Good Shepherd Hospice of San Antonio, L.L.C.

“Based on record review and interview, the agency’s interdisciplinary group (in collaboration with the individual’s attending physician, if any) failed to update the comprehensive assessment and take into consideration changes that had taken place since the initial assessment at least every 15 days for 1 (#1) of 3 bereavement records reviewed, the interdisciplinary group failed to take into consideration the bereavement plan of care after the death of the patient. The failure placed the surviving family or significant others at risk of not receiving adequate bereavement needs. Patient #1:Record review of Patient #1’s clinical record revealed a Plan of Care dated 5/14/2025 to 6/7/2025. The Plan of Care indicated that Patient #1 started on the agency’s services on 5/14/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. Registered Nurse G conducted a skilled nurse visit and documented that Patient #1 had died on 6/29/2025. Patient #1’s clinical record contained documentation of the hospice interdisciplinary group comprehensive assessment and plan of care update report dated 6/29/2025, date of Patient #1’s death. The comprehensive assessment and plan of care update read in part; “...Spiritual: CH (chaplain) was not present when pt (patient) passed away. B/C (bereavement coordinator) will contact next of kin/family to check on bereaved later this week. POC (Plan of Care): Bereavement to follow and B/C will assess spiritual risk.” Patient #1’s clinical record did not contain evidence that the interdisciplinary team had considered the bereavement plan of care after Patient #1’s death. During an interview on 11/4/2025 at 2:08 p.m. with the Administrator/Alternate Supervising Nurse and the Bereavement Coordinator, the surveyor discussed the bereavement plan of care. The surveyor asked who was responsible for the bereavement plan of care. The Bereavement Coordinator stated, “I am.” The surveyor discussed that Patient #1’s record did not indicate that the bereavement plan of care had been reviewed by the interdisciplinary team. The surveyor asked how the Bereavement Coordinator demonstrated that the interdisciplinary group had considered the bereavement plan of care. The Bereavement Coordinator informed the surveyor that the Bereavement Coordinator set up a point of contact with the bereaved for the post bereavement assessment 10-15 days after the patient died; Listen to what was going on during interdisciplinary team meetings; and listen to what the chaplain and social worker say in the interdisciplinary group meeting. The surveyor asked why the bereavement plan of care was not considered by the interdisciplinary team. The Administrator/Alternate Supervising Nurse and Bereavement Coordinator did not know why. During an interview on 11/6/2025 at 11:23 a.m. with the Administrator/Alternate Supervising Nurse, the Supervising Nurse/Alternate Administrator, and the Patient Care Manager, the surveyor discussed the bereavement plans of care and that it was not taken into consideration by the interdisciplinary team. The surveyor asked who was responsible to ensure the bereavement plan of care was considered by the interdisciplinary team. The Administrator stated. “The Bereavement Coordinator would be responsible for the plan of care and managers (Supervising Nurse and Patient Care Manager) to ensure that it was presented to the interdisciplinary team.” The Administrator/Alternate Supervising Nurse, the Supervising Nurse/Alternate Administrator, and the Patient Care Manager did not know why the bereavement plan of care was not considered by the interdisciplinary team. Review of the agency’s policy titled “Bereavement Risk Assessment” that was revised on 8/9/2028, and was labeled “PC.B25” read in part; “Policy statement: Hospice patients and significant family members and other caregivers are assessed for grief and bereavement needs before and after the patient’s death. Procedures...3. Throughout the course of the patient’s care, members of the IDT (interdisciplinary team) reassess, document and address the anticipatory grief needs of the patient, the patient’s family, caregivers and significant others...5. Primary bereaved to receive bereavement services is categorized according to the level of risk for complicated grief reactions and received appropriate interventions according to identified need. 6. The interventions associated with the three levels of risk are as follows: a. Low risk- initial sympathy card, an initial phone call within 10 days of the patient’s death, invitations to bereavement support groups and memorial services, and mailings at 1, 3, 6, and 11 months following the patients death...””

