Armonia Hospice LLC

“Based on record review and interview the agency failed to provide each patient with a written statement on how to exercise his/her patient rights to voice grievances that informed the patient, as required, on how to contact HHSC, and if applicable agency staff for 3 of 3 patients (Patient #1, #2 and #3) reviewed in that:The agency’s policy given to patients was inaccurate on what state agency to file a grievance/complainant with.This failure placed Patients #1, #2 and #3 at risk of being unable to file a complaint due to confusion regarding the correct state entity to report complaints and would delay resolving a patient’s complaint leaving them at risk of abuse, neglect or exploitation. Findings Included:Review of the agency’s new patient admissions documents contained a booklet that read, “CONSUMER COMPLAINT REPORTING- By signing below, I acknowledge that I have been informed that I may register a complaint about (Agency) and/or its employees, including complaints concerning the advance directive requirements to the: Texas- Department of Aging and Disability Services at 1-800-458-9858.”An interview was conducted on 04/14/2026 at 4:25 p.m. with the A/SN. The agency’s new patient admission packet was reviewed. The documents with contact information for DADS instead of HHSC were reviewed. A/SN stated she was not aware the information had not been updated in the packets. Surveyor asked who was responsible for assembling the packets. A/SN stated the Medical Records Manager.Review of the clinical record for Patient #1 revealed a start of care date of 05/02/2025 with a diagnosis of brain cancer.A Home Visit was conducted on 04/15/2026 at 10:00 a.m. with Pt #2 and RNCM-B. Review of documents in the agency admission packet indicated Client Rights and Responsibilities, and how to file a grievance indicated complaints should be directed to The Department of Aging and Disability Services. Pt #2 was not interviewable so FM-A was interviewed. Surveyor asked if she had a complaint or grievance regarding the agency or agency staff, what would she do. FM-A stated, “I would call the agency.” Surveyor reviewed the HHSC Consumer Complaint Hotline contact information.A home visit was conducted on 04/15/2026 at 11:00 a.m. with Pt #1 and RNCM-B. Review of documents in the agency admission packet indicated Patient Rights and Responsibilities, and how to file a grievance indicated complaints should be directed to The Department of Aging and Disability Services. Pt #1 was not interviewable so a family member was interviewed. Surveyor asked if she had a complaint or grievance regarding the agency or agency staff what would she do. Family Member stated, “I don’t know. I guess I would call them (the agency administrator).” Surveyor reviewed the HHSC Consumer Complaint Hotline contact information. Review of the clinical record for Pt #2 revealed a start of care date of 10/24/2025 with a diagnosis of prostate cancer.Review of the clinical record for Pt #3 revealed a start of care date of 11/03/2025 with a diagnosis of heart failure.On 04/15/2026 at 12:12 p.m.- A Home Visit was conducted with Pt #3 and LVN-B. Review of documents in the agency admission packet indicated Client Rights and Responsibilities, and how to file a grievance indicated complaints should be directed to The Department of Aging and Disability Services. Pt #3 was interviewed. Surveyor asked if she had a complaint or grievance regarding the agency or agency staff what would she do. Pt #3 stated, “I would call the agency.” Surveyor reviewed the HHSC Consumer Complaint Hotline contact information.An interview was conducted on 04/15/2026 at 1:50 p.m. with Employee-A. Surveyor asked how long Employee-A had been responsible for assembling the new patient admission packets. Employee-A stated, “Three years.” Surveyor reviewed the packet with Employee-A. Employee-A acknowledged the documents had not been updated from DADS to HHSC.Review of the agency’s online policies and procedures read, “PATIENT RIGHTS & RESPONSIBILITIES JCC 060425 Hospice-L&C”. The hospice will provide a patient who receives hospice services with a written statement that informs the patient that a complaint against the agency may be directed to the: The Texas Health and Human Services Commission’s Complaint and Incident Intake, Mail Code E249, P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858.””

“Based on record review and interview, the hospice failed to meet federal requirements by ensuring their volunteer program met 5% of the total patient care hours of all paid employees for the years 2024 and 2025.This failure to ensure the hospice volunteer program met the 5% requirement placed the 54 active patients and administrative staff at risk of not benefiting from the added services of volunteers. Findings Included:Review of the agency’s Volunteer Cost Savings Report for 2024 revealed total patient care hours were 1,866.57. Total volunteer hours were 4.83. The total percentage of volunteer cost savings was 0.26%.Review of the agency’s Volunteer Cost Saving Report for 2025 revealed total patient care hours were 1,329.37. Total volunteer hours were 44.38. The total percentage of volunteer cost saving was 3.23%.An interview was conducted on 04/13/2026 at 11:56 a.m. with the BC/VC. Volunteer Cost Saving Reports were reviewed for the years 2024 and 2025. Surveyor asked if she was aware of the federal 5% minimum annual cost savings requirement. BC/VC stated she was aware and would work hard to meet the requirements in the future. On 04/13/2026 at 3:47 p.m.- An interview was conducted with the A/SN. The agency’s Volunteer Cost Savings Reports for 2024 and 2025 were reviewed. A/SN acknowledged the agency did not meet the annual 5% minimum. Surveyor asked why the agency did not meet the requirement. A/SN stated, “We had a Volunteer Coordinator who did very little to recruit volunteers. We have a new Volunteer Coordinator, and she is trying hard to get volunteers.Review of the agency’s Policy and Procedure Manual revealed a policy titled “Volunteer Services, JCC 013115 Hospice- L&C”, which read, “Monthly tracking and documenting volunteer services, the cost savings achieved through the use of volunteers and the percentage of patient care hours provided by volunteers. Documentation of volunteer services will include: A. Volunteer role (administrative, direct patient care). B. Work time spent by volunteer. To calculate the total cost savings: Total Volunteer Hours X Volunteer Value Rate = Total Cost Savings.””