New Century Hospice of South Texas

“Based on record review and interview, the Hospice failed to include all services necessary for the palliation and management of the terminal illness and related conditions including the interdisciplinary group’s documentation of the patient’s or representative’s level of understanding, involvement and agreement with the plan of care, in accordance with the hospice’s own policies, in the clinical record for 4 (Patient #1, Patient #2, Patient #3, and Patient #4) of 4 patients whose records were reviewed. This failure could place the Hospice patients at risk of not receiving the care or services to meet their needs and lead to increased pain and suffering. The findings included:Record review of Patient #1’s electronic medical record (EMR) included an initial “Hospice Certification and Plan of Care” signed and dated 04/23/26 that documented a certification period “04/13/26 to 06/11/26”. The POC documented a start of care date of 04/13/26, the patient’s name and address, provider and physician’s name and address, terminal diagnosis, frequency/duration of visits, order of disciplines and treatments, goals, DME (durable medical equipment) and supplies, functional limitations, safety measures, activities permitted, nutritional requirements, advanced directives, mental statuses, allergies, and medications. Further review of Patient #1’s EMR included a “Hospice Recertification Plan of Care (POC) Update” signed and dated 06/04/26 that documented a certification period of “06/12/26 to 08/10/26”. The POC documented calendar frequency, orders, goals, level of care, supplies, and current ordered medications. Patient #1’s initial and current POC failed to include the patient’s or representative’s level of understanding, involvement and agreement with the plan of care in accordance with the hospice’s own policies. Record review of Patient #2’s electronic medical record included a “Hospice Recertification Plan of Care (POC) Update” signed and dated 07/21/26 that documented a certification period of “07/26/26 to 09/23/26”. The POC further documented calendar frequency, orders, goals, level of care, supplies, and current ordered medications. Patient #2’s POC failed to include the patient’s or representative’s level of understanding, involvement and agreement with the plan of care in accordance with the hospice’s own policies. Record review of Patient #3’s electronic medical record (EMR) included a “Hospice Recertification Plan of Care (POC) Update” signed and dated 03/26/26 that documented a certification period of 04/01/26 to 05/30/26”. The POC further documented calendar frequency, orders, goals, level of care, supplies and current ordered medications. Record review of Patient #3’s EMR included an initial “Hospice Certification and Plan of Care (POC)” signed and dated 10/17/25 that documented a certification period “10/03/25 to 12/31/25. The POC documented the patient’s name and address, provider and physician’s name and address, terminal diagnosis, frequency/duration of visits, order of disciplines and treatments, goals, DME (durable medical equipment) and supplies, functional limitations, safety measures, activities permitted, nutritional requirements, advanced directives, mental statuses, allergies, and medications. Patient #3’s initial and current POC failed to include the patient’s or representative’s level of understanding, involvement and agreement with the plan of care in accordance with the hospice’s own policies. Record review of Patient #4’s electronic medical record (EMR) included an initial “Hospice Certification and Plan of Care (POC) signed and dated 08/29/25 that documented a certification period of 08/26/25 to 11/23/25. The POC further documented the patient’s name and address, provider and physician’s name and address, terminal diagnosis, frequency/duration of visits, order of disciplines and treatments, goals, DME (durable medical equipment) and supplies, functional limitations, safety measures, activities permitted, nutritional requirements, advanced directives, mental statuses, allergies, and medications. Further record review of Patient #4’s EMR included a “Hospice Recertification Plan of Care (POC) update” signed and dated 04/09/26 that documented a certification period 04/23/26 to 06/21/26. Record review of Patient #4’s EMR also included a current “Hospice Recertification Plan of Care (POC) update” signed and dated 08/14/26 that documented a certification period 08/24/26 to 10/22/26. Record review of Hospice Recertification POCs signed and dated 04/09/26 and 08/14/26 documented calendar frequency, orders, goals, level of care, supplies and current ordered medications.Patient #4’s initial and recertification POCs failed to include the patient’s or representative’s level of understanding, involvement and agreement with the plan of care in accordance with the hospice’s own policies.In a simultaneous record review and interview on 09/21/26 at 12:05 p.m. Adm/DON confirmed a start of care (SOC) for Patient #1 as 04/13/25 and a certification period of 06/12/26 – 08/10/26. The Adm/DON reviewed the POC and stated the POC did not include documentation of the patient or representative’s level of understanding, involvement and agreement with the plan of care. The Adm/DON stated she did not know why it was not included in the POC. The Adm/DON stated she was not sure if there had been an update to the electronic medical record system that would have caused the component to not be included. In a continued record review and interview the Adm/DON confirmed a SOC for Patient #2 as 05/27/26 and a certification period of 06/12/26 – 08/10/26. The Adm/DON stated the POC also did not include documentation of the patient or representative’s level of understanding, involvement and agreement with the plan of care and that it should be documented on it to reflect the patient or representative’s agreement to the POC. The Adm confirmed a SOC for Patient #3 as 10/03/25 and a certification period of 04/01/26 – 05/30/26 and agreed that the POC also did not include documentation of the patient or representative’s level of understanding, involvement and agreement with the plan of care. The Adm/DON stated the patient or representative’s level of understanding, involvement and agreement should be documented on the POC and the documentation should reflect their agreement with the POC. The Adm/DON stated she did not see the documentation on the POC and that the component was missing. The Adm/DON stated that based on the Hospice’s policy, “it [the documentation] should be there [on the POC]”. The Adm/DON confirmed a SOC of 08/26/25 and a certification period of 04/23/25 to 06/10/26 for Patient #4. The Adm/DON stated the POC did not document the patient or representative’s level of understanding, involvement and agreement with the plan of care. In a follow- up interview on 09/21/26 at 02:00 p.m. the Adm/DON stated the development of the plan of care should involve the patient and family, the IDG and the physician and should include components such as level of care, medications, problems, goals, interventions, diet orders, wound care orders, equipment or supplies, functional status and the proposed schedule for staff visits. The Adm/DON stated the nurse and the physician were responsible for the development of the plan of care and that everyone at the Hospice ensured the plan of care was complete. The Adm/DON stated that the plan of care did not include documentation that stated the patient or family or representative understood and agreed to the plan of care.Record review of the Hospice policies titled, “The Plan of Care, Policy No. 4-027”, with a revised date 05/21/26, quoted in part, “an individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The patient and family/caregiver will be encouraged to participate in the development of and continued updated of the plan of care. This plan of care must be initiated at start of care….13. The written plan of care will contain, but will not be limited to, the following…x. Patient or representative’s level of understanding, involvement and agreement with the plan of care…””

