. The interim Adm reported an incident with the placement of Patient 2’s indwelling urinary catheter by LVN F the morning of 11/14/2025 which resulted in an Emergency Room visit the night of 11/14/2025. Record review of the agency’s “2025 Self Report to the State” binder revealed the agency’s self-reported incident 1050872 dated 11/18/2025 for Patient 2. The interim Adm (previous PCM) documented “Patient Care Manager received a call from” Family member #8 “to report her concern that the nurse that placed the (indwelling urinary) catheter was not competent. Specifically, she reported that” LVN F “inserted the (indwelling urinary) catheter improperly causing injury.” The interim Adm documented “On 11/14/2025 nurse” LVN F “placed a 16 fr. (measurement of the size of the indwelling urinary catheter) catheter, reported no resistance (obstruction or blockage) met, no bleeding. Did not have immediate output of urine. Instructed” Family member #8 “to call if no urine output in 4 hours and encouraged (Patient 2) to drink fluids.” Family member #8” contacted on call (agency’s after hour triage nurse) when no urinary output in 5 hours. On call nurse” RN G went “out to assess (Patient 2)” and “deflate the balloon (holds indwelling urinary catheter in place) of the (indwelling urinary) catheter. Bright red blood came out of the meatus (a passage or opening leading to the interior of the body) of penis, (indwelling urinary) catheter completely removed and bleeding continued. Spoke with on call Physician/NP and patient sent to emergency room” at the Hospital “for further assessment. Patient remained in hospital overnight. The interim Adm documented, Patient 2 “required ultrasound (medical imaging technique that uses high-frequency sound waves to create real time pictures) visualization to place the (indwelling urinary) catheter” while in the hospital. The interim Adm documented “11/16/2025 On call (nurse) visit made to assess patient status when (Patient 2) arrived home from the hospital. (Indwelling urinary) catheter that was placed at hospital, patent (open, clear, with no blockage) and had clear yellow urine output.” The interim Adm documented her contact with Family member #8, the submission of the incident to HHSC Complaint and Incident intake and the interviews with LVN F and RN G. The interim Adm documented under the “Investigation Summary” that the Hospice Agency “found no evidence of intentional mistreatment or neglect. Documentation shows that” LVN F “followed catheter insertion procedures, her competency was current at the time of the occurrence. The post procedure assessment showed no signs of trauma, urinary retention (holding of urine in the bladder), or bleeding. (Patient 2’s) discomfort controlled with current medication regimen. The interim Adm documented that LVN F “was counseled on review of catheter insertion policy” and assigned classes related to indwelling urinary catheter insertion and care. Under the “Agency Action Post Investigation,” the interim Adm documented “Based on information gathered, traumatic (causing physical injury) catheter (indwelling urinary) placement occurred which was a contraindication of (indwelling urinary catheter) placement, but improper placement was not substantiated as it would have caused tissue necrosis (premature death of body tissue) which did not occur. The patient has received care according to standards of practice. The plan of care will be updated to ensure (Patient 2’s) comfort. The family’s concerns have been addressed, and clear communication is being provided.” Record review of Patient 2’s Hospital Emergency Department records dated 11/14/2025 read in part “History provided by patient’s family member. The Patient has been self-catheterizing (use of a soft flexible tube “catheter” to drain the bladder. The catheter is then quickly removed after the bladder is empty) for the past 4 months. Due to financial constraints, he was unable to continue self-catheterization and had a (indwelling urinary) catheter inserted by a nurse. The patient had no sensation from the nipple downwards and did not experience any pain during the procedure. After the (indwelling urinary) catheter was placed, there was no urine output in the bag for approximately 5 hours, despite adequate hydration. A second nurse attempted to deflate the catheter (balloon), which resulted in the release of bright red blood. Upon removal of the catheter, blood was observed to be gushing out. This incident led to the current hospitalization. The patient had no prior history of such complications with (indwelling urinary) catheters. Additionally, he (Patient 2) reported the presence of a significant amount of gooey substance in his urine and had not been able to urinate for the past 9 hours.” The Emergency Department Physician documented Patient 2’s history of Malignant neoplasm (abnormal growth of cells that form a cancerous tumor) of the Brain, Pulmonary Embolism (blockage of a blood vessel in the lung caused by a traveling blood clot), Deep Vein Thrombosis (a blood clot in a deep vein, usually in the leg or thigh), and anticoagulation (process of preventing blood from clotting too quickly) treatment. The Emergency Department Physician documented the “Final Assessment” as “Hematuria (bloody urine) likely due to traumatic or fistulous (abnormal tunnel or passageway connecting two body parts) catheter (indwelling urinary) placement.” The Emergency Department Physician documented that Patient 2’s indwelling urinary catheter was replaced “under direct ultrasound visualization” in the hospital. Record review of Patient 2 revealed a Plan of Care with “Last Updated” date of 11/27/2025 signed by RN B. The POC revealed Patient 2’s hospice diagnosis of “Malignant neoplasm of the Brain,” a history of “venous thrombosis (blood clot in a vein) and embolism (blockage in a blood vessel caused by a traveling blood clot)” and a nurse visit frequency of twice a week. The POC contained a physician order dated 11/14/2025 for indwelling urinary “catheter placement as requested by patient’s family” signed by LVN F. The POC contained the medication Rivaroxaban 20 mg daily (medication used to prevent blood clots that can increase the risk for bleeding) with instructions to switch to coumadin (medication used to prevent blood clots) when current supply of Rivaroxaban is exhausted.Record review of Patient 2 revealed a nurse visit note dated 11/14/2025 with a visit time of 2:57 PM signed by LVN F. LVN documented “Tuck in visit made with” Family member #8’s “request for a (indwelling urinary) catheter insertion, per Hospice md, …order… Sn (skilled nurse) placed a 16 Fr (indwelling) catheter, 10cc (unit of fluid volume equaling one milliliter) balloon, with no resistance, using aseptic (free from germs) technique. During this visit, noticed no urine output.” Family member #8’ “told this nurse, she had straight catheterized pt (Patient 2) two times already today prior this visit…This sn stayed at pt’s bedside an additional 30 minutes, to monitor for urinary return, no sign of any distress or bleeding noted, skilled nurse encouraged fluids and instructed” Family member #8’ to call the Hospice Agency “if no (urine) output occurred within 4 hours.” Patient 2’s records did not contain any evidence that Patient 2 had any urine output prior to LVN F leaving the patient’s home. Records did not contain any evidence that LVN F followed up with a phone call to Patient 2 or Family member #8 after she left the patient’s home. Record review of Patient 2 revealed a nurse visit note dated 11/14/2025 with a visit time of 9:45 PM signed by RN G. The RN documented Family member #8 “called to report patient had a catheter installed today but no output in the bag. Visit made. No urine in bag, deflated bulb (catheter balloon) to assess catheter and blood started gushing out of the penis. Patient was bleeding bright red blood. Notified NP on-call and” manager on call “and options of either going to the IPU (hospice’s inpatient unit) or ER was presented to the family. No beds were available at the IPU, so the family opted to go to the ER. Revocation (cancellation of hospice services) form signed, and patient was taken to” the Hospital. Record review of LVN F’s personnel record on 12/9/2025 revealed a “Nurse Competency Checklist” dated 10/10/2024 signed by evaluators RN H and RN I. The Urinary Catheter Insertion Indwelling (left in the bladder for continuous drainage of urine) section had LVN F’s previous experience as “Feel competent to perform without supervision” and “Feel competent to orient others.” The evaluators documented that a “verbal” evaluation was completed on the urinary catheter insertion task. Record review of the “Clinical Procedure: Indwelling Catheter -Insertion” training certification of completion for LVN F provided by the interim Adm on 12/8/2025, revealed a completion date of 11/27/2025. First attempted phone contact with Family member #8 was made on 12/5/2025 at 11:11am. The surveyor left a voicemail message with contact name and number.Second attempted phone contact with Family member #8 was made on 12/9/2025 at 11:11am. The surveyor left a voicemail message with contact name and number.A phone interview was conducted on 12/9/2025 at 3:16pm with LVN F. When asked about the agency’s ANE policy, LVN F stated the nurses were expected to follow the plan of care and patients should not be abused or neglected. When asked about the agency’s policy and procedures on indwelling urinary catheter placement, LVN F stated “First a hand wash before you do anything. Maintain a sterile (free from germs) field. Position the patient in supine (lying on back, face up) position. Use aseptic (free from germs) technique. Use catheter kit. I use wipes to clean the patient and then dry. Then I clean the meatus (urinary opening) 3 times with the iodine swabs in the kit in an up to down motion. I lubricate the tip of the catheter and with my other hand place the catheter all the way (into the bladder) if there is no resistance until the urine comes out and really flows out. If I feel any resistance, I take it (the catheter) out. I advance it (the catheter) 7 to 9 inches until I get the urine and then I will inflate the balloon.” When asked about the indwelling urinary catheter incident that occurred on 11/14/2025 with Patient 2, LVN F stated, “That’s not the first time I have put in a catheter.” LVN F stated “That date she (Family member #8) told me she had already straight catharized him twice before I got there. So, I asked him (Patient 2) was he drinking enough? he said not really. There was no resistance when I inserted the catheter.” When asked why LVN F did not follow the agency’s policy on verifying urine output before inflating the indwelling urinary catheter balloon, LVN F refused to give a direct answer and stated, “There was no resistance, I waited for 30 minutes and there was no urine because of him (Patient 2) not being hydrated properly that’s why I told her (Family member #8) to call on call after 4 hours” if there was no urine output. When asked if inflating the indwelling urinary catheter balloon before verifying urine output and proper placement in the bladder was patient neglect. LVN F refused to give a direct answer and stated, “There was no resistance” Family member #8 “told me she straight catharized him twice. I did what I was supposed to do.” When asked about the potential negative patient outcome for not following the agency’s policy on indwelling urinary catheters, LVN F refused to answer the question and stated, she had placed catheters in many patients in her nursing career and never had any problems before.A phone interview was conducted with Family member #8 on 12/10/2025 at 10:16am. When asked about the indwelling urinary catheter incident that occurred on 11/14/2024 with Patient 2. Family member #8 stated, the patient had developed a tumor on the spine (back bone) and could not feel anything “from the nipple downwards.” Family member #8 stated the patient had been self-catheterizing himself with the Family member #8’s assistance for “5 months.” Family member #8 stated the hospice agency said that they could pay for the indwelling urinary catheter supplies, so the patient opted to have an indwelling catheter inserted by the hospice nurse. Family member #8 stated LVN F, who initially inserted the indwelling urinary catheter “was incompetent.” Family member #8 stated, “no urine came out.” after the nurse inserted the catheter. When asked how long the nurse stayed to monitor for urine output, Family member #8 stated, “maybe a few minutes.” Family member #8 stated that the nurse told her to “wait for 5 hours and call the hospice” if the patient continued to not have urine output. Family member #8 stated the patient did not have any urine output “and had plenty to drink” and after 5 hours she called the agency. Family member #8 stated the agency sent another nurse (couldn’t recall name) and the nurse deflated the catheter balloon “and blood gushed out. It was traumatic for the family.” Family member #8 stated the family called 911 and had the patient transported to the hospital. Family member #8 stated the Emergency Room doctor (couldn’t recall the name) told her that the catheter was “probably placed in the urethra (urinary tube that cares urine from the bladder out of the body)” which caused the bleeding. Family member #8 stated, “I’m not a nurse but I could tell the catheter was not placed far enough.” When asked about the time between the last self-catheterization and indwelling urinary catheter placement by the nurse. Family member #8 stated “maybe a few hours. He (Patient 2) always self-catharized himself in the morning and afternoon. We never had any problems, and he always had a significant amount of urine out. Every time he goes to the hospital, they (hospital staff) place a (indwelling urinary)catheter and he has never had any problems.” Family member #8 stated the hospital ran some tests and a bladder scan and “there was some blood in the bladder.” Family member #8 stated the patient had a large amount of urine output after the hospital placed an indwelling urinary catheter. When asked if Patient 2 had any current problems resulting from the injury, Family member #8 stated, “he’s (Patient 2 is) healing. The agency assigned a new nurse that comes out twice a week. She is very competent.” Family member #8 stated Patient 2’s urine was clear, and Patient 2 did not have any issues with urine output since returning home. Asked if the surveyor could do a home visit with Patient 2. Family member #8 declined a home visit and stated, “He (Patient 2) is doing fine and we are happy with the nurse.”An interview was conducted with the interim Adm and PCM #2 on 12/10/2025 at 1:28pm. When asked about the agency’s indwelling urinary catheter policy regarding verification of the correct placement of the catheter, the interim Adm stated the nurse advances the catheter into the bladder and verifies urine output before inflating the balloon. The interim Adm stated “If there is resistance, the catheter is removed, and the doctor is notified.” The surveyor shared the findings of Patient 2 and the interviews with LVN F and Family member #8. When asked about the agency’s Abuse, Neglect and Exploitation Policy and if LVN F’s action of not verifying the correct placement of Patient 2’s indwelling urinary catheter before leaving the patient’s home was considered neglect. The interim Adm stated that agency staff should not cause intentional harm and injury to the agency’s patients. The interim Adm stated LVN F did not encounter “resistance” when Patient 2’s indwelling catheter was placed and Family member #8 had told LVN F “that she straight catheterized him (Patient 2) twice” on 11/14/2025. The interim Adm stated Patient 2 was on Apixaban (blood thinner to prevent and treat blood clots) for Deep Vein Thrombosis and had a history of bleeding. PCM #2 stated “She (LVN F) is the nurse that does many of the (indwelling urinary) catheter placements” and no problems were reported with the other patients. When asked if anything could have been done differently by LVN F to avoid Patient 2’s hospitalization, the interim Adm stated, “To wait longer (at Patient 2’s residence), have him (Patient 2) drink fluids until urine came, and notify the physician if there was no urine output.” When asked about the potential negative outcome for not following the agency’s indwelling urinary catheter policy, the interim Adm stated, the patient “having to go to the ER to have the catheter placed.”Review of the agency’s “Indwelling urinary catheter insertion, assigned male at birth” procedure guidelines with revision date 11/17/2024 read in part “advance the catheter to the catheter bifurcation (where the catheter splits into two branches. The longest branch is inserted into the patient’s bladder. The short branch is used to connect the sterile water filled syringe to inflate the catheter balloon) and check for urine flow…Once urine starts to flow, inflate the balloon using the water-filled syringe attached to the inflation port, instilling the recommended amount of sterile water specified on the catheter…Clinical alert: Never inflate a balloon without first establishing urine flow, which ensures that the catheter is in the bladder.”Review of the agency’s “Abuse, Neglect and Exploitation” Policy with “Last Reviewed” date of 9/1/2024, read in part, “Patients have the right to be free from mistreatment, neglect or verbal, mental, sexual and physical abuse, including injuries of unknown sources and misappropriation of property. The Hospice must ensure that alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse, including injuries of unknown sources and misappropriation of property by anyone furnishing services on behalf of the Hospice, are reported immediately by Hospice employees and contracted staff to the Hospice Administrator and other appropriate authorities in accordance with state laws. The Hospice employees and contractors will be aware of signs and symptoms indicating possible abuse, neglect and/or misappropriation of patient property. A Hospice employee, representative or contractor suspected of abuse or neglect of a patient or misappropriation of patient property, will be suspended immediately and an investigation will be conducted by the Hospice. If there is cause to believe abuse or neglect of a patient or misappropriation of patient/property has occurred by a staff member or contractor, the incident(s) will be reported to the appropriate authorities...Any Hospice staff member, contractor, or representative will: Immediately report an assessment of a patient’s condition which indicate abuse or neglect of a patient, pr misappropriation of a patient’s property to the Hospice supervisor. Symptoms that may indicate a need for further investigation may include the following: Adult or Elderly Neglect- Untreated medical conditions; Abandonment.” Review of the agency’s “Abuse, Neglect and Exploitation-Addendum” policy with “Last Reviewed” date of 2/22/2024 read in part, “In replacement of the definitions in the Abuse, Neglect and Exploitation policy in the Provision of Care section of the Administrative Policy Manual, the following state definitions will apply: “Neglect” means the failure to provide for one’s self the goods or services, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services… “Cause to believe” means that a Hospice or individual knows or suspects, or receives an allegation regarding abuse, neglect, or exploitation. “Employee” means a person who:” Is directly employed by the Hospice, a contractor, or a volunteer; Provides personal care services, active treatment, or any other personal services to a patient receiving Hospice services; and Is licensed by the state to perform the services the person performs for the Hospice. Procedure: Hospice management will: Immediately initiate an investigation of known or alleged acts of abuse, neglect, or exploitation of a patient or misappropriation of patient property immediately upon witnessing the act or upon receipt of the allegation or upon having cause to believe abuse, neglect, or exploitation of a patient or misappropriation of patient property occurred. Report if there is cause to believe abuse, neglect, or exploitation of the patient or misappropriation of patient property has occurred by a staff member, representative, or contractor, immediately, meaning within 24 hours. Cause to believe is defined as a Hospice or individual knows or suspects, or receives an allegation regarding abuse, neglect, or exploitation… The Hospice will ensure a thorough investigation is conducted and documented in the PIR (Provider Investigation Report). The Hospice will determine why the incident occurred, what actions the Hospice will take in response to the incident, and what changes will be made to help prevent a similar incident from occurring.””

