Bristol Hospice - Texas, LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 4 of 23 (17%) clinical records reviewed revealed the agency did not ensure the medication profile was updated. HOME VISIT 1: The patient’s date of election was 08/10/2026. The Medication Profile printed on 09/01/2026 revealed Quetiapine 25 mg tablet 1 tables oral 2 times a day. During the Home Visit (Clinical Record #8) on 09/02/2026 with the Registered Nurse (Personnel Record #9), the facility medication record showed Quetiapine 25 mg tablet, 1 tablet orally daily, started 08/13/2026. The facility nurse verified that the patient received the medication once a day. There was no documented evidence that the hospice medication profile was updated to include the Quetiapine. HOME VISIT 3: The patient’s date of election was 04/14/2026. The Medication Profile printed on 09/01/2026 revealed Reglan 5 mg tablet 1 tablet oral every 6 hours hs (hour of sleep) prn (as needed) nausea. During the Home Visit (Clinical Record #7) on 09/02/2026 with the Registered Nurse (Personnel Record # 10), the medications in the home included Prochlorperazine tab 5 mg, take 2 tabs (10 mg) by mouth three times a day as needed for nausea and vomiting, started 04/02/2026.There was no documented evidence that the hospice medication profile was updated to include the Prochlorperazine. HOME VISIT 4: The patient’s date of election was 05/19/2025. The Medication Profile printed on 09/01/2026 revealed a Multivitamin tablet, chewable, 1 tablet chewed once a day for wound healing; Remeron 15 mg tablet, 0.5 tablets oral once a day for Other; and Vitamin C 500 mg tablet, 1 tablet oral once a day for wound healing. During the Home Visit (Clinical Record #2) on 09/02/2026 with the Hospice Aide (Personnel Record # 13), the medication profile at the facility revealed Acetaminophen-hydrocodone 325 mg-10 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain, started 06/09/2026; and Atorvastatin Calcium oral tab 20 mg, take 1 tablet by mouth at bedtime, started 07/22/2024. The facility’s medication record did not include a Multivitamin, Remeron, and Vitamin C. The agency’s medication record did not include Acetaminophen-hydrocodone and Atorvastatin. There was no documented evidence that a medication reconciliation had taken place with the facility. HOME VISIT 6: The patient’s date of election was 08/01/2024. The Medication Profile printed on 09/02/2026 orders for Tramadol Hydrochloride 50 mg tablet 1 tablets oral once a day for pain (one every morning); and Lorazepam 1 mg tablet 1 tablet oral once a day (taken in the evening). During the Home Visit (Clinical Record #18) on 09/03/2026 with the Medical Social Worker (Personnel Record # 11), the medication at the facility revealed Lorazepam 1 mg tablet, take 1 mg by mouth every 6 hours as needed for anxiety (directions on the blister pack); Tramadol Hydrochloride 50 mg tablet, take 1 tablet by mouth every 6 hours as needed for pain, started 11/14/2025. There was no documented evidence that a medication reconciliation had taken place with the facility to update the hospice medication profile. During a joint record review and interview on 09/03/2026, the Regional Director of Clinical Operations confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed revealed the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient’s date of election was 05/27/2026 with a primary hospice diagnosis of anoxic brain damage with the following comorbidities: epilepsy, chronic respiratory failure with hypoxia, tracheostomy, gastrostomy, and a nephrostomy tube. The initial nursing assessment on 05/27/2026 documented “Immediate concerns include respiratory management related to tracheostomy and chronic respiratory failure, PEG tube, seizure precautions, Patient has tracheostomy in place and utilized oxygen PRN ranging from 1-6 liters per caregiver report... Patient also has right nephrostomy tube... Feeding tube was replaced today. The plan of care dated 05/27/2026 did not include documented evidence of planned interventions and goals for the tracheostomy, gastrostomy, and nephrostomy. During a joint review of the record and an interview on 09/04/2026, the Regional Director of Clinical Operations confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview and observation. In 2 of 6 (33%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. DOCUMENT 1: Agency Policy: Hand Hygiene Policy No. 7-009, Revised 09/2024, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients; before donning sterile gloves when performing sterile procedures; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; and after removing gloves... Hand Washing with Soap and Water: Equipment: Paper towels and liquid soap; if water and liquid soap are not available, waterless hand washing products will be used. Wet hands and apply the soap and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. Wash hands for at least fifteen (15) seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet.” HOME VISIT 1: During the home visit (Clinical Record 8) on 09/02/2026 with the Registered Nurse (RN) (Personnel Record 9), the RN was observed washing the hands and donning gloves to provide a patient care assessment. After the assessment of vital signs, the RN doffed the gloves and without decontaminating the hands, retrieved wound care supplies. During wound care the RN turned the patient and began removing the wound dressing. The RN stopped when noticing the patient was “soiled.” The RN collected a new brief and wipes without changing gloves. The RN turned the patient, removed the dressing, cleansed and applied the new wound dressing. The RN then cleaned the patient and changed the brief without decontaminating the hands when moving from a contaminated body site (wound) to a clean body site (providing personal care). After care, the RN removed the gloves and reached into the nursing bag for a new pair of gloves and donned them without disinfecting their hands in between glove changes. HOME VISIT 5: During the home visit, the HA was observed removing the gloves, washing the hands with soap and water for less than 5 seconds, rinsing the hands, and drying them with the hand towel hanging on the towel hook on the wall. The HA donned a new pair of gloves, applied lotion, removed the gloves, washed the hands with soap and water for less than 5 seconds, rinsed the hands, and dried them with the previously used hand towel hanging on the towel hook. During an interview on 10/26/2023, the Regional Director of Clinical Operations agreed the staff did not follow the handwashing technique policy””

