Trinity Hospice

“Based on record review and interview, the hospice failed to ensure the patient’s clinical record contained an addendum election statement as required in 42 CFR (Code of Federal Regulations) §418.52 for 1 of 4 patients (Patient # 2) whose records were reviewed in that: Patient #2’s representative was not provided with an election statement addendum for 2025 before SOC date on 11/10/25. This failure placed Hospice’s patients at risk of not being fully informed about the services to be provided and of receiving care and services that were not consistent with their wishes, needs, or individualized plan of care. The findings included: Review of Patient 2’s electronic clinical record included a Plan of Care (POC) with SOC dated 11/10/25 for the benefit period of 02/09/26 – 06/30/26 that listed the Terminal Diagnosis of Alzheimer’s Disease (a progressive brain disorder that causes memory loss, worsening thinking skills, and changes in behavior) with late onset. The POC revealed skilled Nurse (SN) visit frequency of one time per week with two prn visits (as needed).Further review of Patient 2’s electronic clinical record revealed it failed to contain the updated addendum of Election of Hospice Benefit form - 3071 signed by Patient # 2 or their Representative.During an interview on 07/20/26 at 2:14 p.m. with the Adm and DCS the above findings were presented. After the review of Patient 2’s electronic record and paper record, they were asked if Patient 2’s clinical record contained a signed and dated addendum Election of Hospice Benefit form - 3071. The Adm/DON stated, “No because the 2023 forms were still being used by some of their Hospice agency staff after the addendum was provided and the risk included conditions of payment and compliance with federal and state laws.”According to 42 CFR Chapter IV -§ 418.24 Election of hospice care dated 2/01/25.(6) For Hospice elections beginning on or after October 1, 2020, the Hospice must provide notification of the individual’s (or representative’s) right to receive an election statement addendum, as set forth in paragraph (c) of this section, if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice..”(C) Content of hospice election statement addendum. For hospice elections beginning on or after October 1, 2020, in the event that the hospice determines there are conditions, items, services, or drugs that are unrelated to the individual’s terminal illness and related conditions, the individual (or representative), non-hospice providers furnishing such items, services, or drugs, or Medicare contractors may request a written list as an addendum to the election statement.Review of the Hospice agency’s Administrative Policy Manual included a policy titled “Informed Consent Process” with last reviewed date 02/01/25. The policy read in part… Purpose: To ensure prior to the patient receiving, services and/or treatment related to the terminal illness or related terminal conditions, the hospice will provide information to the patient through an informed consent process for the patient to make their own decision(s) and choice(s) about their medical care. Policy: III. The Hospice will follow the informed consent process in compliance with all applicable federal, state, and local laws, throughout the course of hospice care. Procedure: A. The patient and/or the representative have the right to know of any financial liability prior to implementing care or treatment at admission and ongoing, in order to make an informed choice.Review of the Agency’s Administrative Policy Manual included a policy titled, “Hospice Election Statement”, Numbered: H-11.2023. The document read in part, “... Effects of a Medicare Hospice Election: I understand that by electing Hospice care under the Medicare Hospice benefit, I am waving (give up) all rights to Medicare payments for services related to my terminal illness and related conditions…Review of the Agency’s Administrative Policy Manual included a policy titled, “Hospice Election Statement”, Numbered: H-12.2025. The document read in part, “... Effects of a Medicare Hospice Election: I understand that by electing Hospice care under the Medicare Hospice benefit, I am waving (giving up) the right to Medicare payments for items, services, and drugs related to my terminal illness and related conditions….”

