Heart to Heart Hospice of Dallas, LLC

“It is required that the documented comprehensive assessment include a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs. The drug profile is updated per the hospice policy and procedure 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure the comprehensive assessment included a drug profile that contained the patient’s current medications. CLINICAL RECORD 9: The patient elected the hospice benefit on 03/23/2026 with a diagnosis of acute myeloblastic leukemia without remission. The Registered Nurse (RN) visit note dated 06/02/2026 documented that the patient was experiencing constipation, and that the usual bowel pattern was a bowel movement (BM) every other day. In addition, the RN documented that the patient’s constipation “recently” required an increase in their lactulose dose to 30 mL twice daily to manage the constipation. The patient’s medication profile documented lactulose 10g/15mL oral solution dated 04/22/2026 with instructions to take 10g twice daily scheduled for constipation management. A review of the clinical record revealed that the medication profile was not updated to document the change in dosage that the RN documented on 06/02/2026. During an interview and review of the findings on 07/17/2026, the Administrator (Personnel Record 2), one of the Patient Care Managers (PCM) (Personnel Record 3), and another PCM confirmed the findings. They were unable to provide documentation that the medication had been updated to the dosage documented in the nurse’s note.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 07/10/2026 with the terminal diagnosis of malignant neoplasm of the laryngeal cartilage. The patient resided at a nursing facility (NF). The Registered Nurse (RN) initial comprehensive assessment dated 07/10/2026 documented that the patient had a trach placed on 07/02/2026 and communicated either by mouthing words or by writing with a pen and paper. The Skilled Nurse (SN) visit note dated 07/13/2026 documented that the patient was receiving weekly Respiratory Therapy (RT) visits by the facility RT. A review of the patient’s plan of care for the benefit period from 07/10/2026 to 10/07/2026 revealed no planned interventions based on the identified communication needs or weekly RT visits. During an interview and a review of the findings on 07/17/2026, the Administrator (Personnel Record 2), Patient Care Managers (PCM) (Personnel Record 3), and another PCM agreed that the patient’s communication and RT needs should be reflected in the plan of care. CLINICAL RECORD 9: The Registered Nurse (RN) visit note dated 06/02/2026 documented that the patient reported constipation, not only the need for a laxative but also an increased dose. The patient’s usual bowel pattern was documented as every other day. The patient’s medication list included 4/22/26 Lactulose 10g/15mL oral solution: 10g twice daily (scheduled) for constipation. During the Interdisciplinary Group Meeting dated 06/30/2026, the nurse documented the patient’s constipation, which required increasing the Lactulose dose to 30 mL twice daily. No problem, planned intervention, or patient-specific goal was identified in the POC outside of the nurse’s note during the IDG meeting.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), is required to review, revise, and document the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PE.5 “Patient Assessments” (dated 02/01/2026) reads in part, “Updates to the comprehensive assessment will be accomplished by the IDG/IDT...to include...Changes that have taken place since the initial assessment or last comprehensive assessment, including the patient’s progress toward desired outcomes; Response to care, treatment...Information from the updated comprehensive assessment will be used by the IDG/IDT to update the patient/family POC...” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s plan of care was revised to include information from the patient’s updated comprehensive assessment. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/06/2026 with a diagnosis of chronic systolic congestive heart failure. The Registered Nurse’s initial comprehensive assessment dated 02/06/2026 documented that the patient had no pain upon admission to hospice care. On 02/24/2026, the patient reported occasional left toe pain that was aching and sore, and all activity exacerbated the pain. The patient’s average pain score over 24 hours was documented to be 8/10. The patient’s goal for a pain score was “0.” On 02/24/2026, the physician ordered acetaminophen 300 mg-codeine 30 mg tablets (one tablet every 6 hours as needed for pain) and added them to the patient’s medication profile. A review of the patient’s plan of care (POC) for the benefit period from 02/06/2026 to 05/06/2026 revealed no update to the POC to reflect the development of pain requiring the addition of pain medication or the patient’s stated pain goal of 0/10. On the admission visit on 02/06/2026, the Registered Nurse (RN) documented that the patient was alert and oriented to person, place, and time. Over the past several months, the patient had been hospitalized multiple times due to worsening shortness of breath (SOB). The nurse noted that the patient’s “...dyspnea had significantly progressed, now occurring at rest and with minimal exertion...during assessment, patient appeared dyspneic while seated with noted heavy breathing despite his oxygen saturation remaining within normal limits...” The patient was able to ambulate with a cane for long distances but demonstrated significant