Suncrest Hospice San Antonio LLC

“It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes. CLINICAL RECORD 2: The patient elected the hospice benefit on 10/19/2024 with the diagnosis of congestive heart failure with comorbid conditions of chronic gout and constipation. The plans of care for the benefit periods from 08/20/2025 to 10/18/2025 and 10/19/2025 to 12/17/2025 were reviewed. On 10/27/2025, the skilled nurse (SN) visit note documented a pain score of 8, describing aching and throbbing in both lower extremities. On 11/03/2025, the SN documented the patient’s pain score was 4, worsening upon touching his lower extremities, and he was unable to lie flat due to hypoxia. Medications included tramadol 50 mg every 8 hours as needed. On 11/03/2025, new orders were added: Norco 325/5 mg, one tablet every 6 hours as needed, and gabapentin 300 mg four times daily. The plan of care documented the patient’s goal for the pain as “acceptable.” “Acceptable” pain was not defined and is not a measurable outcome. The plan of care addressed congestive heart failure and respiratory status, including assessments of lung sounds, breathing pattern, secretions, dyspnea, and cough. The plan of care goals documented “stable respiratory status and symptom management aligned with disease progression. “Stable” and “managed as well as possible” were undefined and are not measurable outcomes. The patient’s medications for constipation included Colace 100 mg twice daily and as needed, polyethylene glycol 17 gm daily as needed, Fleet Enema every 3 days as needed, and Senna Plus 50 mg twice daily and every 8 hours as needed. The plan of care goal documented: “establish and maintain regular bowel habits and reduce constipation symptoms.” “Regular bowel habits” and “decrease in symptoms” are not measurable outcomes. CLINICAL RECORD 4: The patient elected the hospice benefit on 08/21/2025 with the diagnosis of senile degeneration of the brain with a secondary diagnosis of dementia with behavioral disturbances and anxiety. The plan of care for the benefit period from 08/21/2025 to 11/18/2025 was reviewed. On 10/01/2025, the SN visit note documented pain and anxiety scores of 7. The patient exhibited signs of awakening to stimuli, including immediate restlessness, tearfulness, and nonsensical speech. During a joint visit with the Hospice Aide, a bed bath was performed; the patient appeared anxious, cried out repeatedly, and was unresponsive to words or touch. On 10/10/2025, pain and anxiety scores were 6, with facial grimacing and moaning noted. The patient’s medications included: trazodone 50 mg at noon for behavioral issues; lorazepam 0.5 mg, 1-2 tablets every 4 hours as needed; Depakote 250 mg twice daily; and bupropion 100 mg twice daily for behavioral management. For pain control, the patient’s medications included: acetaminophen 500mg, two (2) capsules every 6 hours as needed for mild pain, and Norco 325mg-5mg, two (2) tablets every 4-6 hours for moderate to severe pain. The plan of care identified anxiety and stress as problems, with the POC goal documented as symptom control and reduction of anxiety through avoidance of stressors. “Stressors” were not defined and are not a measurable outcome. The plan of care goal addressing pain relief documented “being pain-free or achieving an acceptable pain level.” “Acceptable” is not a measurable outcome. CLINICAL RECORD 6: The patient elected the hospice benefit on 09/11/2025 with the diagnosis of heart failure and the comorbid condition of intracranial injury. The patient’s plan of care for the benefit period from 09/11/2025 to 12/09/2025 was reviewed. The Registered Nurse (RN) visit note dated 09/27/2025 documented that the patient was reported to exhibit aggressive behavior, including grabbing and punching caregivers. An order was received for “Ativan and Benadryl (AB) compound 2mg-25mg topical cream to be applied every 4 hours as needed for agitation.” The medication profile also included Seroquel 100 mg daily for behavioral disturbances. The plan of care identified end-stage dementia as a problem and documented interventions, including assessing mental status and orientation, evaluating caregiver ability, and screening for behavioral disturbances such as anxiety, fear, agitation, restlessness, and wandering. The plan of care documented that the caregiver’s goal was to “minimize risks related to altered mobility and to manage the patient, knowing when to contact hospice effectively.” However, these goals did not directly address the patient’s behaviors and did not include measurable outcomes. CLINICAL RECORD 8: The patient elected the hospice benefit on 07/23/2025 with the diagnosis of malignant neoplasm of the bone. The plans of care for the benefit periods from 07/23/2025 to 10/20/2025 and 10/21/2025 to 01/18/2026 were reviewed. During the admission visit, the RN documented the patient’s complaint of moderate abdominal and pelvic pain, rated at 4. By the visit on 09/23/2025, the pain score had increased to 5 out of 10, prompting medication adjustments. Initial medications included Norco 325/5 mg every 6 hours as needed and morphine 0.25–1 ml every 2 hours as needed. On 09/04/2025, Norco was increased to 325/10 mg every 6 hours, scheduled. On 09/14/2025, a new order was added for hydromorphone 4 mg every 4 hours as needed. Pain