“Based on record reviews and interview Hospice agency failed to maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement for 1 (Patient 1) of 8 active and discharged records reviewed. The failure of the Hospice Agency’s staff to communicate and coordinate care for Patient 1 resulted in a delay in hospice services, interventions and treatments which placed the patient at risk for increased pain, discomfort and emotional distress. Findings:Review of the Health and Human Services Commission Complaint and Incident Intake in TULIP (a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) revealed intake 1053563 received on 12/02/2025. The intake documented the complainant’s statement that on 11/27/2025 (Thanksgiving Day) Patient 1 who was actively dying was transported from the hospital to the patient’s home around 3:30pm and the complainant had been informed a Hospice Admission Nurse would arrive at 4:45pm. The complainant reported that no one showed up to the patient’s home and around 8 pm on 11/27/2025 the complainant received a call from the agency that there was a miscommunication, and an admission nurse would be at the home on 11/28/2025 at 8:25am. The complainant reported on 11/28/2025 at 8:25am no one from the agency showed up at the home and the complainant called the agency multiple times and spoke to an agency Supervisor. The complainant reported that the Hospice Admission nurse arrived to Patient 1’s home on 11/28/2025 at 10:00am and did not submit the medications to the pharmacy until 12:00pm which included Hydromorphone (opioid pain medication used to treat moderate to severe pain) Lorazepam (medication used to treat anxiety), Haloperidol (medication used to treat agitation combative behaviors, nausea and vomiting), Promethazine (medication used to treat nausea), Ondansetron (medication used to treat nausea and vomiting), Acetaminophen (medication used to treat mild pain or fever) and Oxygen (supplemental oxygen that is supplied from oxygen portable tanks or an oxygen concentrator machine) and Patient 1 was in severe pain during that time. Record review of Patient 1 revealed the “Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment” documents signed on 11/27/2025 (Thanksgiving Day) by the hospice agency’s Clinical Liaison and Patient 1’s Family Member #4. The consents contained a “Date Care will Start” of “11/27/2025.” Record review of Patient 1 in the agency’s EMR system, revealed a plan of care with “Effective Date of 11/28/25.” The POC contained information pulled from the SOC visit dated “11/28/25” and signed by RN A. The POC contained an admitting diagnosis of “Malignant neoplasm (abnormal growth of cells that can form a tumor which can spread to other parts of the body. Tumors can affect the function of the organ by pressing on or destroying healthy tissues resulting in pain and inflammation) of Tongue” and a hospice nurse frequency of “1 visit(s) 1 times.” The POC contained a “Problem” statement of “Initial Plan of Care prior to Service Provision” and a “Goal” of “Admission and Initial Plan of Care will be established within 24 hours.” The POC also contained a “Problem” statement of “Presence of pain, either verbalized or non-verbal indicators assessed…” and a “Goal” of “Patient will remain free of non-verbal signs of pain, such as moaning/grimacing, within 24 hours of medication administration.” The POC contained orders for “Fentanyl (powerful opioid medication to treat moderate to severe pain), Hydrocodone (opioid medication used for moderate to severe pain) / Acetaminophen, Haloperidol, Lorazepam, Gabapentin (medication that calms over active nerves and is used to treat nerve pain), Bisacodyl (medication used to treat constipation), hydromorphone (powerful opioid used to treat moderate to severe pain), Hyoscyamine Sulfate (medication used to dry up excessive oral secretions and mucus to help keep the dying patient more comfortable)” and “Oxygen.” Record review of Patient 1 in the agency’s EMR system, revealed a SOC admission completed by RN A on 11/28/2025 RN A documented in the SOC visit that Patient 1’s pain was “Severe” with a pain level of “8” out of 10 and “Shortness of breath” was “Severe” with a level of “9” out of 10. RN A documented that treatment for shortness of breath was initiated on “11/28/25” which included “Opioids” and “Oxygen.” RN A documented in the nurse summary notes that Patient 1 was “currently taking only sips of water,” pain was poorly controlled, and he received IV (a small tube is inserted into a vein in which medication can be administered directly into the bloodstream) Morphine (opioid pain medication given for moderate to severe pain) at the hospital. RN A documented, at home Patient 1 had been taking Hydrocodone (opioid pain medication used to treat moderate to severe pain)/Acetaminophen (medication used to treat mild pain and fever) liquid and used a Fentanyl patch (an adhesive patch that is applied to the skin that delivers the powerful opioid pain medication through the skin into the bloodstream).Record review of Patient 1 in the agency’s EMR system did not contain evidence of a coordination or communication note documenting the reason why Patient 1 was not admitted onto Hospice on 11/27/2025 upon discharge from the hospital. Record review of the agency’s answering service call logs provided by the interim Adm on 12/5/2025 revealed a call received for Patient 1 from Family Member #4 on 11/27/2025 at 4:35 PM. The documentation of the call read “Need help setting up all his (Patient 1’s) equipment and oxygen ASAP. Please call me (Family Member #4) back with ETA for when the nurse will be here (Patient 1’s home).” The answering service documented that a text message was sent to the triage nurse RN B on 11/27/2025 at 4:33 PM and 4:52 PM with no response. The answering service documented a text message was sent to on call nurse RN D at 5:12 PM and 5:31 PM. The answering service documented that Family Member #4 confirmed a return call from one of the agency’s RNs at 5:47 PM.Record review of the triage on call report for date 11/27/2025 received via email from the interim Adm on 12/08/2025 contained triage nurse RN B’s documented call received at 4:47 PM which stated Patient 1’s “referral. Need assistance with setting up equipment and oxygen ASAP. Admission department will need to follow up with this please.” The email was sent to the agency’s “Clinical Teammates” group on 11/27/2025 at 6:07pm. The email did not contain documentation that Patient 1 was discharged from the hospital and needed to be admitted to hospice. Record review of a text message showed to the surveyor on 12/9/2025 by PCM #3 revealed a text message from RN D dated 11/27/2025 at 5:52pm which read “Spoke with” Family Member #4 “Equipment (oxygen equipment) sorted. She would rather have someone come in the morning” to complete Patient 1’s Hospice admission.An interview was conducted on 12/5/2025 at 11:48 am with the interim Adm. When asked about the agency’s policy and procedures on the coordination for a patient discharge from the hospital and admission to hospice. The interim Adm stated the agency tries “to schedule the time (of a patient discharge) with the hospital, so we (agency nurses) can be there when the patient arrives home. There are times when the hospital does not notify us (the agency) that the patient is discharged or that transport has been arranged. In that instance we (agency nurses) have to adjust our schedules.” When asked about the agency’s process of scheduling delivery of comfort medications (medications for pain, anxiety, nausea/vomiting, increased secretions, fever and constipation) on a rapidly declining patient prior to discharging from the hospital. The interim Adm stated, one of the agency’s “admission team” staff (clinical liaison, social worker or admission nurse) meets with the patient and patient’s family at the hospital to “complete consents (Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment).” The interim Adm stated once the consents are completed the agency can order a comfort kit to be delivered to the patient’s home prior to discharge.An interview was conducted with Family Members #4 and #5 during a home visit on 12/5/2025 at 3:35 PM. When asked about the incident that occurred on 11/27/2025, Family Member #4 stated that the agency’s Clinical Liaison met with her at the hospital “around 10 AM” on 11/27/2025 and Family Member #4 signed the Hospice Election of Benefits/ Medicare, Medicaid and Consent to Treatment for Patient 1. Family Member #4 stated the Clinical Liaison had informed her that a nurse from the agency “would be here (at patient’s home) at 4pm.” Family Member #4 stated Patient 1 was discharged from the hospital at approximately “3pm” and arrived home at approximately “3:45pm.” Family Member #4 stated she called the hospice agency after 4pm and asked for assistance on setting up the patient’s oxygen equipment and inquired on the ETA of the admission nurse. Family Member #5 stated they received a call “from a supervisor” at approximately “6:30pm.” When asked for the name of the supervisor, Family Member #5 stated “He refused to tell me his name.” Family Member #5 stated the supervisor told him “there was a mix up in the scheduling and a nurse would not be able to come out until 8:30 am the next morning (11/28/2025).” Family Member #5 stated, RN A “did not show up until 10am.” Family Member #4 stated “he (Patient 1) was receiving 2 to 4 milligrams of morphine (opioid pain medication for moderate to severe pain) in the hospital in addition to the fentanyl patch the hospital put on him that day and it wasn’t touching his pain.”An interview was conducted with PCM #3 on 12/9/2025 at 3:05pm. When asked about the delay in Patient 1’s admission to Hospice. PCM #3 stated, he believed the Admissions Manager or Admission’s Coordinator “that was working on Thanksgiving (11/27/2025), scheduled the admission and the admission nurse was running behind or something, so the admission ended up being later.” PCM #3 stated he reviewed the text message received on 11/27/2025 from the on-call nurse RN D. PCM #3 stated, RN D “was sorting through the equipment delivery or something with our equipment (oxygen equipment) so he was going to reach out to them (Patient 1’s family) after 5:00. He (RN D) talked to me for a little bit. He (RN D) then texted me that he spoke to” Family Member #4 “and she rather have someone (admission nurse) come in the morning.” PCM #3 showed the surveyor the text message dated 11/27/2025 at 5:52pm from RN D.An interview was conducted with the Admission’s Manager on 12/9/2025 at 3:42pm. When asked about the planned hospice admission for Patient 1 for Thanksgiving day 11/27/2025. The Admissions Manager stated, the Clinical Liaison “did the discharge planning (for Patient 1) and ordered the DME” on 11/27/2025. The Admissions Manager stated the admission nurse RN E was scheduled to be at Patient 1’s home on 11/27/2025. The Admissions Manager stated the agency’s part time Admission’s Coordinator assigned Patient 1’s admission to RN E’s schedule but did not call RN E to notify her of the scheduled admission. The Admissions Manager stated the nurses scheduled to work holidays were responsible for reading their “emails” and “calendar invites” that contained the scheduled patients’ admissions. The Admissions Manager stated there was a “missed communication” with RN E’s holiday work schedule and the agency “could not get in contact with” RN E on Thanksgiving Day (11/27//25) “So the admission got pushed to on call.” The Admissions Manager stated when the on-call nurse RN D reached out to Family Member #4, he was told that “it was too late” and Family Member #4 “requested a morning admission.”A phone interview was conducted with the Clinical Liaison on 12/10/2025 at 7:15am. When asked about Patient 1’s health status during her visit with Patient 1 in the hospital, the Clinical Liaison stated Family Member #4 told her Patient 1 “had severe pain when he was at home and was receiving liquid” Hydrocodone/Acetaminophen “and a Fentanyl patch.” The Clinical Liaison stated Family Member #4 “was also concerned of the severe neurological (nervous system that includes the brain, spinal cord and nerves that control movement, senses, thinking, and memory) changes he had from the stroke (condition that occurs when the blood flow to the brain is blocked or a blood vessel bursts, causing the brain cells to die). The Clinical Liaison stated “He (Patient 1) was sleeping when I was there and did not appear to be in distress and looked fairly comfortable. The hospital was giving him a minimal amount of pain medications.” The Clinical Liaison stated an email was sent on 11/27/2025 at 1:08pm to the Admission Nurse, the Admission Manager and the admissions intake department that Patient 1’s consents had been signed. The Clinical Liaison stated another email was sent at 2:37pm that transport had been arranged for Patient 1. When asked who was scheduled to complete the admission at Patient 1’s home, the Clinical Liaison stated RN E “was scheduled for 4pm.” When asked if the Clinical Liaison contacted RN E to update her on Patient 1 or the transport time. The Clinical Liaison stated the Clinical Liaisons communicated through email and the agency’s staff “are supposed to check their email when they are working.” The Clinical Liaison stated RN E was on the “calendar invite” the Clinical Liaison received, that contained the scheduled time of 4pm for Patient 1’s hospice admission. When asked if the Clinical Liaison had any knowledge on why RN E was not present at Patient 1’s home at 4pm on 11/27/2025. The Clinical Liaison stated she was told RN E “was a no call in, no show (did not notify management that she was not working).”An interview was conducted with RN E on 12/10/2025 at 10:03am. When asked if RN E was scheduled to work Thanksgiving Day (11/27/2025), RN E stated “I didn’t know I was scheduled to work on Thanksgiving, and I don’t check my phone when I’m not working. I found out the following Monday (12/1/2025) morning when I looked at my phone…” RN E stated “I generally would sign up to work New Year’s Day and New Year’s Eve. I guess that they (management) did the sign-ups when I was on maternity leave... No one (from management) ever talked to me about it (the holiday work schedule) so I didn’t know that I was working Thanksgiving...” When asked when RN E returned back to work from her leave, RN E stated “I came back November 17.”An interview was conducted with the interim Adm, PCM #2, and Admission Manager on 12/10/2025 at 1:28pm. The surveyor shared the findings of Patient 1, and the interviews with PCM #3, RN E, the Admission’s Manager, the Clinical Liaison, Family member #4 and #5. When asked if RN E was notified in advance of the holiday on-call schedule prior to 11/27/2025. The interim Adm stated she scheduled RN E for Thanksgiving Day (11/27/2025) because “she (RN E) was off Thanksgiving last year.” The interim Adm stated she rotated the agency’s on-call scheduling of staff for major Holidays (Thanksgiving, Christmas, New Years) based on if the staff member had worked a major holiday in the current or previous year. The interim Adm stated she emailed the11/27/2025 holiday on-call staff schedule, on 11/21/2025 at 3:57pm. The interim Adm stated “She (RN E) did not read her email.” When asked if the interim Adm had called RN E to notify her of the holiday on-call schedule when the interim Adm had scheduled RN E for Thanksgiving Day (11/27/2025), the interim Adm stated “No.” The Admission Manager stated, “It can get busy during the holidays” the Admission Intake Team “needs to call the nurses directly” to notify the nurses of the scheduled patient admissions. When asked about the failures in the agency’s communication regarding Patient 1’s hospice admission, the interim Adm stated, PCM #3 “should have followed up with the family” of Patient 1 the evening of 11/27/2025 regarding the hospice admission. The interim Adm stated that the Clinical Liaison should have notified the Hospice team that Family Member #4 reported Patient 1 had severe pain when he was at home so a comfort kit could have been delivered prior to the patient’s discharge. The Admission Manager stated, there was a “mix up” in the holiday staff schedule, and “going into the holidays set us (the agency) for failure. It would have been better if the medications had been ordered ahead of time before the patient was discharged.” When asked about the potential patient outcomes for a lack of communication between agency staff, the interim Adm stated, “Dissatisfaction by the patient or family regarding services and the patient not receiving the care. The ball was dropped,” on the hospice admission of Patient 1.Review of agency’s policy “Coordination of Care” with “Last Reviewed” date of 9/1/2024, read in part, “To ensure coordination of all care provided for patients receiving hospice services and /or services from other providers. The Hospice will develop and maintain a system of communication and integration, in accordance with the Hospice’s own policies and procedures to: Ensure that the care and services provided are based on all assessments of the patient and family needs. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Procedures. Upon referral and/or during the initial assessment, Hospice staff will determine if the patient is receiving care from other providers and coordinate provision of care accordingly. All communications and coordination of care is documented in the clinical record.””

