Accentcare Hospice & Palliative Care of Houston - North, LLC

“Based on record review and interview, the agency failed to document the client’s record of the IDT’s inclusion of FM’s involvement in the plan of care for one of seven (Patient #4) patients whose clinical records were reviewed, in that,The agency failed to include Patient #4 FM’s involvement in the hospice plan of care for Patient #4’s anticipated death. This failure placed patients FM not readily available during the patient transitioning. Findings Patient #4: Review of Patient #4’s CR revealed SOC on 08/18/2023 for routine home care. The POC for the recertification period from 02/03/2026 to 02/12/2026 showed primary diagnosis of degenerative disease of nervous system, unspecified (progressive condition that gradually damages nerve cells in the brain and spinal cord, leading to impaired movement, cognition, and autonomic functions.) The orders for discipline and treatments included:SN effective 2/03/2026 once a week for nine weeks (1WK9); 3PRN for symptom management, crisis management.SW effective 2/03/2026 once every four weeks for eight weeks (1EVERY4WK8); 2PRN for coping, crisis managementHHA effective 2/03/2026, twice a week for nine weeks (2WK9) 5 times/week,CH effective 2/03/2026 once every two weeks for eight weeks (1EVERY2WK8); 1PRN for spiritual support, crisis management Review of Patient #4 IDG comprehensive Assessment and POC updated report dated 02/10/2026 revealed no involvement of the FM when Patient #4 was identified with poor prognosis and need to increase SN to daily visits due to client decline effective on 02/08/2026 and prior to IDG meeting on 02/10/2026. During interview on 05/07/2026 with AA at 11:25a.m., she was asked for the assigned staff responsible for documenting family involvement in the IDG plan of care with the Patient #4’s FM. AA stated RN/CTL was the responsible staff and nurse case manager doing the visit/assessment was responsible in notifying the FM. AA stated she was not aware that IDG POC does not include the patient’s FM involvement and would review this with the agency’s compliance team. During telephone interview on 05/07/2026 with the assigned IDT RN/CTL at 11:40 a.m., she was asked for the reason the updated IDG/POC did not include Patient #4’s FM involvement. RN/CTL stated she had worked in the past as the case manager and knew how to involve FM, usually during quarterly meetings with the ALF because the client lived at a facility. RN/CTL added that Patient #4’s FM preferred to be contacted via text messages for update and changes in Patient #4’s status and not including the involvement in updated IDG/POC was an oversight. Review of the agency’s policy titled “Interdisciplinary Group Coordination of Care” last revised 12/29/2025 revealed in part, 2. The type and scope of services provided by the IDG are based upon comprehensive assessment and ongoing assessments to meet the needs of the patient and chosen family/caregiver, are unique to each unit, and change as needs evolve.4. The IDG, including those providing contracted services, is responsible to:C. Participate in the established of the care plan for each patient and chosen family/caregiver...E. Utilize a case management system to coordinate care to patients and chosen family/caregiver Facilitate communication about changes in the patient’s status between IDG members...”H. Encourage active involvement of the patient and chosen family/caregiver in the development and implementation care plan.I. Prepare a plan working with the patient and chosen family/caregiver for the patient’s anticipated death.””

“Observed in Record Review. In 2 of 18 patient records reviewed, The organization failed to assess the need for volunteer services or follow up if requested to offer support or respite to the patient, family, or other caregivers as evidenced in RRNHV#4: Volunteer requested @ initial comprehensive visit but no referral made. RRNHV#7: No volunteer assessed @ initial comprehensive assessment, this was observed and validated by Director of Clinical Operations Observed in Record Review. In 2 of 18 patient records reviewed, The organization failed to assess the need for volunteer services to offer support or respite to the patient, family, or other caregivers as evidenced in RRNHV#9 & RRNHV#10: No volunteer assessed at SOC, this was observed and validated by the Director of Clinical Operations”