“Based on record review and interview, the agency failed to develop a bereavement plan of care that noted the kind of bereavement services to be offered and the frequency of service to be delivered for 3 (#1, #2, #3) of 3 bereavement records reviewed. The failure placed surviving family members or significant others at risk of inadequate support and that complicated grief would not be identified. Patient #1:Record review of Patient #1’s clinical record revealed a Plan of Care dated 5/14/2025 to 6/7/2025. The Plan of Care indicated that Patient #1 started on the agency’s services on 5/14/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. Registered Nurse G conducted a skilled nurse visit and documented that Patient #1 had died on 6/29/2025. The Administrator/Alternate Supervising Nurse provided the surveyor with the bereavement plan of care, on a document titled “Bereavement Careplan Report.” The document identified the bereaved and indicated that it was a low risk bereavement care plan that was last modified on 7/14/2025. The bereavement plan of care did not list the frequency of service delivery. Patient #2:Record review of Patient #2’s clinical record revealed a Plan of Care dated 6/5/2025 to 8/3/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. Patient #2’s record contained documentation of an interdisciplinary team meeting held on 7/24/2025. The documentation indicated that Patient #2 started on the agency’s services on 3/31/2025. The documentation indicated that Patient #2 died on 7/16/2025. The Administrator/Alternate Supervising Nurse provided the surveyor with the bereavement plan of care, on a document titled “Bereavement Careplan Report.” The document identified the bereaved and indicated that it was a low risk bereavement care plan that was last modified on 7/25/2025. The bereavement plan of care did not include the kind of bereavement services to be offered and the frequency that service was to be delivered. Patient #3:Record review of Patient #3’s clinical record revealed a Plan of Care dated 10/21/20205 to 1/18/2025. The Plan of Care indicated that Patient #3 started on the agency’s services on 10/21/2025. The Plan of Care listed End-Stage Renal Disease (complete or near failure of the kidneys and no longer work to meet the body’s needs) as the terminal diagnosis. Patient #3’s clinical record contained a Discharge Summary that indicated that Patient #3 died on 11/14/2024. The Administrator/Alternate Supervising Nurse provided the surveyor with the bereavement plan of care, on a document titled “Bereavement Careplan Report.” The document identified the bereaved and indicated that it was a low risk bereavement care plan that was last modified on 12/9/2024. The bereavement plan of care did not include the kind of bereavement services to be offered and the frequency that service was to be delivered. During an interview on 11/4/2025 at 2:08 p.m. with the Administrator/Alternate Supervising Nurse and the Bereavement Coordinator, the surveyor discussed the bereavement plan of care. The bereavement plans of care did not have frequency of service delivery or type of service to be provided. The surveyor asked who was responsible for the bereavement plan of care. The Bereavement Coordinator stated, “I am.” The Bereavement Coordinator informed the surveyor that the Bereavement Coordinator set up a point of contact with the bereaved for the post bereavement assessment 10-15 days after the patient died; Listen to what was going on during interdisciplinary team meetings; and listen to what the chaplain and social worker say in the interdisciplinary group meeting. The Administrator agreed that the bereavement plan of care did not indicate that the bereavement service delivery would be at 1 month, 3 month, 6 month, and 11 months following the patient’s death as the agency’s policy listed for low risk bereavement. Review of the agency’s policy titled “Bereavement Risk Assessment” that was revised on 8/9/2028, and was labeled “PC.B25” read in part; “Policy statement: Hospice patients and significant family members and other caregivers are assessed for grief and bereavement needs before and after the patient’s death. Procedures...5. Primary bereaved to receive bereavement services is categorized according to the level of risk for complicated grief reactions and received appropriate interventions according to identified need. 6. The interventions associated with the three levels of risk are as follows: a. Low risk- initial sympathy card, an initial phone call within 10 days of the patient’s death, invitations to bereavement support groups and memorial services, and mailings at 1, 3, 6, and 11 months following the patients death...””

