True Heart Hospice LLC

“Based on record review and interview, after the agency had cause to believe a patient may have been neglected, the agency failed to report the allegation within 24 hours to HHSC as required by state regulation for 1 of 3 patients (Patient #1) with an allegation that the agency failed to provide services. The agency received a complaint of neglect (#524935) from Pt #1 on 08/14/2024 but did not report it to HHSC. This failure placed the patient at risk of physical decline if agency services were not provided. This failure could affect the agencys current 13 patients. Findings included: Review of the agencys complaint log revealed a complaint dated 08/14/2024 that read: Name of Complainant: (Patient #1). Date/Time of Complaint Event: Entire week of 08/12/24. Individual taking complaint: Administrator. Employees/Patients/Individuals Involved in complaint: AA/SN, Administrator, RN #1, ASN and HHA #1. Claims of neglect, despite all charting showing otherwise. Claims of dog theft. Interventions to Correct Complaint: reported to APS case worker. Review of the clinical record for Patient #1 revealed a start of care date of 04/06/2024 with a terminal diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery (hardening of the arteries). Review of the plan of care for 07/05/2024 – 08/31/2024 revealed orders: Skilled Nursing: 1 time per week + 5 prn (as needed), HHA: (6-7-24 – 7-14-24) weekly, Chaplain: 1 time per month + 2 prn, Social Worker: 1 time per month + 2 prn. Review of the clinical record visit notes for the time period 07/05/2024 – 08/31/2024 revealed all services were provided in accordance with the plan of care. All missed visits were documented by agency staff and noted the patients refusal to accept a visit. Home health aide visits were discontinued after 07/14/2024 due to sexually inappropriate requests by the patient. Further review of the record revealed the client accused the agency chaplain of causing his dogs to be taken away by Animal Control. It was estimated there were at least 10 dogs on the property. Chaplain denied the allegation. 01/07/2025 at 12:10 PM during an interview with AA/SN the agency complaint log was reviewed. AA/SN confirmed a complaint was received by the administrator on 08/14/2024 by Patient #1 (Complainant). Surveyor asked if a self-report of the allegation of neglect was reported by the agency to HHSC within 24 hours after the agency received the complaint. AA/SN stated, “;No. We were in contact with APS. I didnt know we needed to report it to you (HHSC) too.” Review of the agencys policy and procedure manual revealed a policy titled ABUSE, NEGLECT, MISTREATMENT AND EXPLOITATION, Policy Number: PC. A010, Original date: February 2018 (No revision date). Policy: This Hospice follows all Federal and State requirements regarding alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property by anyone providing services on behalf of the hospice. Procedure: 5. Violations are reported to State and local bodies having jurisdiction (including the State survey and certification agency) immediately (meaning within 24 hours) after becoming aware of the violation.””