“Upon patient record review, 8 of 19 records (Patient #1,#3,#8,#9,#10,#12,#13,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Medication profile indicated oxygen 2-4L. Nursing documentation from 10/31/23 to current indicated that patient was not wearing oxygen. There was not evidence that this was reflected in the medication profile. Corrected on site. In addition nurse documentation from the admission assessment indicated the patient was taking Dulcolax suppository PRN. There was not evidence that it was added to medication profile. Patient #3: Medication profile indicated Nystatin Powder 100,000/1gram. Apply to affected areas twice daily. There was not evidence of a location. Corrected on site. Patient #8: Medication profile indicated oxygen 3-5L continuously. From 10/30/23 to current nurse documentation indicated oxygen at 6L. There was no indication to change the liter flow of oxygen. Corrected on site. In addition, medication profile for Metamucil oral powder 3 grams as needed PRN constipation. There was no evidence of a diluent or specific frequency. Corrected on site. Patient #9: The medication profile indicated Diclofenac 1% topical gel 1inch three times daily. There was no evidence of a location. Corrected on site. Patient #10: The record indicated Lidocaine pain relief 4% topical patch 1 every 12 h prn pain without evidence of a location. Corrected on site. In addition, Miralax 17Gm powder, 1 daily for constipation without evidence of a diluent. Corrected on site. Also, Tylenol 325, 2 tabs q4h prn pain/fever, and Acetaminophen 650 rectal supp q6h prn pain/fever. There was not evidence of a parameter for the fever and there was not a maximum allowable dose per 24 hours. Corrected on site. Patient #12: The record indicated for Acetaminophen 650mg rectal supp q6h prn pain/fever. There was not evidence of a parameter for the fever. Corrected on site. In addition, Miralax 17 Gm daily prn constipation without evidence of a diluent. Corrected on site. Patient #13: The record indicated ABH cream 1/25/1 q2h prn per instructions. There was not evidence of specific instructions. Corrected on site. In addition, Tylenol 650mg, 1 tab q8h prn pain and hydrocodone5-Acetaminophen325, 1 q4-6h prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. Patient #14 The record indicated oxygen 2-5L/min prn. There was not evidence of a route. Corrected on site.”