“Based on record review and interview, the agency failed to enforce its written policies and procedures regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of patient services among all disciplines providing care and services in all settings, whether the care and services are provided directly of under arrangements, to promote optimal client outcomes in 1 (#1) of 5 patient records reviewed. This failure resulted in the patient and family members not receiving services and support in a timely manner. Findings: Record review of Patient #1’s medical record revealed an admission date of 2/21/2024. Patient #1 lived in a skilled nursing facility and had a diagnosis of Parkinson’s disease, a movement disorder that affects the nervous system and worsens over time. Parkinson’s disease symptoms may include stiffness or rigidity in extremities, cramps, numbness, tingling, or pain in the muscles. The medical record revealed RN C made an on-call visit during the day on 2/15/2025 and 2/16/2025. According to an email dated 8/27/2025 the answering service received two calls on 2/15/2025 and 3 calls on 2/16/2025. One of the calls on 2/15/2025 requested a nurse visit and two of the three calls on 2/16/2025 were regarding pain. There were no after hour nursing visits made on 2/15/2025 or 2/16/2025. On 2/16/2025 at 10:40pm, FM A requested a call from a manager. The triage nurse, RN D, sent an email to the manager on call. The Administrator did not see the email message until 2/17/2025 at 3:42 am. Patient #1 was transferred to the inpatient unit on 2/17/2025.An email dated 5/13/2025 revealed RN D was no longer employed by the agency effective 5/27/2025. In an interview 8/27/2025 at 11:45 am, the surveyor asked if RN C had received any calls to return during the night on 2/15/2025 or 2/16/2025 to visit Patient #1. RN C stated, “no, I don’t remember any other visits being made.” On 8/27/2025 at 2:51 pm FM A stated, “I am trying to get more morphine in her. I am requesting it cause I’m right there and she’s screaming help, help, help. I mean we’re rubbing her; we’re using massage on her, we’re calling Hospice. Hospice never sent anybody out for continuous care. This was the second pain breakthrough. We are pushing morphine and finally got her comfortable. I had a [paid] caregiver at the bedside. I had to put in a [baby] monitor. I mean by this point I’m exhausted. They’re [facility nurses] paying attention to her at the facility too. I got home at 10:30 p.m. I called the triage nurse, RN D, and I’m like what’s the plan she’s had two pain breakthroughs, they [hospice] did not start continuous care, they [hospice] did not send a nurse out to assess nothing and RN D said, “Well I don’t know what the plan is you’ll have to talk to my boss.”” Review of complaint #1016722 revealed FM A spoke to the Administrator 2/17/2025 at 9:00 a.m.During an interview 9/3/2025 at 2:15 pm with the Administrator and Alternate Administrator the surveyor asked about the coordination of care and the triage process. The Administrator said, “we made a change of where we had a designated triage nurse now our own call staff triages themselves and I think there’s fall through when that happens.” The Administrator stated, “in all transparency I think our on-call team needs a lot of work.” The Administrator commented, “I think there was just a lot of miscommunications, but the reality is that those facility nurses aren’t hospice nurses.” The Administrator said, “I think there needs to be more accountability for sure.” When asked how it could affect the patients or family members if a nurse was not sent or if the agency doesn’t triage properly the Administrator stated, “you have to take care of the patient and if they’re calling three times you’ve got to go there’s just no question.” The undated “On Call Visits- Best Practice” read in parts: “…new onset of symptoms- requires SN visit to assess …urgent needs (see symptom priority list) to receive SN visit within 2 hours. Non urgent needs (see symptom priority list) to receive SN visit on same day of report of new symptom…”The agency had a policy (PC.10) titled: “On Call for Patient Care” dated 9/1/24. The policy read in parts: “…Purpose: To ensure that patient care needs will be met safely and appropriately after the hospice office hours, during weekends, and on holidays. Policy: I. Nursing and physician services will be available 24 hours, seven days a week. A. Hospice will assign appropriately designated staff coverage for triage and/ or visits that need to be made after hours, on weekends, or on holidays. …Procedure: …II. The hospice will develop protocols and procedures for: …II. The on-call RN will respond to all calls and use professional judgement in determining any need to call the Administrative on-call RN…”The agency had a policy (PC.110) titled: “Coordination of Care” dated 9/1/24. The policy read in parts: “…Purpose: To ensure coordination of all care provided for patients receiving hospice services and/ or services from other providers. Policy: I. The hospice will develop and maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures to: …C. Ensure that the care and services provided are based on all assessments of the patient and family needs. D. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, …””

