Three Oaks Hospice

“Based on record review and interview, the agency failed to ensure effective symptom control for 1 of 6 hospice patients (Patient #1), whose records were reviewed in that: Patient #1 did not receive adequate end of life services for symptom management prior to her death. This failure placed the agency’s patients at risk for inadequate end of life care. Findings include: Review of the agency’s TULIP (a database utilized by the state to maintain licensing demographic information, complaint and self-reported incidents on Home Health and Hospice agencies for the State of Texas), a complaint that was received by HHSC, dated 3/20/2025, revealed that Patient #1’s symptoms prior to her death was not adequately controlled during her inpatient hospice stay at HOSP A. The complaint stated that Patient #1 had two days of uncontrolled fever that lead to seizures (abnormal brain functioning). The complaint further revealed that the hospice agency’s medical director did not have prescribing authority during inpatient hospice placement at HOSP A, therefore the HOSP A’s attending physician had prescribing authority. The complaint further stated that HOSP A’s attending physician declined to adjust the medication to control her fever. The Complainant further stated that the hospice agency failed to provide interventions necessary for Patient #1’s end of life as her condition deteriorated prior to her death. The complaint further revealed that Patient #1 expired on 2/21/2025. Three attempts to contact FM A were made on 7/21/2026, 7/2023/2026 and 7/2024/2026 were unsuccessful. A return number was left on voicemail. During a record review of Patient #1’s clinical record revealed Patient #1’s admission date into inpatient hospice on 2/18/2026 with a terminal diagnosis of respiratory failure (lungs are no longer functioning). Patient #1’s clinical record further revealed that Patient #1 was experiencing a fever on 2/18/2026 at 102 degrees, 2/19/2026 at 100.8 degrees and 103 degrees, and 2/20/2026 102 degrees. Record review revealed that the hospitals physician declined to administer medication to decrease Patient #1 ‘s body temperature as per hospice guidelines. Further revie w reviewed that on 2/20/2026, the family decided to revoke hospice services and to resume hospital services prior to her death when it was discovered that the hospice medical director and the hospice nurses did not have jurisdiction for making decisions in Patient #1 end of life care. Patient #1’s clinical records further revealed that on 2/21/2026, hospital staff pronounced Patient #1’s death. During a record review of the signed contract agreement between HOSP A and the hospice agency dated, 1/1/2022, revealed no documentation of the hospice agency’s medical director being authorized to prescribe care under inpatient hospice care for agency’s hospice patient. Three attempts to call RN C on 7/21/2026 and 7/24/2026 were unsuccessful. RN C no longer worked at the hospice agency. During the joint interview with the Administrator on 7/24/2026 at 3:00 p.m., the Administrator was informed of the above findings. The Administrator stated that she was not the Administrator at the time Patient #1 was on service but agreed this is a serious issue if they are to admit patients from the hospital for end of life inpatient care. Review of the agency’s policy, dated 11/22/2024, titled “Hospice Care in an [inpatient facility],” revealed in part, “Continuity of Care…the Hospice will 1. Authorize services to be provided in the facility. The Hospice will be responsible for determining an appropriate course of hospice care, including changing level of service e provided…provide overall coordination of the hospice car of the patient with the facility representatives…communicating with the facility representatives and other health care providers participating in the provision of care for terminal illness…to ensure quality of care for the patient and family……””

“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 1 of 6 (17%) home visits observed the agency did not ensure that the staff member used standard precautions such hand hygiene that followed accepted standards of practice and agency policy. Document 1: The agency’s policy titled, Hand Hygiene, IC.15, last reviewed 12/12/22 stated in relevant parts, “ Policy: All Hospice staff providing patient care will perform hand hygiene in accordance with Center for Disease Control (CDC) recommendations. Procedure: II. Hand Hygiene with an Alcohol-based Hand Rub, D. Staff may use an alcohol-based hand run for routinely decontaminating hands in clinical situation described below: 4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings and supplies (PPE) if hands are not visibly soiled. 7. After contact with blood, body fluids and contaminated surfaces. 8. After removing gloves.” Home Visit 6: A home visit was conducted with staff #14, a Registered Nurse (RN), on 2/8/24. The RN was providing wound care to the patient, and it was observed that the RN doffed their gloves twice and donned new gloves without first performing hand hygiene, once after cleansing the patient’s wound and once after packing the wound. In an interview conducted with the Director of Clinical Services (DCS) on 2/8/24 they did confirm that the RN, staff #1 did not follow standard precautions and established agency policy for hand hygiene.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the hospice election form and physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 2 of 2 (100%) home visits conducted in a Skilled Nursing Facility (SNF) the agency did not ensure that the designated IDG member provided the SNF with the patient’s Election of Benefit (EOB) and Certification/ Recertification of Terminal Illness (CTI). Home Visit 1: A home visit was conducted on 2/7/2024 with the Hospice Aide to a patient (clinical record 13) residing in a SNF. The patient’s hospice record maintained in the SNF was reviewed and lacked evidence that the patient’s EOB and CTI had been provided to the facility. Home Visit 2: A home visit was conducted on 2/7/2024 with the Registered Nurse (RN) to a patient residing in a SNF (clinical record 14). The patient’s hospice record maintained in the SNF was reviewed and lacked evidence that the patient’s EOB and CTI had been provided to the facility. Personnel Record 15: In an interview conducted with the RN (case manager), for the patients (records 13 and 14) managed in the SNF they did state that they were “unsure what documents were required to be provided to the SNF for hospice patients”. In an interview conducted with the Director of Clinical Services (DCS) on 2/7/24 they did confirm that the EOB and CTI had not been provided to the SNF and should have been.”