“Upon patient record review, 2 of 19 records (Patient #10,#11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #10:The patient was admitted on 9/16/23. The record indicated that the bereavement assessment was completed on 11/9/23. Patient #11:The patient was admitted on 6/13/23. The record indicated that the bereavement assessment was completed on 6/21/23.”

“Upon patient record review, 1 of 19 records (Patient #4) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family’s needs and t coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #4: Record indicated a call from Triage on 11/12/23 at 10:22pm that the patient had a fall and was complaining of pain in her head. A visit was advised. There was not evidence of a visit until 11/14/23 at 7:54am.”

“Upon patient record review, 3 of 19 records (Patient #2,#4,#12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #2: Patient was admitted with metastatic malignant neoplasm of right bronchus and lung, has a history of laryngectomy. There was no evidence that the hospice has developed an individualized written plan of care that reflects patient/family goals and interventions based on the problems identified in the initial assessment including pain. Corrected on site. Patient #4: Record indicated in nursing documentation and the certification of terminal illness that the patient has frequent behavioral outbursts with frequent anxiety, yelling and hitting at times. She has had a psych evaluation and requires 2 aides for care, and was started on Depakote. There was not evidence that the care plan reflected goals and interventions related to her Alzheimer’s/Neurological well-being. Corrected on site. Patient #12: The patient was admitted with a Gastrostomy tube and was receiving feedings. There was not evidence of care plan goals and interventions related to the gastrostomy tube.”

“Upon patient record review, 4 of 19 records(Patient #2,#10,#11,#12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2: The visit frequency on admission for the Spiritual Care counselor and for the Social Worker was 1 PRN. Patient #10: The visit frequency for the spiritual care counselor and the social worker on the date of admission (9/16/23) was 1 PRN for both disciplines. Patient #11: The visit frequency for the Social Worker was 2 PRN. Patient #12: The visit frequency on admission for the Spiritual Care counselor and for the Social Worker was 1 PRN.”

“Upon patient record review, 8 of 19 records (Patient #1,#3,#8,#9,#10,#12,#13,#14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient#1: The record indicated oxygen was ordered 2-4L continuously. Nurse documentation from 10/31/23 to current did not indicate patient was wearing oxygen. There was not evidence to change the oxygen order. Corrected on site. In addition nurse documentation from the admission assessment indicated the patient was taking Dulcolax suppository PRN. There was not evidence of an order. Patient #3: The record indicated Nystatin Powder 100,000/1gram. Apply to affected areas twice daily. There was not evidence of a location. Corrected on site. Patient #8: The record indicated oxygen 3-5L continuously. From 10/30/23 to current nurse documentation indicated oxygen at 6L. There was no indication of an order to change the liter flow of oxygen. Corrected on site. In addition, the record indicated for Metamucil oral powder 3 grams as needed PRN constipation. There was no evidence of a diluent or specific frequency. Corrected on site. Patient #9: The record indicated for Diclofenac 1% topical gel 1inch three times daily. There was no evidence of a location. Corrected on site. Patient #10: The record indicated Lidocaine pain relief 4% topical patch 1 every 12 h prn pain without evidence of a location. Corrected on site. In addition, Miralax 17Gm powder , 1 daily for constipation without evidence of a diluent. Corrected on site. Also, Tylenol 325, 2 tabs q4h prn pain/fever, and Acetaminophen 650 rectal supp q6h prn pain/fever. There was not evidence of a parameter for the fever and there was not a maximum allowable dose per 24 hours. Corrected on site. Also, the nurse documentation indicated the presence of a Foley catheter on 10/9/23 and nurse documentation dated 10/13/23 revealed that the patient had oliguria and incontinence with no documentation of a Foley catheter. There was not evidence of an order to remove the catheter. Patient #12: The record indicated for Acetaminophen 650mg rectal supp q6h prn pain/fever. There was not evidence of a parameter for the fever. Corrected on site. In addition, Miralax 17 Gm daily prn constipation without evidence of a diluent. Corrected on site. Patient #13: The record indicated ABH cream 1/25/1 q2h prn per instructions. There was no evidence of specific instructions. Corrected on site. In addition, Tylenol 650mg, 1 tab q8h prn pain and hydrocodone5-Acetaminophen325, 1 q4-6h prn pain. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. Patient #14 The record indicated oxygen 2-5L/min prn. There was not evidence of a route. Corrected on site.”