was identified as a problem in the plan of care, with interventions to educate the patient and family on pain management and conduct regular pain assessments using a 0-10 scale. The plan of care goal documented “being pain-free or verbalizing an acceptable pain level.” “Acceptable” was not defined, and it is not a measurable outcome. CLINICAL RECORD 11: The patient elected the hospice benefit on 08/05/2025 with the diagnosis of cirrhosis of the liver and a comorbid diagnosis of heart failure. The plans of care for the benefit periods from 08/05/2025 to 11/02/2025 and 11/03/2025 to 01/31/2026 were reviewed. On 10/23/2025, the nurse documented an anxiety score of 6, noting recent confusion and agitation. By 11/01/2025, the anxiety score decreased to 3, with the caregiver reporting a hallucination the previous day. The care plan identified liver disease as a problem, with interventions including medication education—dosing, administration, side effects, interactions, and symptom reporting—and assessing mental status for signs of delirium or confusion. The goal was to prevent complications and ensure symptoms aligned with the disease stage. The plan of care goals “free of preventable complications” and “symptoms consistent with disease stage” did not include measurable outcomes. CLINICAL RECORD 15: The patient elected the hospice benefit on 06/10/2025 with malignant neoplasm of the pharynx. The patient was discharged for cause due to non-compliance with narcotic medication orders. The plan of care for the benefit period 06/10/2025 to 08/08/2025 was reviewed. The patient was discharged on 06/27/2025 due to non-compliance with the plan of care. During the RN visit on 06/13/2025, the nurse documented that the hospice Medical Director ordered a 100 mcg Fentanyl patch every 72 hours for pain management. The physician offered no additional recommendations, as the patient was also on oxycodone 40 mg every 6 hours as needed for breakthrough pain. The patient refused the Fentanyl patches, and a Narcotic Agreement signed by the patient and spouse was in place. Narcotics in the home were counted and stored in a lockbox. On 06/19/2025, the nurse documented a witnessed narcotic count. On 06/20/2025, she noted a video conference narcotic count: the patient had 22 oxycodone 20 mg tablets and 24 lorazepam 1 mg tablets. The patient reported taking two extra oxycodone yesterday and acknowledged understanding the doctor’s orders and the importance of medication adherence. The nurse emphasized that prescriptions would not be filled earlier than ordered. A discussion with the patient and clinical leaders was documented regarding potential discharge plans due to non-compliance with the care plan and pain contract. At the 06/26/2025 Interdisciplinary Group Meeting, the nurse reported that non-compliance with the physician’s orders was a barrier to the patient’s goals. The plan of care documented pain as a problem, with goals for the patient and caregiver to understand medication use and to be “pain-free or verbalize an acceptable pain level.” “Acceptable” pain was undefined and is not a measurable outcome. There was no evidence that the patient or caregiver understood medication use. CLINICAL RECORD 19: The patient elected the hospice benefit on 05/05/2025 with the diagnosis of malignant neoplasm of the prostate with a secondary bone malignancy. The patient also had a comorbid condition of anxiety disorder. The plan of care for the benefit period from 05/05/2025 to 08/02/2025 was reviewed. The patient died on hospice services on 05/30/2025. During a routine RN visit on 05/06/2025, it was documented that the patient could drink fluids but vomited pureed foods. On the same day in 1938, an on-call visit noted the patient in severe pain and nausea. The nurse administered 4 mg of ondansetron and applied a newly ordered 25 mcg/hr Fentanyl patch. On 05/21/2025, the nurse documented the patient crying, anxious, and in moderate pain, despite receiving 1 ml of morphine and lorazepam earlier. The Fentanyl patch was increased to 50 mcg/hr. The patient’s medications included lorazepam 2 mg every 6 hours as needed and morphine 20 mg/ml, 0.25–1 ml every 2 hours as needed. Pain was addressed in the care plan with assessments using a 0-10 scale and interventions to evaluate severity, location, and quality. Education on pain management and comfort measures was provided, but goals for patient and caregiver understanding lacked specificity and were unmeasurable. Nausea and vomiting were identified as issues, with interventions to monitor symptoms. Goals to maintain comfort during nausea and to achieve a peaceful death were not defined or measurable. Anxiety was addressed during the 05/14/2025 Interdisciplinary Group Meeting, where “comfort care” was listed as the goal. No specific or measurable pain or anxiety management goals were established. During an interview and a joint clinical record review on 11/14/2025, the Senior Director of Clinical Quality confirmed the findings and provided information that the agency had not had consistent clinical leadership, with the current clinical leaders beginning mid-year. Before exiting, the clinical records were being brought into compliance.