Heritage Hospice of East Texas

“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, and 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, and 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 2 of 14 (14%) clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile during the comprehensive assessment. HOME VISIT 1/CLINICAL RECORD 6: The patient’s date of election was 02/13/2024 with diagnosis of Chronic obstructive pulmonary disease, Secondary DX: pneumonia, acute and chronic respiratory failure with hypoxia, history COVID-19, hypertension, atrial fibrillation. The patient resided in a skilled nursing facility (SNF). The medication profile printed on 04/01/2025 by the hospice agency included three medications that were duplicated. The Tylenol with Codeine #3 300-30 mg tablet, take one tablet three times a day as needed for pain; Acetaminophen-Codeine 300-30 mg tablet, take one tablet three times a day as needed for pain; Budesonide Inhalation Suspension 0.25 mg/2 ml, inhale one vial twice daily; Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale 2 ml daily; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale one vial every two hours as needed for shortness of breath; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale 3 ml every 4 hours as needed for shortness of breath); Diltiazem HCl 60 mg tablet, take one tablet daily; Benzonatate 100 mg capsule, take one capsule three times a day as needed for cough/congestion; Metoprolol Tartrate 25mg tablet, take 0.5 tab twice daily; and Promethazine HCl 25 mg, take one tablet every 4 hours as needed for nausea/vomiting. During the home visit with the Registered Nurse (Personnel Record 3), a review of the medication at the facility revealed Multivitamin with Minerals, take one tablet daily, started on 01/13/2025; Claritin 10 mg tablet, take one tablet every 24 hours as needed for allergy, started on 12/27/2024; and Azithromycin 250 mg, take one tablet every Monday, Wednesday, and Saturday, started on 01/13/2025. The facility medications did not include Diltiazem, Benzonatate, Metoprolol Tartrate, and Phenergan. The facility medications only listed the medications duplicated on the hospice agency medication profile one time. There was no documented evidence that the registered nurse comprehensive assessment dated 03/25/2025 included a medication reconciliation and medication profile update. During a joint record review and interview on 04/02/2025, the Hospice Supervising Nurse/Registered Nurse confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile. HOME VISIT 3/CLINICAL RECORD 8: The patient’s date of election was 04/27/2024. The patient resided at an assisted living facility . The medication profile printed on 04/01/2025 by the agency was reviewed during the home visit (Clinical Record 8) with the Chaplain (Personnel Record 7). The medications at the facility revealed Ibuprofen 200 mg capsule, take two capsules every six hours as needed for mild pain, started on 10/02/2024. The Ibuprofen was not included in the hospice agency’s medication profile. The last registered nurse comprehensive assessment was dated 03/26/2025. There was no documented evidence that the registered nurse comprehensive assessment dated 03/26/2025 included a medication reconciliation and medication profile update. During a joint record review and interview on 04/02/2025, the Director of Hospice confirmed that there was no documented evidence the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“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, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: duplicate drug therapy. 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, observation, and interview. In 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure a medication reconciliation, including the identification of duplicate drug therapy, was completed and medications updated to the medication profile at the time of the comprehensive assessment. HOME VISIT 1: The patient’s date of election was 02/13/2024. The Medication Profile printed on 04/01/2025 revealed duplicate drug therapy for the following medications: Tylenol with Codeine #3 300-30 mg tablet, take one tablet three times a day as needed for pain; Acetaminophen-Codeine 300-30 mg tablet, take one tablet three times a day as needed for pain; Budesonide Inhalation Suspension 0.25 mg/2 ml, inhale one vial twice daily; Budesonide Inhalation Suspension 0.5 mg/2 ml, inhale 2 ml daily; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale one vial every two hours as needed for shortness of breath; and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3 ml, inhale 3 ml every 4 hours as needed for shortness of breath. The last registered nurse comprehensive visit was dated 03/25/2025. There was no documented evidence that a medication review occurred during the comprehensive assessment on 03/25/2025. During a joint record review and interview on 04/02/2025, the Hospice Supervising Nurse/Registered Nurse confirmed that there was no documented evidence that medication reconciliation, including the identification of duplicate drug therapy, was completed and medications updated to the medication profile.”

“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. This standard was not met as evidenced by document review, interview, and observation. In 2 of 3 (67%) home visit observations revealed the agency did not ensure the staff followed the agency hand hygiene policy. Agency Policy: Hand Hygiene IC.15, last reviewed 09/01/2024, stated in part, “Hand Hygiene with Soap and Water: Staff will identify and gather appropriate supplies. Staff will wet hands and wrists with water using temperature that is comfortable. Staff will apply the amount of product recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds (with recommendation of 20 seconds, but either time is acceptable), covering all surfaces of the hands and fingers. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet... Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: after removing gloves.” HOME VISIT 1: During the home visit (Clinical Record 6) on 05/22/2024 with the Registered Nurse (RN) (Personnel Record 3), the RN was observed donning gloves. The RN was observed removing the gloves three times during the visit without disinfecting the hands after each glove removal. HOME VISIT 2: During the home visit (Clinical Record 3) on 04/02/2025 with the Hospice Aide (Personnel Record 8), the aide was observed washing the hands with soap and water. The aide rinsed the hands and then turned off the water faucet with wet hands. The aide used paper towels to dry the hands. During a joint document review and interview on 04/02/2025, the Director of Hospice agreed the staff did not follow the hand hygiene policy.”

“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. This standard was not met as evidenced by document review and interview. A review of the volunteer program revealed the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through January 2025. The total patient care hours from April 2024 through January 2025 was 0.3% and for February and March 2025 revealed 26 volunteer hours, which equaled 3.4%. Total volunteer hours from April 2024-March 2025 were 3.7%. During a joint review of the volunteer program records and interview on 04/02/2025, the Volunteer Coordinator confirmed the documented volunteer hours, patient care hours, and current percentage. The Volunteer Coordinator stated that the previous Coordinator had not kept any documentation for volunteer efforts from April 2024 through January 2025. Upon reviewing the volunteer program, the documentation lacked evidence of the number of direct care staff hours, the volunteer percentage, and the cost savings the hospice would have incurred if paid employees occupied the positions from April 2024 through January 2025. The documentation for February and March 2025 revealed 26 volunteer hours, which equals 3.4% of the total patient care hours for the two months and 0.3% of the total patient care hours over the last twelve months.”