“Based on record review and interview, the agency failed to make bereavement counseling, including emotional, psychological, and spiritual, support and services available to a patient’s family and other persons before and after the death of the client to assist with issues related to grief, loss, and adjustment in the bereavement plan of care in 1 (#1) of 5 patient records reviewed. This failure resulted in additional family members not receiving available support and services and experiencing increased grief, anxiety, and stress. Findings:Record review of Patient #1’s medical record revealed an admission date of 2/21/2024. Patient #1 lived in a skilled nursing facility and had a diagnosis of Parkinson’s disease, a movement disorder that affects the nervous system and worsens over time. The undated demographics page revealed two daughters listed as emergency contacts. The initial bereavement assessment only listed one daughter and a risk factor of moderate. The patient died in the inpatient unit on 2/24/2025. During the patient’s stay in the inpatient unit the two daughters and a spouse had been frequent visitors. During the interdisciplinary team meeting 2/25/2025 bereavement was “discussed”, and the “family” was classified as a “low” risk. The bereavement plan of care dated 2/24/2025 only list FM A to receive bereavement services.In an interview 8/27/2025 at 12:08 pm, when asked who makes the decision regarding the bereavement level Chaplain A stated, “the nurse.” The surveyor stated, “so normally after the death the nurse would discuss with the team during IDT what the bereavement level would be.” Chaplain A stated, “yes.”During an interview 8/27/2025 at 12:46 pm the surveyor asked the bereavement Coordinator (BR A) how the bereavement level was assessed. BR A stated, “the nurse didn’t see any red flags when the client passed. So, it was discussed in interdisciplinary team meeting.” The surveyor asked, “how is it determined who receives the bereavement services?” BR A responded, “the initial assessment determines who is included in bereavement such as children, family members, or staff.”On 8/27/2025 at 2:51 pm FM A stated, “the only bereavement has been for me not FM B not FM C. There’s not just one bereaved in this family. FM B was traumatized by this.” Surveyor asked, “did anybody talk to any of you before or after she passed about where you were in your bereavement level.” FM A stated, “Nope.” The surveyor asked what FM A would have classified her bereavement level as when Patient #1 died. FM A stated, “they [hospice] probably classified me as low because of my clinical background. I probably would have been low to medium, but FM B and FM C would have been high.”On 8/28/2025 at 10:49 am when asked what the process for bereavement was; RN E stated, “bereavement is supposed to coordinate the plan of care for the next year after the death.” How is the level of risk for bereavement determined after death? RN E said, “it’s discussed in IDT.” Surveyor asked who should be included for bereavement services? RN E stated, “The main point of contact [on the demographics page].”On 9/3/2025 at 2:15 pm the surveyor met with the Administrator and the Alternate Administrator. The surveyor said, “tell me what your process is for bereavement.” The Administrator stated, “OK so after the primary bereaved person is identified during admission the social worker and the chaplain determine the bereavement risk.” The surveyor asked, “how is the bereavement risk assessed? Also, if they’re in the inpatient unit do you have an IDT? How does that work?” The Administrator said, “our [inpatient unit] patient care manager attends the IDT with the doctor, the social worker, the chaplain, and the nurse practitioner. They go over all the patients. Anybody that is medium or high risk we talk about those first and then we talk about the low risk.” The surveyor stated, “your demographics page might have more than one person listed as an emergency contact, but the additional people aren’t being listed on the bereavement assessments. Who does your initial bereavement assessments?” The administrator stated, “the social worker does the initial bereavement assessment.” Surveyor asked, “How do you think it would affect the additional family members and other persons if the bereavement wasn’t done properly?” The Administrator responded, “The additional family members may not receive the support and counseling for their grief.”The agency had a policy (PC.130) titled; “Bereavement” dated 9/1/24. The policy read in parts: “…Purpose: I. To ensure appropriate bereavement services are provided to hospice family members, caregivers, and other bereaved persons. …Policy: …IV. The hospice will make bereavement services available to the family and other individuals in the Bereavement Plan of Care (POC) before, and for up to one year following the death of the patient. … Procedure: I. the hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals…””