“Observed in Record Review. In 3 of 18 patient records reviewed, The organization failed to assesses and reassesses its patients as goals remained the same into the next benefit period as evidenced in RRNHV#1: Goals Patient will demonstrate decreased symptoms related to depression in the next 14 days AEB engaging in MT sessions through verbal discussion of music, lyrics and life review RRNHV#2: Patient/family/ symptoms of anxiety or agitation will be decreased in benefit period AEB patient and family report decreased anxiety. RRNHV#5: CG will verbalize understanding of risks v’s benefits of pleural drain and that these will be reviewed every 14 days based on patients changing condition. this was observed and validated by the Director of Clinical Operations Observed in Record Review. In 5 of 18 patient records reviewed, The organization failed to assess and reassess its patients as evidenced by goals remained the same into next benefit period in the following records. RRNHV#3: Care coordination services will be initiated within 5 days of request this goal on care plan since admission. RRHV#5: patient will report pain ( physicial, emotional, spiritual) is at an acceptable level within 3 weeks continued . RRHV#6: patient/facility staff will demonstrate interventions to minimize fall risk and maximize safety at each visit AEB the patient will remain injury free within the next 2 weeks. RRNHV#1: Goals remained the same into next benefit period:Patient will demonstrate decreased symptoms related to depression in the next 14 days AEB engaging in MT sessions through verbal discussion of music, lyrics and life review. RRVNHV#9:Patient symptoms of anxiety or agitation will be decreased every 14 days AEB patient showing calming behaviors. RRNHV#10: No plan of care updates for 90 days and patient has a wound that had healed RRNHV#10: Wound measurements or assessment not done for 18 days, this was observed and validated by Director of Clinical Operations”

“Observed in Record Review. In 4 of 18 patient records reviewed, The organization failed to create measurable outcomes anticipated from implementing and coordinating the plan of care as evidenced in RRHV#1 goal was patient/family/caregiver to verbalize need for transmission based precautions with the scope of their disease process and demonstrate precautions during each visit during the cert period. RRHV#2: patient/family will understand O2 safety and effectively. RRHV#6: Chaplain will provide patient/family/ Cg with faith rituals and spiritual support including sharing inspirational stories and recorded inspirational stories and music. RRNHV#1: Patient/family/CG will verbalize need for transmission based precautions with the scope of their disease process and demonstrate precautions during each visit during the cert period this was observed and validated by Director of Clinical Operations”

“Observed in Record Review. In 5 of 18 patient records reviewed, The organization failed to plan the patient’s specific precautions in the HHA care plan as evidenced in RRHV#1: there was no aspiration precautions/PEG tube care specific precautions, RRHV#2; did not specify bleeding or fall specific precautions. RRHV#3: fall and oxygen precautions not specified. RRHV#5: wound care specific precautions or safety in transferring of patients not specified. RRHV#6: use of assistive devices for transfer was not specified, this was observed and validated by the Director of Clinical Operations. Observed in Record Review. In 1 of 18 patient records reviewed, The organization failed to provide accurate written patient care instructions for the hospice aide HHA care plan as evidenced in RRNHV#5: had no specific precautions for pleural drain dressing, this was observed and validated by the Director of Clinical Operations Observed in Record Review. In 4 of 18 patient records reviewed, The organization failed to provided specific written patient care instructions for the HHA care plan as evidenced in RRNHV#3: HHA care plan did not include wound dressing specific precautions. RRNHV#9: HHA did not have specific precautions for the aide to verify that the caregiver had given the PRN lorazepam prior to scheduled bath. RRNHV#10:HHA care plan no g-tube precautions specified. RRNHV#11: HHA care plan did not have specific instructions for the foley or wound care, this was observed and validated by the Director of Clinical Operations”

“Observed in Record Review. In 2 of 18 patient records reviewed, The hospice plan of care failed to identify the care and services that are needed and identifies which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. This was identified in RRHV#1 plan of care did not include SNF responsibilities in providing care for the patient. RRHV#5:Patient ordered cipro 500mgs BID x 5 days, nursing note did not have documentation that assisted living staff were notified this was observed and validated by the Director of Clinical Operations”