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed revealed the organization did not ensure a medication reconciliation was completed and medications updated to the medication profile and plan of care. Clinical Record 3: The patient’s date of election was 06/17/2023 with a diagnosis of heart failure unspecified. The patient resided in an assisted living facility (ALF). The medication profile dated 06/17/2023-3/28/2024 revealed Acetaminophen 650mg suppositories, give one suppository rectal every 6 hours as needed for fever/temp; Ropinirole Hcl 0.5mg tablet, one tablet oral one time a day; Trazadone 50mg tablet, one tablet oral one time a day; and Voltaren 1%, one application topical two times a day as needed for pain. During Home Visit 3 with the registered nurse (Personnel Record 5) on 03/28/2024, the medications were reviewed with the ALF medication aide, who reported that the Ropinirole, Trazadone, and Voltaren were discontinued “two to three months ago.” The Acetaminophen suppositories were not in the home. The patient had Acetaminophen 325mg tablets, one to two tablets every 4 hours as needed for pain, dispensed on 07/20/2023; Loperamide 2mg, one tablet daily, dispensed on 10/18/2023; and Hydrocodone 7.5/325mg solution, 5ml by mouth every 12 hours as needed for pain last dispensed on 10/04/2023 available in the home. There was no documented evidence that the medications were reconciled and updated to the hospice medication profile and plan of care. During a joint review of the record and an interview on 03/28/2024, the Supervising Nurse agreed there was no documented evidence the Acetaminophen, Hydrocodone, Voltaren, Ropinirole, Trazadone, and Loperamide were updated to the medication profile and plan of care.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hosp ice 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 4 of 13 (31%) clinical records reviewed of patients receiving hospice aide services revealed the hospice did not ensure that a registered nurse prepared the written plan care instructions before the aide began services. Clinical Record 2: The patient was admitted to home health services on 02/10/2024. The physician ordered home health aide services on 02/12/2024. The clinical record review revealed home health aide visit notes dated 02/13/2024, 02/15/2024, and 02/16/2024. The registered nurse developed the hospice aide care plan on 02/19/2024. The documented aide visits were completed without an aide plan of care. Clinical Record 4: The patient was admitted to home health services on 12/03/2023. The physician ordered home health aide services on 02/19/2024. The clinical record review revealed home health aide visit notes dated 02/20/2024, 02/22/2024, 02/27/2024, and 02/29/2024. The registered nurse developed the hospice aide care plan on 03/03/2024. The documented aide visits were completed without an aide plan of care. Clinical Record 6: The patient was admitted to home health services on 02/28/2024. The physician ordered home health aide services on 03/10/2024. The clinical record review revealed home health aide visit notes dated 03/11/2024 and 03/14/2024. The registered nurse developed the hospice aide care plan on 03/19/2024. The documented aide visits were completed without an aide plan of care. Clinical Record 9: The patient was admitted to home health services on 07/28/20023. The physician ordered home health aide services on 11/01/2023. The clinical record review revealed home health aide visit notes dated 11/01/2023, 11/09/2023, 11/15/2023, 11/17/2023, 11/22/2023, 12/01/2023, 12/05/2023, 12/12/2023, 12/19/2023, 12/26/2023, 01/04/2024, and 01/09/2024. The registered nurse developed the hospice aide care plan on 01/12/2024. The documented aide visits were completed without an aide plan of care. During a joint record review and interview on 03/29/2024, the Supervising Nurse agreed that hospice aide visits occurred before the registered nurse prepared the written hospice aide plan of care.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical record review with hospice aide services revealed that the agency did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group. Clinical Record 2: The hospice aide plan of care dated 02/19/2024 revealed light housekeeping, shower, supplies, and light meal prep. The hospice aide documentation for 02/23/2024 did not include light housekeeping, shower, supplies, and light meal prep as per the plan of care. Clinical Record 12: The hospice aide plan of care dated 07/14/2023 revealed clothing assist, foot care, nail care, oral care, perineal care, shampoo, shower, skin care, and clear any trash around pt area. The hospice aide visit documentation for 08/24/2023 did not include oral care, shampoo, and shower and for 08/29/2023 did not include oral care as per the plan of care. During a joint record review and interview on 03/29/2024, the Supervising Nurse agreed that the records lacked evidence of documented hospice aide visits as ordered by the Interdisciplinary Group.”

“It is required that hospice aides must report changes in the patient t’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide reported changes to the Registered Nurse. Clinical Record 2: The hospice aide plan of care dated 02/19/2024 revealed light housekeeping, shower, supplies, and light meal prep. The hospice aide documentation for 02/23/2024 did not include light housekeeping, shower, supplies, and light meal prep as per the plan of care. There was no documented evidence that the hospice aide reported the changes to the Registered Nurse. Clinical Record 4: The hospice aide plan of care dated 03/04/2024 revealed bed bath, linen change, light housework, lotion, nail care, peri care, shave, and supply drop off: med briefs, chucks, and wipes x1 weekly. The hospice aide visit documentation for 03/05/2024 revealed that the bed bath, lotion, nail care, and peri care were refused. There was no documented evidence that the hospice aide reported the changes to the Registered Nurse. Clinical Record 12: The hospice aide plan of care dated 07/14/2023 revealed clothing assist, foot care, nail care, oral care, perineal care, shampoo, shower, skin care, and clear any trash around pt area. The hospice aide visit documentation for 08/24/2023 did not include oral care, shampoo, and shower and for 08/29/2023 did not include oral care as per the plan of care. There was no documented evidence that the hospice aide reported the changes to the Registered Nurse. During a joint record review and interview on 03/29/2024, the Supervising Nurse agreed that the hospice aide did not report changes to the Registered Nurse.”