“Based on record review and interview, the agency failed to follow the plan of care for 3 (1, 7, & 9) of 4 patients receiving routine home care. This failure placed patients at risk for a decline in health status due to not receiving services as ordered in the plan of care. Findings: Record review of the clinical record revealed Patient 1 was admitted to hospice 2/21/24. Review of the initial plan of care dated 2/21/24 revealed a nursing frequency of 1 time a week. Review of the nursing visits revealed no nurse visited the week of 7/7/24 to 7/13/24. In an interview 10/14/24 at 1:00 pm with the administrator and the DON, the DON stated, “;it was a miscommunication with scheduling.” Record review of patient 7s medical record revealed patient 7 was admitted to hospice 1/24/24. Review of the plans of care dated 6/2/24, 6/18/24, and 7/2/24 revealed a nursing frequency of 2 visits a week. Review of the plans of care dated 6/2/24 and 6/18/24 revealed no aide frequency. Review of the plans of care dated 7/2/24 revealed an aide frequency of 3 times a week. Review of the orders revealed orders written 4/9/24 and 7/2/24 for a nurse aide to visit 3 times a week. Review of the visits in the medical record revealed patient 7 did not receive an aide visit the week of 6/16/24 to 6/22/24. The patient received 2 aide visits the weeks of 6/23/24 to 7/6/24. Patient 7 received one aide visit the week of 7/7/24 to 7/13/24. In an interview 10/14/24 at 1:00 pm with the administrator and the DON, the DON stated, “;I think she refused for a while and thats why there isnt a frequency on the plan of care.” Surveyor stated that the patient received some aide visits during this time. The DON stated, “;I dont know.” Record review of patient 9s medical record revealed patient 9 was admitted to hospice 3/25/24. Review of the initial plan of care dated 3/25/24 revealed the aide frequency was one visit a week. Review of the visits in the medical record revealed patient 9 did not receive an aide visit the weeks of 6/23/24 to 6/29/24, 7/7/24 to 7/13/24, and 7/21/24 to 7/27/24. In an interview 10/14/24 at 1:00 pm with the administrator and the DON, the DON stated, “;I dont know why they werent made.” The agency had a policy (PC.30) titled; “;Plan of Care Process” dated 09/01/24. The policy read in parts: “;...Purpose: To ensure that the care is provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients and familys specific needs. ...Policy: I. All hospice care and services furnished to patients and their family members will follow an individualized written POC established by the Hospice Interdisciplinary Group/ Team (IDG/ IDT) in collaboration with the attending physician, if any, the patient representative, and the primary caregiver, if any of them so desire and in accordance with the patients needs...””

