West Texas Hospice, LLC

“It is required that each patient’s individualized written plan of care reflects patient and family goals and includes measurable outcomes anticipated from implementing and coordinating the plan of care. The agency policy “Plan of Care” dated 09/24/2025 stated in part that “...The plan of care is individually tailored to meet the...needs of the patient and family...” The agency policy “Initial and Comprehensive Assessment” dated 09/24/2025, stated in part that “The comprehensive assessment...shall take into consideration...severity of symptoms...shall include data elements that allow for measurement of patient outcomes.... Data elements shall...be used in individual patient care planning...” This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 14 (07%) clinical records reviewed, the agency did not ensure the patient’s individualized plan of care reflected the patient and family goals and included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient, a resident of a nursing facility, elected the hospice benefit on 02/20/2026 with a terminal diagnosis of hypertensive heart disease with heart failure and a comorbid condition of chronic pain. Review of the plan of care (POC) for the certification period 02/20/2026–05/20/2026 identified pain as an active problem. The POC included goals that documented: “signs and symptoms of pain would improve with prescribed interventions”, “pain would be managed at an acceptable level” and “patient or caregiver would understand the need to report changes in pain to hospice staff by the end of the certification period”. The clinical record did not include documentation identifying the patient’s individualized acceptable pain level. Without a defined pain goal, the plan of care did not contain measurable criteria for evaluating whether pain management outcomes were achieved. During an interview on 02/27/2026 with the Site Visit Readiness Specialist/RN, she confirmed that the goals documented in the patient’s plan of care were not patient-specific or measurable.”

“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. The agency policy “Bereavement Services and Coordination” dated 09/24/2025 stated in part, “The bereavement assessment will identify the needs of the patient’s family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered...must be considered in the bereavement plan of care. The bereavement plan of care will note the kind 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. In 1 of 2 (50%) clinical records reviewed with bereavement service revealed that the agency did not ensure that the clinical record included a bereavement plan of care identifying the needs of the bereaved and the type and frequency of bereavement services to be provided. CLINICAL RECORD 14: The patient elected hospice benefit on 01/28/2026. The patient died while on hospice service on 02/17/2026. Review of the clinical record did not include a bereavement plan of care addressing the needs of the bereaved or identifying the type and frequency of bereavement services to be provided following the patient’s death. Review of the post-death Interdisciplinary Group meeting documentation dated 02/25/2026 also did not include documentation of bereavement needs or a bereavement plan of care. During an interview conducted on 02/26/2026, the Survey Readiness Specialist confirmed that the bereavement plan of care had not been completed for this record and stated, “We missed that one.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with a live discharge, the agency did not ensure that the patient’s discharge summary was provided to the attending physician upon discharge from hospice services. CLINICAL RECORD 11: The patient elected hospice benefits on 09/17/2025. Review of the clinical record revealed the patient was discharged from hospice services on 12/01/2025 due to an extended prognosis. The clinical record did not include documentation indicating that the hospice discharge summary was provided to the patient’s attending physician. During a joint clinical record review and interview on 02/26/2026, the Survey Readiness Specialist confirmed that the clinical record did not contain documentation demonstrating that the discharge summary had been sent to the patient’s attending physician.”

“It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by clinical record review, document review, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure that a social worker with a bachelor’s degree was supervised by a qualified CMS-Medical Social Worker (MSW). The agency’s policy “Social Work Assistant Supervision” dated 02/25/2026 (previously dated 3Q/2024) stated in part “Guidelines: Medical social services are provided under the supervision of a social worker who has a master’s or doctoral degree...Medical Social Services are provided under the supervision of a social worker who has a master’s or doctoral degree...” CLINICAL RECORD 2: The patient elected the hospice benefit on 06/11/2025. Review of the clinical record documented the initial psychosocial assessment completed on 06/13/2025, and the development of the social work plan of care was completed by a Licensed Bachelor-Level Social Worker (LBSW). The clinical record did not include documentation that a CMS-qualified MSW supervised the LBSW. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/26/2025 with a documented terminal diagnosis of chronic obstructive pulmonary disease and a comorbid condition of dementia with anxiety. Review of the clinical record revealed the initial psychosocial assessment was completed on 10/29/2025, and the subsequent psychosocial plan of care was completed by a Licensed Bachelor-Level Social Worker. The clinical record did not include documentation that a CMS-qualified MSW supervised LBSW. CLINICAL RECORD 14: The patient, who resided in an assisted living facility (ALF), elected the hospice benefit on 01/28/2026 with the primary diagnosis of Alzheimer’s disease and the comorbid condition of dementia with anxiety and agitation. Review of the clinical record revealed the initial psychosocial assessment was completed on 01/29/2026, and the development of the psychosocial plan of care was completed by a Licensed Bachelor-Level Social Worker. The clinical record did not include documentation that a CMS-qualified MSW supervised LBSW. During an interview conducted on 02/27/2026, the Administrator confirmed that the hospice did not have a Licensed Master Social Worker on staff from 04/01/2025 to 02/24/2026. The Administrator provided documentation demonstrating a Performance Improvement Project (PIP) addressing the absence of a CMS-qualified MSW was initiated on 02/25/2026, during the time of the site visit. The review of the Governing Body meeting minutes dated 04/07/2025 and 01/12/2026 did not include documentation identifying the absence of a Licensed Medical Social Worker, recruitment efforts, or actions to ensure supervision of the Bachelor-level Social Worker.”