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: a revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care was updated to reflect newly identified problems in the updated comprehensive assessment. CLINICAL RECORD 1: The patient elected the hospice benefit on 02/27/2025 with the diagnosis of Alzheimer’s disease. The plans of care for the benefit periods from 08/26/2025 to 10/24/2025 and 10/25/2025 to 12/23/2025 were reviewed. During a face-to-face visit on 10/11/2025, the Nurse Practitioner (NP) noted that the patient had difficulty swallowing, was on a pureed diet, and that the daughter used a syringe to give liquids. The physician’s terminal illness certification for 10/25/2025 through 12/23/2025 documented that the patient “exhibits signs of aspiration.” At the 10/22/2025 Interdisciplinary Group Meeting, the nurse documented that worsening dysphagia and increased aspiration risk led to deprescribing gabapentin and lisinopril. The patient remained on a pureed diet. However, the plan of care was not updated with interventions or goals for the dysphagia. CLINICAL RECORD 9: The patient elected the hospice benefit on 05/21/2025 with the diagnosis of multiple sclerosis. The plans of care for the benefit periods dated 05/21/2025 to 08/18/2025 and 08/19/2025 to 11/16/2025 were reviewed. During the RN visit on 09/09/2025, the patient’s pain was recorded as 7, following a reported fall. The physician was notified, and an X-ray was ordered. On 09/10/2025, the pain score decreased to 4, with reports of knee and ankle discomfort. X-ray results suggested a likely left tibial fracture and were sent to the physician. The medication list included “pregabalin 75 mg three times daily” and “acetaminophen 325 mg (2 tablets every 4 hours as needed).” However, pain management was only addressed through discipline-specific interventions by Music and Massage Therapists. The plan of care was not updated to reflect the new pain associated with the fall. CLINICAL RECORD 15: The patient elected the hospice benefit on 06/10/2025 with a malignant neoplasm of the pharynx. The patient was discharged for cause due to non-compliance with narcotic medication orders. The plan of care for the benefit period dated 06/10/2025 to 08/08/2025 was reviewed. The patient was discharged on 06/27/2025 due to non-compliance with the plan of care. On 06/13/2025, the Registered Nurse (RN) documented that the hospice Medical Director ordered a 100 mcg Fentanyl patch every 72 hours for pain management. The physician had no additional recommendations, as the patient was also on oxycodone 40 mg every 6 hours as needed for breakthrough pain. The patient refused the Fentanyl patch, and the patient and spouse signed a Patient Safety Narcotic Agreement. Narcotics in the home were counted and stored in a lockbox. On 06/19/2025, the narcotic count was witnessed and documented. On 06/20/2025, the RN performed a video conference count, noting 22 oxycodone 20 mg tablets and 24 lorazepam 1 mg tablets. The patient reported taking two extra oxycodone tablets the previous day and confirmed understanding of dosing instructions. The RN emphasized that medications would not be refilled earlier than scheduled. During the 06/26/2025 Interdisciplinary Group Meeting, the nurse identified non-compliance with the physician’s orders as a barrier to the patient’s goals. A discussion with the patient and clinical leaders was documented, and the patient was informed of discharge plans due to non-compliance with the care plan and pain contract. The plan of care was not updated to include interventions or goals addressing challenging behaviors or non-compliance. During a joint record review and interview on 11/14/2025, the Senior Director of Clinical Quality confirmed that the agency has lacked consistent clinical leadership, with current leaders assuming roles mid-year.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 4) and the Senior Director of Clinical Quality on November 11, 2025, it was determined that the average volunteer contribution for 01/01/2024 through 12/31/2025 was 1.43%, with a year-to-date average of 1.48% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation of a Performance Improvement Project (PIP) on October 22, 2025. The PIP includes monthly meetings with the Volunteer Coordinator and the Administrator to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 4) and the Senior Director of Clinical Quality on November 11, 2025, it was determined that the average volunteer contribution for 2024 was 1.43%, with a year-to-date average of 1.48% for 2025. These figures are below the established target, which requires volunteers to contribute at least 5% of the total patient care hours performed by all paid hospice employees and contract staff. This discrepancy prompted the initiation of a Performance Improvement Project (PIP) on October 22, 2025. The PIP includes monthly meetings with the Volunteer Coordinator and the Administrator to monitor recruitment and retention efforts, as well as the percentage and hours of volunteer service. Recruitment strategies documented include outreach through trade schools and nursing programs, yoga studios, and informal interactions during the Volunteer Coordinator’s regular daily activities. Retention activities include individual and group luncheons with volunteers, invitations for volunteers to attend all staff meetings, and regular communication, primarily through text messages.”