“Based on record review and interview, hospice nurse (RN A) failed to ensure the nursing needs for 1 of 3 discharged patients (#1) were met when she failed to update patient #1’s comprehensive assessment to include that a right heel pressure ulcer had developed, and deteriorated to require treatment, and failed to complete any Skilled Nurse visit notes from 5/12/24 – 5/21/24, and failed notify the physician of the wound and obtain and implement wound care orders. These failures resulted in the pressure ulcer on Patient #1s right foot deteriorating and the patient being transferred to the hospital for treatment of the pressure ulcer. This failure placed Patient #1 at risk of poor health outcomes including a decline in health status. Findings Include: Review of complaint intake # 507480 revealed the complainant alleged that the Med Tech (ALF staff) was assisting Patient #1 up for breakfast and he noticed that Patient #1 had a change in condition of the right heel. The Med Tech reported Patient #1s wound dressing appeared to have extensive discharge with a strong odor. The complainant stated they (the ALF) informed the Hospice of their observations and RN A arrived on 05/10/24 at 10:00am to assess Patient #1s change in condition of the right heel. The ALF staff reported RN A cleaned the wound and no further orders were received during RN As SN visit. Review of RN As nursing visit note dated 05/07/24 revealed documentation of vital signs but no documentation that the Patient# 1s feet were assessed. Further review revealed the clinical record did not contain a nursing visit note for the 05/10/24 Skilled Nursing visit, no documentation that the RN notified the physician of the wound and the comprehensive assessment was not updated to include the heel wound or the wound care procedures used. A phone interview with RN A was attempted on 06/04/24 at 3:12 pm. A voicemail was left to return call. No return call was received. Review of Patient #1s IDG Plan of Care dated 05/07/24 read in part that Patient # 1 had bilateral 2 + pitting edema to lower legs. Additional Comprehensive Assessment Comments: SN to continue to monitor for patient decline. Record review revealed no skilled nursing visit assessments of Patient # 1s feet. Record review of the ECR revealed no documented evidence of collaboration with the interdisciplinary team regarding Patient #1’s change in status (wound development) and no documentation that RN A collaborated with facility staff. Record review of the Hospice complaint investigation documentation titled, “;Patient Complaint Form” provided by Adm/DON on 06/03/24 included the following information that RN A did not document Patient #1s pressure ulcer to right heel, failed to document any wound assessments, wound care orders and/ or any clinical notes. The form also read in part that due to [RN As] failure to provide a minimum standard of care this patient was subsequently sent to the hospital due to the wound and found to be septic [septic shock is a severe complication of sepsis that can include very low blood pressure, an altered mental state, and organ dysfunction]. The Patient Complaint Form also included that RN A resigned when she was given the option as she was going to be termed and failed to document any completed visits that were outstanding. Her resignation was received on 05/21/24 at approximately 12 pm and was effective immediately. She was instructed to complete her documentation on her completed visits but failed to document any visits. Further review of the “;Patient Complaint Form” read in part... “;05/30/24 self-report completed by Trinity Hospice. [RN A] reported to the Texas State board of nursing due to significant safety concerns, possible neglect, and failure to document visits.” Interview on 06/04/24 at 11:32 am with the ALF executive director, stated that the Med Tech (ALF staff) was assisting Patient # 1 and noticed that she had a change in condition of the right heel. The Med Tech reported Patient # 1s wound dressing appeared to have extensive discharge with a strong odor. The ALF executive director stated they (the ALF) informed the Hospice of their observations and RN A arrived on 05/10/24 at 10:00am to assess Patient # 1s change in condition of the right heel. The ALF staff reported RN A cleaned the wound and no further orders were received during the SN visit. The ALF executive director stated RN A did not leave any visit notes or MD orders for patient Patient # 1 during any visits. The ALF executive director stated RN A visited Patient # 1 once per week and as needed for skilled nurse visits while patient #1 lived at the ALF. During an interview and concurrent record review with the Adm/DON on 06/05/24 at 5:05 p.m., the above findings on Patient # 1 were presented. The Admin/DON stated, she had been hired last week. When asked what the responsibilities of the Adm / DON were, she replied the Adm/DON was responsible for overseeing field staff to ensure they were following agency policies regarding documentation, assessments, communicating with IDG members and updating the POCs in a timely manner. Review of the policy titled, “Implementing care and treatment” dated 04/04/23 read in part:”....VI. When the provision of care/treatment cannot be implemented as established on the care planning document(s), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by discipline or Clinical Care Manager......” Review of the policy titled; “Plan of Care Process” dated 01/26/24 read in part:”.... VII. The Hospice IDG/IDT (in collaboration with the individuals attending physician, if any) will review, revise, and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. A. A revised POC will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals specified in the POC. Documentation will support that the patient receives the appropriate level of care and services as indicated by the disciplinary assessments.......””