Journey Hospice LLC
A hospice in San Antonio, Texas 78216
434 Breesport St, San Antonio, Texas 78216. (210) 455-0101.
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The short answer
Record last released by CMS on Oct 23, 2026.
- 9 deficiencies cited in the last three years
- Not rated family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
9 deficiencies cited in the last three years
The middle of the 92 hospices serving ZIP code 78216 had 4.
The last inspection on record was on Mar 21, 2024: a reaccreditation inspection by the Accreditation Commission for Health Care.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
9 deficiencies in 1 month of the last 36. Last cited Mar 2024. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Mar 21, 2024: reaccreditation inspection by the Accreditation Commission for Health Care9 deficiencies
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EP Training Program (42 CFR 418.113(d)(1))
The inspectors’ words, 117 words
“Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #12 and 13: PT and PTA did not have documented evidence that they received emergency preparedness training”
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Content of comprehensive assessment (42 CFR 418.54(c)(6))
The inspectors’ words, 140 words
“Upon patient record review, 1 of 15 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #2: During patient visit, observed discussion between nurse and CG including review of recent pain regimen. Morphine Concentrate was recently started due to patient decline. The order was included in most recent IDG POC, but not yet transcribed to medication profile. (Morphine Sulfate Concentrate Oral Solution 20 mg/ml Dose: 0.25 ml every 1 hr prn pain, sob. CG is to administer 0.24-1 ml SL q 4 hr. prn.)”
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Professional management responsibility (42 CFR 418.100(e))
The inspectors’ words, 106 words
“Upon contract review, 1 of 3 (Texas United Rehab contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Delivered in accordance with the patient’s plan of care Texas Rehab contract does not clearly specify that all services must be authorized by the hospice, furnished by qualified personnel and delivered in accordance with the patient’s plan of care.”
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Training (42 CFR 418.100(g)(1))
“Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #12, 13 did not have evidence received orientation on the hospice philosophy.”
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Training (42 CFR 418.100(g)(2))
“Upon personnel record review, 2 of 15 (Personnel #12, 13 ) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #12, 13: There is no evidence that contracted employees received orientation to specific job requirements.”
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Training (42 CFR 418.100(g)(3))
“Upon personnel record review, 3 of 15 (Personnel #10,12,13 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #10,12,13: Upon review, there is no documented evidence of competency for #10 volunteer. No patients have accepted services since hire and staff interview plan to observe/verify competencies during initial visit. Personnel 12, 13 PT, PTA have provided services, but competency skills checklist not available from contractor, by end of survey.”
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Authentication (42 CFR 418.104(b))
The inspectors’ words, 228 words
“Upon patient client record review, 3 of 15 (Patient #5, 7, 14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #5: In review of admission/consent forms, including election statement, noted that both Page 4 and Page 6 include effective date of hospice election. Page 4 identifies 01/09/24 as the effective date, whereas Page 6 identifies effective date as 01/29/24. All other dates are 01/29/24 and signature dates are 01/29/24. Patient #7: Noted that agency utilizes templates to prompt/facilitate clinician narrative in various formats. In reviewing record #7, noted that the template had not been individualized for specific patient. The narrative of 1/24/24 IDG Plan of Care Order reads “SNF facility care planning meeting (include day and time). NA. Identify attending physician and if they are involved in care: patient level of care: routine respite/GIP. Facility name_____________/ Dates of service __________ continuous care: reason________________ date started________date ended_________/ ..... “ This patient did not reside in SNF, and therefore, this section of template should be removed. Patient #14: Patient admitted and passed away in SNF. DC Death note inadvertently documents patient status as expired at Assisted Living.”
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Personnel qualification (42 CFR 418.114(b)(4))
“Upon personnel record review, 1 of 15 (Personnel #15 ) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions. Upon personnel review, there is no SLP personnel file provided by contractor by end of survey. No SLP services have been ordered or provided.”
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Criminal background checks (42 CFR 418.114(d)(1))
“Upon personnel record review, 2 of 15 (Personnel #14, 15 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #14, 15: There is no evidence of criminal background check. There have been no OT, ST services ordered/provided.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Mar 21, 2024 | Reaccreditation inspection by the Accreditation Commission for Health Care | 9 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Mar 24, 2021.
- Ownership: for-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 9.4 nurse care minutes per routine home care day, 8.9% of skilled nursing minutes at weekends and a visit near death for 96.4% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 98% at home, 1% in assisted living, 1% in a skilled nursing facility.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 9.4 min |
| Skilled nursing minutes at weekends | 8.9% |
| Visits near death | 96.4% of patients who died |
Who owns it?
- 7 owners or officers are people: Denise Mata (owns 5% or more directly, 65%); Gerardo Mata (owns 5% or more directly, 35%); Lucina B Trevino (managing employee (under contract)); Gerardo Mata (corporate director); Denise Mata (corporate officer, 0%); Denise Mata (corporate director, 0%); Denise Mata (managing employee (on the payroll), 0%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 96.3% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 75.6% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | Not rated |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 92 hospices CMS’s data show serving patients in ZIP code 78216, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 4; this one had 9.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Compassus - San Antonio | 4 |
| Aspen Hospice and Palliative Care | 0 |
| Ms Mission Hospice LLC | 0 |
| Altus Hospice | 7 |
| The Medical Team Inc. | 0 |
| Summit Home Health and Hospice | 21 |
| Sacred Heart Hospice | 1 |
| Santa Rita Home Health Services | 0 |
| Journey Hospice LLC This hospice | 9 |
| Admt Caring Hospice | 4 |
| Passion Hospice, Inc. | 0 |
| Alta Vita Hospice | 6 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.