“It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. CLINICAL RECORD 1: The patient’s date of election was 04/23/2026. The hospice aide visit notes dated 04/27/2026, 04/29/2026, and 05/01/2026 documented, “Shower was done, all needs were met.” During a discussion, it was determined that the aide was given verbal instructions by the registered nurse of the tasks to complete during the aide visits but was not entered into the electronic medical record until 05/01/2025 with an effective date of 04/23/2026. CLINICAL RECORD 6: The patient was admitted on 01/28/2026 The aide services started 01/30/2026. The aide care frequency was 3 times a week starting the week of 02/01/2026. The hospice aide care plan dated 01/28/2026 included interventions for keep patient clean and dry; RN notified of any changes; RN notified of any refused care; Safely dispose of medical waste; Encourage self-care of skin; and Report skin breakdown or redness to SN. The hospice aide visit note dated 08/21/2026 that stated, “gave patient bed bath, put Vaseline on patient back.” The hospice aide visit note dated 08/24/2026 and 08/26/2026 that stated, “gave patient bed bath.” The hospice aide visit note dated 08/28/2026 that stated, “gave patient bed bath.” A bed bath and application of Vaseline to back, were not included in the plan of care. During a joint review of the record and an interview on 09/04/2026, the Regional Director of Clinical Operations confirmed that the hospice aide provided services that were not included in the plan of care.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 22 (9%) clinical records that had aide services reviewed revealed that the agency did not that the registered nurse did not make an on-site supervisory visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 6: The patient’s date of election was 01/28/2026. Hospice aide services started on 01/30/2026. A hospice supervisory visit was completed on 07/28/2026. There was no documented evidence that a registered nurse made a supervisory visit after 07/28/2026 to the current date of 09/04/2026. CLINICAL RECORD 18: The patient’s date of election was 08/01/2024. A hospice supervisory visit was documented on 08/04/2026. There was no documented evidence that a registered nurse made a supervisory visit after 08/04/2026 to the current date of 09/04/2026. During a joint clinical record review and interview on 09/04/2026, the Regional Director of Clinical Operations confirmed that the registered nurse did not make on-site supervisory visits every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice IDG meet the patient’s needs.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the volunteer program, the documentation revealed that the agency did not ensure that the hospice volunteer hours were, at a minimum, equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency’s overall volunteer percentage was 1.07% for the last twelve months. The Parent’s percentage was 0.71%, ADS 1 was 0.08%, and ADS 2 was 2.51. A Performance Improvement Project regarding Volunteer Hours was initiated in December 2025 and remains open at the time of the site visit. Despite recruitment and onboarding efforts, the agency continued to see low volunteer hours. During a joint review of the volunteer program records and an interview on 09/04/2026, the Volunteer Coordinator and the corporate Volunteer Coordinator reported on the program’s status. The team discussed the Performance Improvement Project and the efforts and challenges in the service areas since December 2025. During a joint review of the volunteer program records and an interview on 09/04/2026, the Regional Director of Clinical Operations confirmed that the agency did not meet the five percent (5%) minimum requirement for volunteer hours of the total patient care hours of all paid hospice employees and contract staff. Upon reviewing the volunteer program, the documentation revealed that the agency did not ensure that the hospice volunteer hours were, at a minimum, equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency’s overall volunteer percentage was 1.07% for the last twelve months. The Parent’s percentage was 0.71%, ADS 1 was 0.08%, and ADS 2 was 2.51. A Performance Improvement Project regarding Volunteer Hours was initiated in December 2025 and remains open at the time of the site visit. Despite recruitment and onboarding efforts, the agency continued to see low volunteer hours.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were transferred to a Medicare/Medicaid certified facility revealed that the agency did not ensure the discharge summary was sent to the receiving facility. CLINICAL RECORD 20: The patient’s care was transferred to another hospice provider on 02/05/2026. There was no documented evidence that the discharge summary was forwarded to the receiving hospice. During a joint record review and interview on 09/03/2026, the Regional Director of Clinical Operations confirmed there was no documentation that the discharge summary was sent to the receiving facility.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation 418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 19: The patient was discharged from hospice on 10/20/2026 (no longer terminally ill). There was no documented evidence that the discharge summary dated 10/20/2025 was forwarded to the patient’s attending physician. During a joint record review and interview on 09/03/2026, the Regional Director of Clinical Operations confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician.”