Compassion Hospice of Texas

“Based on record review and interview, the agency failed to establish and maintain a comprehensive that must have a written and updated at least every 2 years. in that there was no written plan for 2024 and 2025.This failure placed patients at risk for inadequate care and services when the agency could not respond to natural or man-made disasters that were likely to occur in their service area. Findings included:An Entrance Conference was conducted on 06/24/2026 at 10:20 a.m. with the Administrator. The agency’s Emergency Preparedness Plan, implementation, and drills for the years 2024 and 2025 were requested for review. The Administrator stated she did not know if the agency had the documentation.An interview was conducted on 06/29/2026 at 2:10 p.m. with the AA. Surveyor requested to review any documentation of the Emergency Preparedness and Response Plan for 2024 + 2025. The AA stated the agency was purchased on 03/30/2026 and the PA/ former owner did not transfer the Emergency Preparedness and Response Plan documents to the agency after the sale. Review of the agency’s Policy and Procedure Manual revealed a policy titled, “Emergency Preparedness and Response Plan, ED.40, Reviewed: 09/01/2024,Page 467,” which read, “The Hospice will establish an emergency program that must include, but not be limited to, an Emergency Plan, Policies and Procedures, Communication Plan, and the Training and Testing Program. The Hospice will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services.””

“Based on record review and interview, the agency failed to provide the counseling services that included bereavement services for 2 (Pt #13, #14) of 2 records reviewed.Failure to provide bereavement services had the potential to disregard the counseling needs of the family, caregivers, and other individuals in need of support. Findings Included:Review of the agency’s Bereavement Roster identified bereaved parties for Patients #13 and #14.Review of the clinical record for Patient #13 revealed a discharge date of 05/27/2025, due to death.There was no documentation in the clinical record that bereavement services were provided to the individual listed on the Bereavement Roster for Patient #13.Review of the clinical record for Patient #14 revealed a discharge date of 10/25/2025, due to death.There was no documentation in the clinical record that bereavement services were provided to the individual listed on the Bereavement Roster for Patient #14.On 06/29/2026 at 12:52 p.m. an interview was conducted with the Administrator. Surveyor requested documentation of bereavement activities for Patient #13 and #14. The Administrator stated the agency had not provided any bereavement services. The Administrator stated she was not aware that there were patients that were supposed to receive bereavement services until the list of bereavement activities was requested. Surveyor asked who was responsible for bereavement activities. The Administrator stated it was the Chaplain’s responsibility.A telephone interview was conducted on 06/30/2026 at 4:05 p.m. with the Chaplain. The Chaplain confirmed he was the agency’s Bereavement Coordinator. Surveyor asked if he had experience as a hospice Bereavement Coordinator. The Chaplain stated no he did not. Surveyor discussed the bereavement requirements for hospice services. The Chaplain verbalized understanding. Surveyor advised there were two individuals listed on the agency’s bereavement list. Surveyor asked if he provided bereavement services to those individuals. The Chaplain stated he was not aware there were individuals on the bereavement list.Review of the agency’s Policy and Procedure Manual revealed a policy titled, “Bereavement, PC.130, Reviewed: 09/01/24”, which read “The Hospice will have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief and/or loss counseling. The program will provide referrals to appropriate community resources for those who may be experiencing pathologic grief. The bereavement services will reflect the needs of the bereaved. The Hospice will make bereavement services available to the family and other individuals in the Bereavement Plan of Care before, and for up to one year following the death of a patient.””