unsteadiness even with short distances. He was still eating approximately 75% of three (3) meals daily. On 03/12/2026, the Skilled Nurse (SN) noted the patient was alert and oriented x3, was using 2 liters per minute (LPM) of oxygen per nasal cannula at night, and was able to ambulate with a walker. The SN visit note dated 03/16/2026 documented that the patient was experiencing more dyspnea on exertion and was now unable to ambulate without assistance. Additionally, the SN documented that the patient was observed sitting on the sofa after a restroom break, exhibiting shortness of breath (SOB) with an oxygen saturation of 88%. The SN documented placing oxygen on the patient at 2 LPM and giving the patient a nebulizer treatment and Ativan for anxiety. During the Interdisciplinary Group (IDG) Meeting on 03/18/2026, the SN documented that the patient now required continuous oxygen at 2-3 LPM, an increase from the patient only using oxygen at night. The SN documented to continue the current plan of care. The plan of care was not updated to reflect the patient’s increased dyspnea and inability to ambulate without assistance. During an interview and a review of the findings on 07/17/2026, the Administrator (Personnel Record 2), the Patient Care Managers (PCM) (Personnel Record 3), and another PCM agreed that the POC was not updated to include updated information.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PC.130 “Bereavement” (dated 09/01/2024) read in part, “The bereavement services will reflect the needs of the bereaved. The Hospice will make bereavement services available to the family and other individuals in the Bereavement Plan of care (POC)...up to one year following the death of a patient...The bereavement coordinator will review the assessment for potential family and/or caregiver needs, and a Bereavement POC that addresses those identified...issues will be developed and implemented...After the death of a patient...the bereavement coordinator will...develop a bereavement POC for bereavement services...The Bereavement POC will include delineation of services and frequency to be provided...A bereavement record will be maintained on each family and/or caregiver and will contain: Bereavement assessments; Bereavement POC; Bereavement clinical notes and documentation of letters and/or resources sent to the bereaved; Contacts, declinations of bereavement assistance, inability to contact, and referrals will be documented in the patient’s medical record...” In 3 of 3 (100%) clinical records reviewed with bereavement services, the agency did not ensure that bereavement services were provided per the plan of care. CLINICAL RECORD 17: The patient elected the hospice benefit on 07/18/2025 and died on hospice service on 12/03/2025.The post-death bereavement assessment of the patient’s daughter was reviewed at the Interdisciplinary Group (IDG) Meeting on 12/10/2025, which assigned the bereaved as low risk, and a bereavement plan of care was developed. The POC documented the following interventions: sympathy card, one-month letter, three-month letter, six-month letter, 9-month letter, 11-month letter, and a 13-month letter. Also included were ongoing bereavement risk assessments, in collaboration with the Interdisciplinary Group, and phone calls at 6 months and 11 months. The 1-month letter due on 01/03/2026 was sent late on 02/23/2026. At the time of the record review, there was no documentation indicating that the 3-month letter (due on 03/03/2026), the 6-month letter (due on 06/03/2026), or the 6-month phone call interventions had been completed per the plan. CLINICAL RECORD 18: The patient elected the hospice benefit on 02/20/2024 and died on hospice services on 01/02/2026. The post-death bereavement assessment of the patient’s spouse was reviewed at the Interdisciplinary Group (IDG) Meeting on 01/08/2026, assigned the bereaved as low risk, and a bereavement plan of care (POC) was developed. The POC included the following interventions: a sympathy card, a one-month letter, a three-month letter, a six-month letter, a 9-month letter, an 11-month letter, and a 13-month letter. Also included were ongoing bereavement risk assessments, in collaboration with the Interdisciplinary Group, and phone calls at 6 months and 11 months. At the time of record review, the 1-month letter due on/around 02/02/2026 was not documented as sent. There was documentation that the 3-month letter was sent on 04/15/2026. CLINICAL RECORD 19: The patient elected the hospice benefit on 02/06/2026 and died on hospice services on 03/21/2026. The post-death bereavement assessment of the patient’s daughter was reviewed at the Interdisciplinary Group (IDG) Meeting on 04/01/2026 and assigned the bereaved as low risk, and a bereavement plan of care was developed. The POC included the following interventions: a sympathy card, a one-month letter, a three-month letter, a six-month letter, a nine-month letter, an eleven-month letter, and a thirteen-month letter. Also included were ongoing bereavement risk assessments, in collaboration with the Interdisciplinary Group, and phone calls at 6 months and 11 months. At the time of record review, there was no documentation that a sympathy card, a one-month letter, or a three-month letter was sent. During an interview on 07/17/2026, the Bereavement Coordinator (BC) (Personnel Record 4) confirmed the findings and stated that many items were missing or late and documented in February, as the BC was still learning how to “batch” letters and document in the electronic medical record (EMR).”

