Companion Hospice and Palliative Care of South Texas LLC

“Observed in Record Review. In 3 of 3 patient records reviewed, During RR# 1, RR# 2, and RR# 3’s patient records it was noted the organization had not ensured the written plan of care was based on the patient’s goals and services required to meet those goals. For example: review of RR# 1 and RR# 2’s patient records revealed documentation of a high risk for falls. However, review of RR# 1 and RR# 3’s plan of care revealed no goals related to falls. Review of RR# 2’s patient record revealed RR# 3 had a risk for aspiration and on a mechanical soft diet with thickened liquids for dysphagia. However, review of RR# 2’s plan of care revealed no goals related to the aspiration risk. This was reviewed, discussed, and validated with the Director of Clinical Services/Alternate Administrator.”

“Observed in Record Review. During RR# 1, RR# 2, and RR# 3’s patient record review it was noted the organization had not ensured the patients’ plans of care included all interventions to manage pain and symptoms. For example: review of RR# 1 and RR# 3’s patient records revealed RR# 1 and RR# 3 were both high risk for falls. However, review of RR# 1 and RR# 3’s plans of care revealed no fall safety precautions. Review of RR# 2’s patient record revealed RR# 2 had risk for aspiration. However, review of RR# 2’s plan of care revealed no aspiration safety precautions. This was reviewed, discussed, and validated with the Director of Clinical Services/Alternate Administrator.”

“Observed in HR File Review. In 2 of 3 HR files reviewed with date of hire after August 2025, During review of HR# 2 and HR# 3’s HR files it was noted the organization had not ensured staff completed an initial competence assessment. For example: review of HR# 2’s (Volunteer Coordinator) HR file revealed a blank initial competence assessment form. Review of HR# 3’s (Chaplain/Bereavement Coordinator) HR file revealed a blank Chaplain initial competence assessment form and a blank Bereavement Coordinator initial competence assessment form. This was reviewed, discussed, and validated with the Director of Clinical Services.”

“Observed in HR File Review. In 1 of 4 HR files reviewed, During review of HR# 2’s HR file it was noted the organization had not ensured it verified staff qualification required by Texas state law and regulation that required licensure examination for a Master of Social Work to work as a Master of Social Work. For example: review of HR# 2’s date of hire was approximately 45 days prior to the surveyor review of the record. Further review of HR# 2’s HR file revealed HR# 2 had a LBSW (licensed Baccalaureate Social Worker). This was reviewed and discussed with the Director of Clinical Services/Alternate Administrator that revealed HR# 2 was not licensed in the state of Texas as a Master of Social Work and supervision by a LMSW was required for a LBSW to work as a Medical Social Worker. Further discussion with the Director of Clinical Services/Alternate Administrator revealed HR# 2 had graduated with a Master of Social Work approximately 70 days prior to the surveyor review of the record and was scheduled to take the licensure exam but had not done yet and did not have a temporary license.”

“Observed in Record Review. In 9 of 10 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. On review of records there were examples of goals that were not specific, measurable and/or time-bound. For example: in RRHV#1 a non measurable goal was Prevent discomfort due to increasing edema. In RRHV#3 an example was Promote rest status for Pt/Family/PCG. In RRNHV#4 a non specific not measurable goal was Facilitate bowel elimination and comfort each visit within 4 weeks -Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. In RRNHV#5 an example was Achieve and maintain peripheral circulation for Pt comfort. Another example in RRNHV#7 was Prevent discomfort due to increasing edema by elevating lower extremities when sitting and using compression stockings appropriately. Further examples could be seen in RRNHV#8, RRNHV#9, RRNHV#6, and RRNHV#10. These observations were reviewed with the Administrator and Executive Director.”

“Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 there was documentation the patient was a high fall risk yet there was no care plan for fall safety. In RRNHV#4 there was documentation of increased weakness with staggered gait and walker use but no fall safety care plan. Also, there was documentation of dyspnea with ordering of oxygen but no respiratory care plan to guide the care. In RRNHV#5 the documentation noted the patient was using a Pure Wick device for urinary incontinence but the device use was not reflected in the orders of in the care plans. In RRNHV#7 the documentation noted nausea and vomiting with the ordering of Zofran and Cough and congestion with Mucinex ordered but no care plan to reflect the issues and guide the care. These observations were reviewed with the Administrator.”

“Observed in Record Review. In 5 of 10 patient records reviewed, the organization failed to ensure the plan of care revisions are based on information from updates to the patient’s comprehensive assessment and address the patient’s progress toward goals and outcomes. On Review of RRHV#1 there were goals that were not addressed over time as they remained without progress to goals IDG to IDG. An example was Pt/pcg will verbalize/express understanding of treatment orders and side effects, of no cardiac medications. The goal was established on admit in February and remained unchanged to date of survey. In RRHV#2 an example was Pt/Family/Caregiver will verbalize understanding of expected symptoms associated with terminal disease process established in December and remained without progress to goal. In RRHV#3 an example was Pt will verbalize improvement of symptoms associated with GERD yet no progress to the goals was noted in the record. In RRNHV#7 a goal established in March read Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects of Spirolactulone and Furosemide within 1 month but remained unchanged to date of survey. In RRNHV#7 an example was Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. within 6 weeks the goals was established in March without progress to survey. These observations were reviewed with the Administrator.”

“Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, the organization failed to ensure a supervisor evaluate skill by observing the aide’s performance of required tasks with a patient or pseudo-patient as part of a simulation. On review of HR#2 for the Hospice Aide there was no documentation of an initial competency evaluation noted in the HR file. Observation was reviewed with the Executive Director. Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide, there was no documentation of a competency evaluation that addressed each of the required subjects. On review of HR#2 for the Hospice Aide there was no documentation of an initial competency evaluation documented as part of orientation. This observation was reviewed with the Administrator.”

“Observed in Tracer Activities. the organization failed to ensure the hospice aide receive ongoing education and training. On review of the hospice aide in-service training records it was noted that there was no documentation of 12 hours of in-service training during the last 12 months for the hospice aides currently employed. There was documentation of 6 hours of education in 2025. Prior to 2025, there were sign in sheets for 4 months (July 2024 - Oct 2024) yet the sheets did not contain content of what was taught or time elapsed during the training. There was no further documentation of aide in-servicing in November or December. These observations were reviewed with the Administrator and Executive Director.”

“Observed in Record Review. In 3 of 9 patient records reviewed, with aide services assigned, the organization failed to ensure the Registered Nurse provide written patient care instructions for the hospice aide. On review of RRNHV#4 the patient was on Eliquis yet the aide assignment for plan of care did not include bleeding precautions. Further the RN assigned the aide to take vital signs yet there were not parameters for when to report vital sign findings. In RRNHV#5 the patient was also on Eliquis but no bleeding precautions noted on the aide’s assigned plan of care. Further, there was documentation the patient was using a Pure Wick device but no specific instruction on how the Aide was to handle the device when providing care. In RRNHV#8 the patient had multiple wounds with dressing but no instruction for how the aide was to handle the dressings during care. These observations were reviewed with the Administrator.”

“Observed in HR File Review. In 3 of 8 HR files reviewed, the organization failed to ensure staff competence was initially assessed and documented as part of orientation. On review of HR#4 for the MSW, HR#6 for the Volunteer Coordinator, and HR#6 for the Spiritual Counselor there was no documentation of an initial competency noted in the employee HR file. This observation was reviewed with the Administrator. Observed in HR File Review. In 3 of 8 HR files reviewed, the organization ailed to ensure staff competence was assessed and documented annually as required by organization policy 1-008. On review of HR#3 for the MD, HR#5 for the Administrator, and HR#6 for the volunteer coordinator, there was no documentation on review of the file of annual competency evaluation as required. For HR#3 the last competency was 2023, for HR#5 the last documented was initial in 2022, and for HR#6 the last was the initial in 2021. These observations were reviewed with the Administrator.”

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the Medical Director review the clinical information for each hospice patient and provide written certification that the patient’s life expectancy is six months or less if the illness runs it’s normal course to include all required elements. On review of RRNHV#6 the Certificate of Terminal Illness (CTI) documented at the time of the April 2025 patient payor change from a non-Medicare payor to Medicare did not include current subjective and objective findings. This observation was reviewed with the Administrator and Executive Director.”

“Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure hospice obtains the signature of the patient or representative to confirm that the patient or representative has received a copy of the notice of rights and responsibilities in accordance with 42 CFR 418.52 and obtains a signed election statement in accordance with 42 CFR 418.24. On review of RRNHV#6 there was no Election of Benefits signed at the time of a payor change from non-Medicare to a Medicare payor in April of 2025. This observation was reviewed with the Administrator and Executive Director.”

“Observed in Record Review. In 1 of 6 patient records reviewed, the organization failed to maintain complete and accurate patient records. On review of RRNHV#6 the record was not maintained complete, readily available, or systematically organized to facilitate retrieval for a patient with a April, 2025 payor change from non-Medicare to Medicare. The organization maintained 2 separate records for the same period of time, a discharge record and an April admission record. Staff continued to document their hospice care in the discharged record after the change in payor source to Medicare. Therefore both the discharge record and the April 2025 admission record had to be reviewed by the surveyor in order to determine what care had been provided. This observation was reviewed with the Administrator and Executive Director.”

“Observed in Competency Session. In 1 of 5 contracts reviewed, the organization failed to ensure the written agreement with and outside agency providing contracted services for the hospice include all the required elements. On review of the contract for pharmacy it was noted the contract did not include all required stipulations such as a stipulation that services may be provided only with the authorization of the hospice - A stipulation that services will be delivered in accordance with the patient’s plan of care - The manner in which contracted services will be coordinated, supervised, and evaluated by the hospice - The delineation of the role of the hospice and contractor in the admission process, patient/family assessment, and the interdisciplinary group conferences - Requirements for documenting that services are furnished in accordance with the agreement - The qualifications of the individuals providing the services - A stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the Executive Director.”