“Based on observation (on-site visit), interviews and record review, the Hospice failed to provide surveyor access to conduct a Recertification survey necessary to determine whether the hospice routinely provided all core services required under the Hospice Condition of Participation, including nursing services, physician services, medical social services and counseling services.This failure had the potential to place all Hospice patients at risk of not receiving the required core services, including nursing services, physician services, medical social services and counseling services necessary to identify, assess and address patient needs in accordance with Hospice Conditions of Participation. The Findings Included:Based on observations, interviews and record review, the Hospice failed to provide the surveyor access to conduct a Recertification survey to determine whether nursing care and hospice services were provided by or under the supervision of a registered nurse, and whether the nursing needs of hospice patients were identified and met through the initial, comprehensive, and updated assessments.This failure had the potential to place all Hospice patients at risk for unmet clinical needs, unmanaged symptoms, and lack of appropriate nursing oversight.Refer to L0591 §418.64(b)Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine compliance with hospice medical social services requirements, including whether medical social services were provided by a qualified social worker under the direction of a physician and based on the patient’s psychosocial assessment, identified needs, and acceptance of services.This failure had the potential to place all patients and families at risk for unmet psychosocial needs and lack of appropriate support during Hospice care.Refer to L0594 §418.64(c)Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine compliance with hospice counseling services, including whether counseling services were available to the patient and family to assist in minimizing the stress and problems arising from terminal illness, related conditions, and the dying process.This failure had the potential to place all patients and families at risk for unmet emotional and spiritual needs during hospice care.Refer to L0595 §418.64(d)”

“Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine compliance with the Hospice Condition of Participation requiring the hospice to be organized, managed, and administered in manner that enables it to provide hospice patients, caregivers, and families necessary palliation management of the terminal illness and related conditions.This failure had the potential to place all hospice patients and families at risk for unmet palliative care needs related to the management of the terminal illness and related conditions. The Findings Included:Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC (Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine whether hospice care service provided were consistent with acceptable standards of practice for the following:(i) Nursing services.(ii) Medical social services.(iii) Physician services.(iv) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling.(v) Hospice aide, volunteer, and homemaker services.(vi) Physical therapy, occupational therapy, and speech-language pathology services.(vii) Short-term inpatient care.(viii) Medical supplies (including drugs and biologicals) and medical appliances.This failure had the potential to affect all Hospice patients by placing them at risk for receiving Hospice care and services that were not verified to be consistent with the acceptable standards of practice including but not limited to nursing services, medical social services, counseling services and medical supplies. Refer to L0652 §418.100(c)(1)Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine whether hospice nursing services, physician services, and drug and biological services were provided on a 24 hour basis, seven days a week, in order to meet the needs of the patient and families. This failure had the potential to place all patients at risk for avoidable pain, distress, or clinical deterioration when essential services are not accessible at all times required.L0653 §418.100(c)(2)”

“Based on observations, interviews and record review, the Hospice failed to provide the surveyor access to conduct a Recertification survey and determine whether nursing care and hospice services were provided by or under the supervision of a registered nurse, and whether the nursing needs of hospice patients were identified and met through the initial, comprehensive, and updated assessments.This failure had the potential to place all Hospice patients at risk for unmet clinical needs, unmanaged symptoms, and lack of appropriate nursing oversight. The Findings Included:Record review of web-based licensure system Texas Unified Licensure Information Portal (TULIP - a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 05/14/2026, revealed the agency listed an Administrator and Alternate Administrator, the agency address (Address A), and the operating Hours: 9:00 am - 5:00 pm (Monday - Friday). The agency’s category of services was listed as Hospice. TULIP showed the Agency with an active license with an expiration date of 01/08/2027. Observation on 05/14/2026 at 2:30 p.m., the surveyor arrived at the agency address (Address A) listed in TULIP to conduct a Re-licensure and investigation survey. There was a sign in the front of the office suite with the agency’s name on it. There were signs posted on the agency’s door to indicate hours of operation and phone number to contact agency staff should the office be closed during business hours. The surveyor knocked on the agency door and rang the doorbell with no answer. On 05/14/2026 at 2:34 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 2:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 3:00 p.m., the surveyor spoke with employees in nearby office suite who stated that the agency has been closed for at least six months, further stating “they were there one day and gone the next.” On 05/14/2026 at 3:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 4:06 p.m., the surveyor emailed the administrator, alternate administrator and Chief Financial Officer to the emails for agency listed in TULIP and the emails were returned and undeliverable. On 05/14/2026 at 4:30 p.m., the surveyor left the agency without being able to conduct a Re-licensure and investigation survey, the Surveyor was unable to verify whether the Hospice provided nursing care and services under the supervision of a registered nurse.On 05/15/2026 at 4:06 p.m., the surveyor emailed to the agency forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS).”On 5/18/2026 at 12:13p.m., the administrative assistance sent the agency the federal forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS)” via certified letter and email.”

“Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification and investigation survey to determine compliance with hospice medical social services requirements, including whether medical social services were provided by a qualified social worker under the direction of a physician and based on the patient’s psychosocial assessment, identified needs, and acceptance of services.This failure had the potential to place all patients and families at risk for unmet psychosocial needs and lack of appropriate support during Hospice care. The Findings Included:Record review of web-based licensure system Texas Unified Licensure Information Portal (TULIP - a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 05/14/2026, revealed the agency listed an Administrator and Alternate Administrator, the agency address (Address A), and the operating Hours: 9:00 am - 5:00 pm (Monday - Friday). The agency’s category of services was listed as Hospice. TULIP showed the Agency with an active license with an expiration date of 01/08/2027. Observation on 05/14/2026 at 2:30 p.m., the surveyor arrived at the agency address (Address A) listed in TULIP to conduct a Re-licensure and investigation survey. There was a sign in the front of the office suite with the agency’s name on it. There were signs posted on the agency’s door to indicate hours of operation and phone number to contact agency staff should the office be closed during business hours. The surveyor knocked on the agency door and rang the doorbell with no answer. On 05/14/2026 at 2:34 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 2:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 3:00 p.m., the surveyor spoke with employees in nearby office suite who stated that the agency has been closed for at least six months, further stating “they were there one day and gone the next.” On 05/14/2026 at 3:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 4:06 p.m., the surveyor emailed the administrator, alternate administrator and Chief Financial Officer to the emails for agency listed in TULIP and the emails were returned and undeliverable. On 05/14/2026 at 4:30 p.m., the surveyor left the agency without being able to conduct a Re-licensure and investigation survey, the surveyor was unable to verify whether the Hospice provided medical social services by a qualified social worker, under the direction of a physician.On 05/15/2026 at 4:06 p.m., the surveyor emailed to the agency forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS).”On 5/18/2026 at 11:46 a.m., the administrative assistance sent the agency the federal forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS)” via certified letter and email.”

“Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine compliance with hospice counseling services, including whether counseling services were available to the patient and family to assist in minimizing the stress and problems arising from terminal illness, related conditions, and the dying process.This failure had the potential to place all patients and families at risk for unmet emotional and spiritual needs during hospice care. The Findings Included:Record review of web-based licensure system Texas Unified Licensure Information Portal (TULIP - a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 05/14/2026, revealed the agency listed an Administrator and Alternate Administrator, the agency address (Address A), and the operating Hours: 9:00 am - 5:00 pm (Monday - Friday). The agency’s category of services was listed as Hospice. TULIP showed the Agency with an active license with an expiration date of 01/08/2027. Observation on 05/14/2026 at 2:30 p.m., the surveyor arrived at the agency address (Address A) listed in TULIP to conduct a Re-licensure and investigation survey. There was a sign in the front of the office suite with the agency’s name on it. There were signs posted on the agency’s door to indicate hours of operation and phone number to contact agency staff should the office be closed during business hours. The surveyor knocked on the agency door and rang the doorbell with no answer. On 05/14/2026 at 2:34 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 2:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 3:00 p.m., the surveyor spoke with employees in nearby office suite who stated that the agency has been closed for at least six months, further stating “they were there one day and gone the next.” On 05/14/2026 at 3:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 4:06 p.m., the surveyor emailed the administrator, alternate administrator and Chief Financial Officer to the emails for agency listed in TULIP and the emails were returned and undeliverable. On 05/14/2026 at 4:30 p.m., the surveyor left the agency without being able to conduct a Re-licensure and investigation survey, the Surveyor was unable to verify whether Counseling Services were available to the patient and family.On 05/15/2026 at 4:06 p.m., the surveyor emailed to the agency forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS).”On 5/18/2026 at 11:46 a.m., the administrative assistance sent the agency the federal forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS)” via certified letter and email.”

“Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC (Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine whether hospice care service provided were consistent with acceptable standards of practice for the following:(i) Nursing services.(ii) Medical social services.(iii) Physician services.(iv) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling.(v) Hospice aide, volunteer, and homemaker services.(vi) Physical therapy, occupational therapy, and speech-language pathology services.(vii) Short-term inpatient care.(viii) Medical supplies (including drugs and biologicals) and medical appliances.This failure had the potential to affect all Hospice patients by placing them at risk for receiving Hospice care and services that were not verified to be consistent with the acceptable standards of practice including but not limited to nursing services, medical social services, counseling services and medical supplies. The Findings Included:Record review of web-based licensure system Texas Unified Licensure Information Portal (TULIP - a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 05/14/2026, revealed the agency listed an Administrator and Alternate Administrator, the agency address (Address A), and the operating Hours: 9:00 am - 5:00 pm (Monday - Friday). The agency’s category of services was listed as Hospice. TULIP showed the Agency with an active license with an expiration date of 01/08/2027. Observation on 05/14/2026 at 2:30 p.m., the surveyor arrived at the agency address (Address A) listed in TULIP to conduct a Re-licensure and investigation survey. There was a sign in the front of the office suite with the agency’s name on it. There were signs posted on the agency’s door to indicate hours of operation and phone number to contact agency staff should the office be closed during business hours. The surveyor knocked on the agency door and rang the doorbell with no answer. On 05/14/2026 at 2:34 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 2:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 3:00 p.m., the surveyor spoke with employees in nearby office suite who stated that the agency has been closed for at least six months, further stating “they were there one day and gone the next.” On 05/14/2026 at 3:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 4:06 p.m., the surveyor emailed the administrator, alternate administrator and Chief Financial Officer to the emails for agency listed in TULIP and the emails were returned and undeliverable. On 05/14/2026 at 4:30 p.m., the surveyor left the agency without being able to conduct a Re-licensure and investigation survey, the Surveyor was unable to verify whether the Hospice provided nursing services, medical social services, physician services, counseling services, hospice aide, physical/occupational/speech language pathology services, short-term inpatient care and medical supplies and whether the services were provided in accordance with acceptable standards of practice.”

“Based on observation (on site visit), interview and record review, the Hospice failed to provide HHSC ( Health and Human Services Commission) surveyor necessary access to conduct a Recertification survey to determine whether hospice nursing services, physician services, and drug and biological services were provided on a 24 hour basis, seven days a week, in order to meet the needs of the patient and families. This failure had the potential to place all patients at risk for avoidable pain, distress, or clinical deterioration when essential services not accessible at all times required. The Findings Included:Record review of web-based licensure system Texas Unified Licensure Information Portal (TULIP - a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on home health and hospice agencies for the State of Texas) on 05/14/2026, revealed the agency listed an Administrator and Alternate Administrator, the agency address (Address A), and the operating Hours: 9:00 am - 5:00 pm (Monday - Friday). The agency’s category of services was listed as Hospice. TULIP showed the Agency with an active license with an expiration date of 01/08/2027. Observation on 05/14/2026 at 2:30 p.m., the surveyor arrived at the agency address (Address A) listed in TULIP to conduct a Re-licensure and investigation survey. There was a sign in the front of the office suite with the agency’s name on it. There were signs posted on the agency’s door to indicate hours of operation and phone number to contact agency staff should the office be closed during business hours. The surveyor knocked on the agency door and rang the doorbell with no answer. On 05/14/2026 at 2:34 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 2:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 3:00 p.m., the surveyor spoke with employees in nearby office suite who stated that the agency has been closed for at least six months, further stating “they were there one day and gone the next.” On 05/14/2026 at 3:35 p.m., the surveyor telephoned the listed phone number for agency listed in TULIP (210-XXX-1122) and the call failed to go through. On 05/14/2026 at 4:06 p.m., the surveyor emailed the administrator, alternate administrator and Chief Financial Officer to the emails for agency listed in TULIP and the emails were returned and undeliverable. On 05/14/2026 at 4:30 p.m., the surveyor left the agency without being able to conduct a Re-licensure and investigation survey, the Surveyor was unable to verify whether nursing services, physician services, and drugs and biologicals were routinely made available 24-hours a day, 7 days a week.On 05/15/2026 at 4:06 p.m., the surveyor emailed to the agency forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS).”On 5/18/2026 at 11:46 a.m., the administrative assistance sent the agency the federal forms “MEMO 2023-01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services (HHS)” and “MEMO 2023-01 Inability to Access Records or Perform a Survey by Texas Health and Human Services (HHS)” via certified letter and email.”