“Based on record review and interview, the agency failed to include the frequency of nursing visits on the plan of care for 2 (1 & 4) of 4 routine home care patient records reviewed. This failure placed the patients at risk of not receiving nursing visits as ordered. Findings: Record review of patient 1s medical record reveal patient 1 was admitted to hospice 2/21/24. Review of the initial plan of care dated 2/21/24 revealed a nursing frequency of 1 time a week. Review of the plans of care dated 6/26/24 and 7/10/24 revealed no nurse visit frequencies. Review of the plan of care dated 7/23/24 revealed a nursing frequency of 1 time a week. Review of the nursing visits revealed no nurse visited the week of 7/7/24 to 7/13/24. Record review of patient 4s medical record revealed patient 4 was admitted to hospice 9/22/24. Review of the plans of care dated 9/22/24 and 9/24/24 revealed no frequencies for nursing visits. In an interview 10/14/24 at 1:00pm with the administrator and the DON, the surveyor asked asked why the frequencies for nursing were not on the plan of care? The DON stated, “;they [nurses] arent clicking everything in the EMR [electronic medical record] so its not all getting attached to the plan of care.” The agency had a policy (PC.30) titled; “;Plan of Care Process” dated 09/01/24. The policy read in parts: “;...Purpose: To ensure that the care is provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients and familys specific needs. ...Procedure: ...VI. The POC includes, but is not limited to: ...B. A detailed statement of the scope and frequencies of services necessary to meet the specific patient and family needs, including level of care; ...D. Drugs and treatments necessary to meet the needs of the patient...””

