Monarch Hospice

“Based on interview and record review, the agency failed to enforce written policies to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for two of two active patients (Patient #1 and Patient #2) with infections, in that: 1. Patient #1 received Bactrim DS Tablets (antibiotic) (kills bacteria in the urine) and there was no documented evidence that it was included in the infection control log. 2. Patient #2 received Tobramycin Ophthalmic Solution (antibiotic) (used to treat bacterial infections of the eyes) there was no documented evidence that it was included in the infection control log. This deficient practice placed the active hospice patients at risk of receiving inadequate care and services from the agency’s inability to monitor and trend infections and antibiotic use while receiving care from the agency. The findings included: 1. Review of Patient #1’s medical record revealed a certification Plan of Care (POC) from 04/15/2024 through 07/13/2024 with a diagnosis of Alzheimers disease, unspecified (A brain disorder that gets worse over time. It’s characterized by changes in the brain that lead to deposits of certain proteins. Alzheimer’s disease causes the brain to shrink and brain cells to eventually die.) and a SN frequency of 1 time a week. Review of Patient #1’s “Patient Medication Record” revealed Start: 4/24/2024 Discontinue: 04/30/2024 Bactrim DS Oral Tablet (tab) 800-160 Milligram (mg) Dose: 1 Tab(s) Frequency: take one tablet twice a day Indication: UTI (Urinary Tract Infection). Review of the Infection Control Log documents revealed no documented evidence of the infection was completed for Patient #1. 2. Review of Patient #2’s medical record revealed a certification POC from 04/11/2024 through 07/09/2024 with a diagnosis of chronic kidney disease, stage 3 unspecified (Long-term kidney disease, in which either there is a gradual loss of kidney function occurs over a period of months to years, or abnormal kidney structure.) and a SN frequency of 1 time a week. Review of Patient #1’s “Patient Medication Record” revealed Start: 4/26/2024 Discontinue: 05/28/2024 Tobramycin Ophthalmic Solution 0.3% Dose: 2 drops Frequency Q (every) 4 hr (hours) Indication: Infection. Review of the Infection Control Log documents revealed no documented evidence of the infection was completed for Patient #2. In an interview on 07/26/2024 at 12:30 PM, with the Director of Nursing and the Administrator, the surveyor presented the above findings. The Director of Nursing stated, “;I have no explanation for what happened. It was an oversight.”Review of agency policy, dated 041423, quoted in part, “ “Infection Control Program IC.10...a. The Hospice will track all infections...c. All reported infections will be documented on the appropriate hospice form for monthly review, analysis, trending, and initiation of performance improvement activities if deemed necessary...””

“Based on record review and interview, the agencys governing body failed to follow their agency policy for notifying Health and Human Services (HHSC) of a change in the administrator and alternate administrator positions no later than seven days after the change. This deficient practice could place clients at risk of harm when the state licensing agency is unaware of the administrative changes and therefore unable to determine that the new administrator and alternate administrator staff met the required qualifications. FINDINGS INCLUDE: During pre-survey preparation on 7/22/2024 a review of the Texas Unified Licensing Information Portal System (TULIP is a database utilized by the State to maintain licensing, demographic information, complaints and self-reported incidents on Home Health and Hospice agencies for the State of Texas) revealed the Administrator was former Employee A, and Alternate Administrator was former Employee B. During the entrance conference on 7/23/2024 at 10:56 AM with the Administrator. The Administrator and surveyor discussed the current information noted for the agency address and administration in TULIP. The surveyor asked about the current Administrator and Alternate Administrator. The Administrator confirmed the current Administrator was designated as the Administrator after former Employee A expired on 07/02/2024.” The Administrator said the Alternate Administrator was designated after former Employee B resigned. The surveyor asked when did former Employee B resign as Alternate Administrator. The Administrator stated, “;Former Employee B resigned as Alternate Administrator in April 2024.” The surveyor asked if the agency had submitted changes to the State through TULIP. The Administrator stated, “No, we have not yet”. During a telephone interview on 07/23/2024 at 12:23 PM with the Owner of the Hospice agency, the surveyor reviewed the current information for administration in TULIP. The Owner stated, “;I assigned someone to make sure the changes were submitted to the State. I thought the person did their job and the changes were submitted.” Review of Employee A’s personnel record revealed a signed job description for the position of Administrator dated 07/15/2024.The new Administrator was designated 13 days after former Employee A Administrator expired on 07/02/2024.The agency failed to submit written notice to HHSC, no later than seven days after the date of a change in administrator position. Review of Employee B’s personnel record revealed a signed job description for the position of Alternate Administrator dated 07/15/2024.The new Alternate Administrator was designated 3 months after former Employee B Alternate Administrator resigned as Alternate Administrator in April 2024.The agency failed to submit written notice to HHSC, no later than seven days after the date of a change in alternate administrator position. Review of agency policy, dated 041423, quoted in part, “ Reporting Changes LD.12-TX... Policy The Hospice will comply with and follow the states requirements for reporting a change to Texas Health and Human Services Commission (HHSC) within the specific time frame for a specific type of change...Procedure...D. For Changes in the Hospices Organizational Management Personnel 1. If a change occurs in the following management personnel, the Hospice must submit written notice to HHSC through TULIP no later than seven days after the date of change in: a. Administrator; b. Alternate Administrator...””