“It is required that hospice aides be assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Hospice Aide received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/14/2025 with a diagnosis of chronic obstructive pulmonary disease (COPD). The plans of care (POCs) for the benefit periods from 05/13/2026 to 07/11/2026 and 07/12/2026 to 09/09/2026 ordered Hospice Aide services 5 times per week. The SN visit note dated 11/14/2025 documented a stage 2 pressure ulcer on the patient’s left buttocks with an order for the wound to be cleaned daily with wound cleanser and covered with bordered gauze. On 03/30/2026, the physician ordered metronidazole 500mg tablet - sprinkle crushed tablet on wound bed daily for foul-smelling drainage.” On 04/20/2026, the Skilled Nurse (SN) documented that the left buttock pressure ulcer was restaged to stage 4 on 04/02/2026 and measured 6 cm x 8 cm x 2 cm, with moderate purulent drainage and odor. On 05/15/2026, the physician ordered, “to cleanse the wound with wound cleanser, apply collagen and silver alginate on the wound bed, cover with bordered gauze, change daily, and PRN (as needed).” On 06/11/2026, the stage 4 wound had progressed to 7 cm x 9 cm x 2.4 cm, with a small amount of purulent drainage and a faint odor. The wound continued, and on 07/13/2026 the physician ordered cleansing of the stage 4 wound with wound cleanser, patting dry with gauze, placing Adaptic over the exposed bone, placing Vashe-moistened gauze, and then covering with a silicone-bordered Suprasorb dressing. The wound care was to be done daily and PRN for soiling or a loose dressing. The HA POC dated 11/17/2025, and active at the time of review, assigned the HA the tasks: a bed bath to be performed every Monday, Wednesday, and Friday; on every visit, perineal, hair, nail, oral, and skin care, including deodorant and lotion; the patient was to be dressed and transferred between bed and chair using a two-person transfer. The HA care plan safety precautions documented included falls, oxygen, skin, and standard precautions. The HA care plan did not provide instructions for what to do should the wound dressing become dislodged, soiled, or wet during the bath or personal care. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/19/2026 with a diagnosis of alcoholic cirrhosis of the liver with ascites. The plans of care for the benefit periods from 03/19/2026 to 06/16/2026 and 06/17/2026 to 09/14/2026 ordered Hospice Aide (HA) services five (5) times a week. The Registered Nurse (RN) initial comprehensive assessment dated 03/19/2026 documented that the patient had severe ascites and would require draining of the abdomen soon via the PleurX drain in the right lateral abdomen. The HA POC dated 03/20/2026, and active at the time of review, assigned the HA the following tasks at every visit: bed bath, foot care, hair care, oral care, perineal care, and skin care. The HA care plan safety precautions documented included: bleeding, fall, skin integrity, and standard precautions. The HA care plan did not include instructions for the PleurX drain and dressing should they become soiled, wet, or dislodged during personal care. CLINICAL RECORD 8: The patient’s plan of care (POC) for the benefit period 06/10/2026 to 09/07/2026 ordered Hospice Aide (HA) services five (5) times a week. The Registered Nurse (RN) initial comprehensive assessment dated 06/10/2026 documented that the patient had exploratory surgery on 06/04/2026 before hospice admission and a gastrostomy (G-tube) was placed for draining purposes. A midline abdominal incision with 20 staples measuring 16 cm x 1 cm was documented. The HA POC dated 06/11/2026 assigned the HA the tasks to be performed every visit: shower, perineal care, skin care, oral care, hair care, and dressing the patient. The HA was to shampoo the patient’s hair weekly. The HA care plan safety precautions documented included: fall and oxygen precautions. The HA care plan did not provide instructions for what to do should the abdominal incision/dressing become soiled or wet, or the G-tube/dressing become dislodged, soiled, or wet, during bath or personal care. The findings were reviewed and discussed on 07/15/2026, 07/16/2026, and 07/17/2026 with the Patient Care Manager (PCM) (Personnel Record 3), another PCM, the Area Clinical Specialist, and the Regional Vice President of Clinical Operations, who confirmed that the HA needed to be provided with full, complete instructions to provide care for the patients.”