“Upon client record review 2 of 19 records (Patient #10,#11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10: The visit frequency for the spiritual care counselor was 1 every 2m2, 1m1. The record indicated that an evaluation was conducted on 9/22/23 and routine visits were conducted on 10/19/23 and 11/16/23. In addition, the Skilled nurse visit frequency was 4w1, 2w7, 1w1 effective 10/15/23. The record indicated only 2 visits for the week of 10/15/23-10/21/23, and 1 visit for the week of 11/19/23-11/25/23. Patient #11: The visit frequency for the spiritual care counselor was 1 every 2m2, 1m1. The record indicated that visits were conducted on 10/3/23 and 11/9/23. In addition, the visit frequency for the skilled nurse was 2x/week For the weeks of 11/19/23-11/25/23. The record indicated only 1 visit.”

“Upon patient record review, 3 of 19 records (Patient #17, #18, #19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery. Patient #17: Wife accepted bereavement support services. Phone call made and sympathy card sent out on 07/18/23. There was not evidence of further letters sent or calls per bereavement care plan. Patient #18: Daughter accepted bereavement support services. Phone call made and sympathy card sent out on 6/27/23. There was not evidence of further letters sent or calls per bereavement care plan. Patient #19: Patient expired 06/29/23. Per bereavement plan of care first bereavement call and sympathy card was due by 07/13/23. Daughter was not called until 09/01/23.”

“Upon patient record review 4 of 19 records (Patient #2,#10,#12,#13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #2: Record indicated an order for aide visit 1W1 effective 11/26/23. There was not evidence of a visit by the aide. Patient #10: The aide visit frequency was 3x/week. There was not evidence of aide visits since the date of 10/25/23. Patient #12: The aide visit frequency was 3x/week. During the month of October, visits were made only 2 x/week with no visits documented since 10/31/23. Patient #13: The aide visit frequency was 2x/week. For the weeks of 11/5/23-11/11/23 and 11/19/23-11/25/23, the record indicated only 1 visit each of these weeks.”

“Upon patient client record review, 1 of 19 records (Patient #8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #8: Nurse note indicated on 11/24/23 that patient was a DNR. An IDG dated 11/28/23 in the MSW narrative indicated that patient was not a full code. The nurse narrative from the same IDG, indicated that patient was a full code. The code status could not be determined due to the conflicting information.”

“Upon client record review, 1 of 19 records (Patient #12) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #12: The visit frequency for the spiritual care counselor was 1 every 2m2, 1m1. The record indicated that an evaluation was conducted on 9/26/23 and subsequent routine visits were conducted on 10/3/23 and 11/16/23. In addition, the visit frequency for the social worker was 1 every 2m2, 1m1. The record indicated that an evaluation was conducted on 9/22/23 and subsequent routine visits were conducted on 10/10/23 and 11/9/23. Also, the skilled nurse visit frequency was 2x/week. For the week of 10/22/23-10/28/23 and 11/19/23-11/25/23, only 1 visit was made each of these weeks.”

“Upon client record review, 1 of 19 records (Patient #12) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #12: An order dated 9/22/23 indicated to cleanse wound with Hibicleanse and water daily. Apply zinc oxide every brief change. There was not evidence of a wound location or which provider was to perform the wound care,”