“Based on record review and interview, the agency failed to include medications on the plan of care for 1 (#1) of 4 routine home care patient records reviewed. This failure placed the patient at risk of not receiving medications as ordered. Findings: Review of the clinical record revealed Patient 1 was admitted to hospice 2/21/24. Review of the plans of care dated 6/26/24 and 7/10/24 revealed no medications listed on the plan of care. Review of the “;IDG Comprehensive Assessment” dated 6/26/24 revealed the assessment did include orders for Lasix on 6/22/24 as 20mg one tab now and 6/26/24 as 20mg 2 times a day. Review of the “;IDG Comprehensive Assessment” dated 7/10/24 revealed the assessment did include orders for Lasix on 6/22/24 as 20mg on tab now, 6/26/24 as 20mg 2 times a day, and on 7/10/24 Lasix 40mg 1 time a day. Review of the plan of care dated 7/23/24 revealed Lasix was ordered 20mg 1 time a day. In an interview 10/14/24 at 1:00pm with the administrator and the DON, the surveyor asked which is considered the plan of care? The plan of care or the IDG Comprehensive Assessment? The DON stated, “;the plan of care is the plan of care.” Surveyor asked why the medications were not on the plan of care? The DON stated, “;they [nurses] arent clicking everything in the EMR [electronic medical record] so its not all getting attached to the plan of care.” The agency had a policy (PC.30) titled; “;Plan of Care Process” dated 09/01/24. The policy read in parts: “;...Purpose: To ensure that the care is provided is in accordance with the written plan of care (POC), appropriately planned, and delivered in a timely manner to meet the patients and familys specific needs. ...Procedure: ...VI. The POC includes, but is not limited to: ...B. A detailed statement of the scope and frequencies of services necessary to meet the specific patient and family needs, including level of care; ...D. Drugs and treatments necessary to meet the needs of the patient...””

“Based on record review and interview, the agency failed to maintain a system of communication to ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 2 (1 & 3) of 2 patients receiving routine home care services in an assisted living facility. This failure placed the patients at risk of not receiving care and services as ordered. Findings: Review of the clinical record revealed patient 1 was admitted to hospice 2/21/24. On admission, patient 1 resided in an assisted living facility. The facility was responsible for medication administration. Review of the “;IDG Comprehensive Assessment” dated 6/26/24 revealed the assessment did include orders for Lasix on 6/22/24 as 20mg on tab now and 6/26/24 as 20mg 2 times a day. Review of the physician orders revealed Lasix 20mg two times a day on 6/26/24. Review of the “;IDG Comprehensive Assessment” dated 7/10/24 revealed the assessment did include orders for Lasix on 6/22/24 as 20mg on tab now, 6/26/24 as 20mg 2 times a day, and on 7/10/24 Lasix 40mg 1 time a day. Review of the nursing visits dated 6/5/24, 6/13/24, 6/20/24, 6/28/24, and 7/5/24 revealed no coordination or documentation of communication regarding the Lasix order increase on 6/26/24 with the assisted living facility. The assisted living facility did not receive the new orders for the increase in Lasix. The patient did not receive the increased Lasix as ordered after 6/26/24. In an interview 10/14/24 at 1:00pm with the administrator and the DON, the surveyor asked how communication and coordination with the assisted living was done. The DON stated, “;prior to this the nurses were communicating and giving verbal instructions. They should be documenting in the EMR. Now we create an alert in the EMR who they need to talk to and what needs to be communicated.” Surveyor asked why the Lasix order was not followed up on? The DON stated, “;it was an issue of coordination prior to this new process.” Review of the clinical record of patient #3 revealed the client was admitted to hospice service on 4/16/24. On admission, patient 3 resided in an assisted living facility. The facility was responsible for the activities of daily living of patient 3. Further review revealed documentation that the family member of patient 3 called the DON and stated patient 3 had a wound. The family member said the assisted living facility said they found it and told HHA A to report it to the hospice nurse. The family member was inquiring if this statement was true. Record review revealed the DON called HHA A and was told that HHA A found the wound and reported it to the assisted living facility staff. HHA A stated she was told by the assisted living facility to notify the hospice nurse. HHA A stated she thought she had notified the nurse but she couldnt find it in her emails. In an interview 10/14/24 at 1:00 pm with the administrator and the DON, the DON stated, “;HHA A reported it to the assisted living facility, but not the hospice nurse and she didnt document it.” The agency had a policy (PC.110) titled; “;Coordination of Care” dated 09/01/24. The policy read in parts: “;...Purpose: to ensure coordination of all care provided for patients receiving hospice services and/ or services from other providers. Policy: I. The hospice will develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures to: ...B. Ensure that the care and services provided in accordance with the Plan of Care (POC). ...Procedure: ...VI. All communications and coordination of care is documented in the clinical record...””

“Observed in Record Review. In 2 of 23 patient records reviewed, the Hospice did not develop a comprehensive care plan for patients receiving services in the community. RR#17 and RR#18 was transferred from the IPU to the community and received skilled nursing, chaplain, and social work services in the community. There was no comprehensive care plan developed post transfer to the community that detailed the services, treatments, and or medications that were provided in the community for these patients and there was no update to the care plans detailing these items. The policy titled - Plan of Care Process reflected that the care plan should be updated when the patient condition requires. This observation was discussed with the RN Manager.”

“Observed in Record Review. In 2 of 23 patient records reviewed, the Hospice did not update the assessment after the admission. RR#8 had orders for a music therapy visit which was not completed. The subsequent IDT did not address the status of the music therapy visit. The following medications were discontinued for RR#10 - methadone, a medication to treat hypothyroidism, and one to treat acid reflux. On the following day, RR#10 was placed on an antibiotic. The subsequent IDG following these changes did not address these medications or the patient response to changes. These observations were discussed with the RN manager. Observed in Record Review. In 6 of 23 patient records reviewed, the organization failed to document progress towards desired outcomes. During record review for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRHV#5 and RRHV#6, the Hospice Nurse Surveyor observed no documentation of progress towards goals. Goals were opened at SOC and closed when achieved but there was no documentation in between. This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 9 of 23 patient records reviewed, the organization failed to plan the patient’s care. During record review for all records, the Hospice Nurse Surveyor #2 observed the plan’s of care did not contain timeframes of when the goal’s were to be achieved. After discussion with the organization they stated that target dates were not in place. This was discussed and reviewed with the Hospice Administrator. Observed in Record Review. the hospice comprehensive care plan did not include reasonable/measurable timeframes to achieve goals. Based on the assessment RR#7, this patient had a wound, had dysphagia, was at risk for falls, and had limited mobility. The goals listed for these problems did not include timeframes to achieve. RR#8 had a wound that required care and the comprehensive care plan did not include a goal that addressed wound healing. RR#9 was oxygen dependent, was severely dyspneic, weak, and essentially wheelchair/bed bound. The goals listed for these issues did not have target dates to achieve. This observations was discussed with the RN manager.”