“Based on record review and interview, the agency failed to provide a copy of the hospice discharge summary to the patient’s attending practitioner in accordance with the Title 42 Code of Federal Regulation Subchapter B, Part 418.26, for 2 (#4, #5) of 2 patient records reviewed where the patients were discharged by the hospice due to no longer being terminally ill. The failure placed the patients at risk for a negative outcome when post agency discharge continuity of care information was not sent to the healthcare provider assuming the patients’ care after discharge. The Code of Federal Regulations § 418.26 read in part; “Reasons for discharge Discharge. A hospice may discharge a patient if (1) The patient moves out of the hospice’s service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill...” Patient #4:Record review of Patient #4’s clinical record revealed a Plan of Care dated 3/21/2025 to 6/18/2025. The Plan of Care indicated that Patient #4 started on the agency’s services on 3/21/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. Patient #4’s clinical record contained a Discharge Summary that indicated that Patient #4 was discharged due to no longer being terminally ill. The summary listed Physician E as the physician. Physician E was a hospice physician. Patient #5:Record review of Patient #5’s clinical record revealed a Plan of Care dated 3/7/2025 to 6/4/2025. The Plan of Care indicated that Patient #5 started on the agency’s services on 3/7/2025. The Plan of Care listed Acute Respiratory Failure with Hypoxia (inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function) as the terminal diagnosis. Patient #5’s clinical record contained a Discharge Summary that indicated that Patient #5 was discharged due to no longer being terminally ill. The Discharge Summary listed Physician F as the physician. Physician F was a hospice physician. During an interview on 11/6/2025 at 11:23 a.m. with the Administrator/Alternate Supervising Nurse, the Supervising Nurse/Alternate Administrator, and the Patient Care Manager, the surveyor discussed the discharge summaries. The surveyor asked why the Discharge Summaries were sent to Physician E and Physician F. The Supervising Nurse/Alternate Administrator informed the surveyor that sometimes the hospice doctor would be the attending physician. The surveyor asked would the hospice physicians assume the patients’ care after discharge from the hospice. The Administrator stated, “No, we try to send it to the physician they were seeing prior, or to a new physician.” The surveyor asked who would be responsible for sending the Discharge Summary to the physician. The Administrator stated, “It should be medical records.” The surveyor asked who would ensure that Medical Records would coordinate with the physician taking over care after discharge from hospice. The Administrator/Alternate Supervising Nurse and the Patient Care Manager informed the surveyor that the nurse would be the one. The Patient Care Manager stated, “We talk about discharge or if they have made an appointment with the physician, option that we are given.” The Administrator stated, “The nurse and social worker should discuss who will be taking over care.” The Administrator informed the surveyor that the hospice physician is being chosen (in electronic medical record) instead of the physician that would be taking over care. Review of the agency’s policy titled “Coordination of Services” that was revised on 5/13/2014, and labeled “PC.C45” read in part; “Policy statement: The IDT (interdisciplinary team) ensure that there is a coordinated and effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers and in all settings. Procedures...2. The RN (registered nurse) Case Manager coordinates the patient’s plan of care and facilitates the ongoing sharing of information with the attending physician, contracted facilities, vendors, other member of the IDT and non-hospice healthcare providers...6. Coordination of services and continuity of care is facilitated by established formal and informal communication mechanisms between all disciplines providing care (whether directly or under contract). These communication mechanisms include, but are not limited to...d. discharge and/or transfer summaries...””