“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. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The data provided indicated that volunteers contributed an average of 0.64% of total patient care hours among all paid hospice employees and contract staff for the calendar year 2025. A QAPI Performance Improvement Project (PIP) was initiated on 02/25/2026 due to noncompliance with the 5% requirement. Year-to-date 2026 Volunteer percentages were as follows: January 0%, February 0.49%, March 0.77%, April 0.19%, May 0.36%, June 3.39%. During a review of the agency’s Volunteer Program documentation and an interview on 07/14/2026, the Volunteer Coordinator (Personnel Record ) confirmed that the organization did not meet the requirement for hospice volunteers to provide administrative or patient care services in the amount of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A review of the agency’s Volunteer Program documentation, along with an interview conducted on 07/14/2026 with the Volunteer Coordinator (Personnel Record ), identified that the organization did not meet the requirement for hospice volunteers to provide administrative or patient care services in the amount of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The data provided indicated that volunteers contributed an average of 0.64% of total patient care hours among all paid hospice employees and contract staff in 2025. A QAPI Performance Improvement Project (PIP) was initiated on 02/25/2026 due to noncompliance with the 5% requirement. Weekly monitoring and meetings between the VC and the Administrator to track total volunteer hours and the VC’s percentage of total patient care hours for 90 days (weekly), then monthly; VC to provide quarterly reports to the Area Clinical Specialist (ACS) for review with QAPI activities. The VC previously split hours between this program and another, but is now devoting full time to this program. Year-to-date 2026 Volunteer percentages were as follows: January 0%, February 0.49%, March 0.77%, April 0.19%, May 0.36%, June 3.39%. Top recruitment activities have been health fairs, health career high schools, and Idealist (online), while documented retention activities included one-to-one calls, texts, emails, and holiday/birthday cards.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.10 “Staff Competency” (dated 11/15/2024) read in part, “The Hospice will provide for competency assessments...on hire and annually to assess direct care staff’s basic skill levels for all staff providing care...” In 2 of 12 (17%) personnel records reviewed, the agency did not ensure that skills and competency were assessed according to the agency’s policy. PERSONNEL RECORD 6: The Registered Nurse (RN) was hired on 10/08/2024. An Initial Hospice Nursing Competency Checklist was completed on 10/30/2024. There was no documentation of an annual Hospice Nursing Competency Assessment for 2025. Following review and interview on 07/17/2026, the Business Operations Manager (BOM) and Regional Vice President of Clinical Operations confirmed the finding, and an attestation dated 07/17/2026 was produced and documented: “Upon routine file audit, it was identified that the following historical document was missing from the file: Annual Evaluation/Competency Assessment for 2025 - was completed in 2026” and signed by BOM. PERSONNEL RECORD 11: The Music Therapist was hired on 04/27/2026. No initial competency assessment was completed. Following review and interview on 07/17/2026, the Business Operations Manager (BOM) and Regional Vice President of Clinical Operations confirmed the finding and an attestation dated 07/17/2026 was produced and documenting: “Upon routine file audit, it was identified that the following historical document was missing from the file: Initial Competency Checklist (no other Music Therapist in the area to sign off) and signed by the BOM. The findings were confirmed during an interview and a joint review of personnel records with the Business Operations Manager (BOM) and the Regional Vice President of Clinical Operations on 07/17/2026.”