“Observed in Individual Tracer. In 10 of 23 patient records reviewed, the hospice plan of care did not reflect the services required and provided to the patient. RR#12 had a Pleurx drain and neither the comprehensive care plan or updates to the care plan stipulated orders related to the frequency of drainage or any limitations related to drainage, or the care to the insertion site. RR#13 had a 18 French Foley based on a review of the assessment however the standing orders reflected a 16 French foley and there was no updates to the care plan to accurately reflect the Foley size. Spoke with the RN manager.”

“Observed in Record Review. In 6 of 6 patient records reviewed, the organization failed to plan the patient’s care. During record review for all records, the Hospice Nurse Surveyor #2 observed the plan’s of care did not contain goals with measurable outcomes. For example in RRHV#1, the Hospice Nurse Surveyor #2 observed a problem statement related to a Pleurex Drain with a goal of provide measurable relief. The interventions included assess patency of tube, drainage flow adequate, collaborate with medical provider, educate patient/ cg on how to drain and maintenance. The goal was not measurable. For RRHV#2, the patient had a problem statement related to diarrhea and the goal was measures in place to manage diarrhea. Interventions included auscultate bowel sounds, assess use of medications, use antidiarrheal medications Documentation includes no longer using the antidiarrheal medications as diarrhea is no longer a problem but the goal was not updated. 

Also the organization failed to have complete medication orders. During record review for RRHV#1, RRHV#2, and RRHV#3, the Hospice Surveyor #2 observed patients had two different PRN medications for pain ordered but the orders did not include which medication to use first. For example in RRHV#1 the patient had Acetaminophen PRN and Morphine PRN with no indication when to use which. And in RRHV#2 the patient had Acetaminophen and Dilaudid ordered for pain with no indication when to use which medication. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Individual Tracer. the Hospice record did not accurately reflect the medication that the patient was taking. RR#8 reflected that the patient had 3 different prn doses or route of acetaminophen for the indication of pain. There was no further qualification of this prn order for pain. Similarly, RR#7 had four different prn orders for pain, some of which where narcotics,. and there was no further qualification of when to give a particular prn medication. Additionally, RR#7 had two different prn medications for the symptom of constipation and there was no further qualification of the indication for use of these medications. This observation was discussed with the RN mmanager.”

“Observed in Tracer Activities. The surveyor noted the HCO did not use the results of data analysis to identify improvement opportunities as evidenced by the organization was collecting data but unable to provide analysis or aggregation of that data at the time of survey. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The surveyor noted the HCO did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by the organization was collecting data but not aggerating and analyzing the data. Specifically the hand hygiene data, infection data and falls data was not analyzed and aggregated. 

This was discussed and reviewed with the Hospice Administrator. 
”

“Observed in Tracer Activities. The surveyor noted performance improvement was not organization wide as evidenced by the organization was unable to provide an individualized QAPI plan for 2022 or 2023. During tracer activities for Data Management, the Hospice Nurse Surveyor #2 observed the organization had purchased a blank template for QAPI and had not individualized the plan or the goals. 

This was discussed and reviewed with the Hospice Administrator. Observed in Tracer Activities. The surveyor noted the HCO leadership did not establish priorities for data collection/PI activities as evidenced by the organization was unable to provide an individualized QAPI plan for 2022 or 2023. During tracer activities for Data Management, the Hospice Nurse Surveyor #2 observed the organization had purchased a blank template for QAPI and had not individualized the plan or the goals. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Patient Home. In 4 of 6 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned related to cleaning and disinfecting of equipment. During home visit for RRHV#1, RRHV#3, RRHV#5 and RRHV#6, the Hospice Nurse Surveyor #2 observed the staff did not follow the organizational policy or manufacturer guidelines for equipment cleaning. For example in RRHV#1, the LPN did not clean the thermometer before placing it bag into the nursing bag, the blood pressure cuff was cleaned with sani-wipes but immediately placed back into her nursing bag and the pulse oximeter was wiped with alcohol and immediately placed back into her nursing bag. For RRHV#3, the staff used wipes not supplied by the organization which did not have directions for use. During the interview the staff member stated she wasn’t sure what the dry/ wet time was. During RRHV#5 and RRHV#6, the staff member used over the counter facial wipes to clean her equipment and was not certain what the wet/ dry time was. The package had no guidance for cleaning equipment. 

This was discussed and reviewed with the Hospice Administrator. Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During RRHV #1 and RRHV#4, the Hospice Surveyor #2 observed staff did not follow the organizational policy on bag technique. For example in both RRHV#1 and RRHV#4, the staff failed to perform hand hygiene when going in and out of the nursing bag, as required by policy. They also failed to perform hand hygiene between glove changes. Also for RRHV#4, during a bed bath the aide removed her glove, wiped sweat from her forehead and put a new glove on without performing hand hygiene. 

This was discussed and reviewed with the Hospice Administrator.”

“Observed in Record Review. In 1 of 4 bereavement records reviewed, the surveyor noted that the organization did not follow the bereavement care plan. The death occurred November 10, 2022. A care plan was generated at the time of death and the care plan indicated a low risk. Per the care plan and the organization’s policy, the bereaved would receive a sympathy card, an initial phone call and a letter at months 1, 3, 6, 9 and 13. At the time of the survey, the bereaved was at month 12. The bereavement record indicated that a letter was sent at 1 month and there was no other documentation of bereavement services provided. There was no documentation that the bereaved opted out or declined services. The Bereavement Manager was present during this observation and observed the same.”

“Observed in Record Review. The organization failed to plan the patient’s care. During record review for RRHV#1, RRHV#3, RRHV#4 and RRHV#6, the Hospice Nurse Surveyor #2 observed the patients had Aide services and were on oxygen but the aide care plan did not address whether the oxygen could be removed during the bath. Also for RRHV#6 the patient was a fall risk but this was not listed on the Aide Care Plan. This was discussed and reviewed with the Hospice Administrator. Observed in Individual Tracer. In 7 of 9 patient records reviewed, the hospice aide care plan did not include all required written instruction based on the assessed needs of the patient. RR#7 was wheelchair bound and had dysphagia. The hospice aide care plan reflected a shower without further qualifications and did not include aspiration precautions. RR#8 was oxygen dependent and had a wound, the hospice aide care plan did not include wound or oxygen precautions. RR#11 had seizures and although the patient was receiving aide services, the care plan did not reflect any details related to the aide’s tasks and or any seizure precautions. This observation was discussed with the RN manager.”

“Observed in Record Review. In 2 of 3 patient records reviewed, that were transferred to another facility, did not have evidence that the discharge/transfer summary was sent to the receiving facility. DC #1 revoked, was sent to the hospital and discharge from service. There was no evidence in the record or elsewhere that the discharge summary was sent to the hospital. Similarly, DC#3 was transferred to another Hospice and there was no documentation in the record that summary was sent to the receiving Hospice. This observation was discussed with the RN manager.”