“Based on observation, record review, and interview, the agency failed to include in the written agreement with the skilled nursing facility, the delineation of the hospice’s responsibilities that included: medical direction and management of the patient; nursing; counseling, including spiritual, dietary, and bereavement counseling; social work, medical supplies, durable medical equipment; drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that would be necessary for the care of the patient’s terminal illness and related conditions for 2 (#6, #7) of 2 patients that resided in a skilled nursing facility and a home visit was conducted. The failure placed the patients at risk of omission of care or delayed care due to confusion of the hospice’s responsibilities, which could result in poor symptom control. Patient #6:Record review of Patient #6’s Patient record revealed a Plan of Care dated 10/27/2025 to 1/24/2026. The Plan of Care indicated that Patient #6 started on the agency’s services on 10/27/2025. The Plan of Care listed Senile Degeneration of the Brain (progressive decline in attention, memory, reasoning, language, perception, and motor control severe enough to interfere with daily life) as the terminal diagnosis. The Plan of Care did not identify which provider would be responsible for performing functions included in the plan of care. Patient #6’s clinical record did not contain a delineation of the hospice responsibilities. Patient #6 lived at Facility Z, a skilled nursing facility. A home visit was conducted on 11/5/2025 at 9:00 a.m. at Facility Z. Registered Nurse C was present during the visit. The surveyor observed Registered Nurse C conduct the visit to Patient #6. The surveyor and Registered Nurse C reviewed the hospice record at the facility. The hospice record at the facility did not contain a delineation of hospice responsibilities. Registered Nurse C stated, “I haven’t seen it.” During an interview on 11/5/2025 at 9:30 a.m. with Facility Z’s Assistant Director of Nursing, the surveyor asked where to find the delineation of duties at the facility. Facility Z’s Assistant Director of Nursing said, “It would be in the hospice binder.” Patient #7:Record review of Patient #7’s clinical record revealed a Plan of Care dated 10/22/2025 to 12/20/2025. The Plan of Care did not list the terminal diagnosis. Patient #7’s record contained a Certification of Terminal Illness, signed 8/21/2025, by Physician X. The Certification of Terminal Illness listed Atherosclerotic Heart Disease without Angina Pectoris (plaque buildup in the arteries of the heart but does not cause chest pain) as the terminal diagnosis. The Plan of Care did not identify which provider would be responsible for performing functions included in the Plan of Care. Patient #7’s clinical record did not contain a delineation of the hospice responsibilities. Patient #7 lived at Facility Y, a skilled nursing facility. A home visit was conducted on 11/5/2025 at 9:50 a.m. to visit Patient #7. Registered Nurse C was present during the visit. The surveyor observed Registered Nurse C conducted the visit. The surveyor observed Registered Nurse C assessed a new skin lesion on Patient #7’s lower right lateral abdomen. The surveyor and Registered Nurse C reviewed the hospice record at the facility. The hospice record at the facility did not contain a delineation of hospice responsibilities. During an interview on 11/5/2025 at 10:00 a.m. with Facility Y Wound Care Nurse/Former Assistant Supervising Nurse, the surveyor asked where to find the delineation of duties. Facility Y Wound Care Nurse/Former Assistant Supervising Nurse stated, “I don’t know that I have seen one.” During an interview on 11/5/2025 at 10:00 a.m. with Facility Licensed Vocational Nurse informed the surveyor, “If they have a wound, it would be our responsibility, it’s usually done that way, but I don’t know about the supplies.” During an interview on 11/4/2025 at 3:15 p.m. with the Administrator/Alternate Supervising Nurse, the surveyor discussed the delineation of duties. The Administrator/Alternate Supervising Nurse informed the surveyor that Corporate Compliance said that a Handbook was sent out to every facility. The Administrator/Alternate Supervising Nurse was reviewing the Handbook for the form and stated, “It’s not in here.” During an interview on 11/6/2025 at 11:23 a.m. with the Administrator/Alternate Supervising Nurse, the Supervising Nurse/Alternate Administrator, and the Patient Care Manager, the surveyor discussed the delineation of duties. The surveyor discussed that the Patient records at the hospice did not contain a delineation of duties, and the hospice records at the facilities did not contain a delineation of duties. The surveyor asked who would be responsible for delineating the duties. The Supervising Nurse/Alternate Administrator stated, “The nurse admitting the patient.” The Administrator/Alternate Supervising Nurse informed the surveyor that this was shared with the Quality Assessment Director. The Administrator/Alternate Supervising Nurse (new in position) stated, “I did have a form that I used before, and we are going to start to use that.” The surveyor asked how this could affect the agency’s clients. The Administrator/Alternate Supervising Nurse stated, “It could cause a breakdown in the continuity of care.” Review of the agency’s policy titled “Hospice Care for Nursing Facility Residents- Hospice Plan of Care,” with a revision date December 2009, and labeled “PC.H45” read in part; “Policy Statement: A written plan of care is established and maintained for each facility patient and is developed and coordinated with the hospice IDT (interdisciplinary team) in consultation with the facility representatives and the patient’s attending physician. Procedures 1. The RN (registered nurse) Case Manager assigned to the facility patient is responsible for coordination and implementing the patient’s plan of care in collaboration with members of the hospice IDT and with representatives from the facility...The Plan of Care for the facility patient identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care...””