Texas Hospice Providers LLC

“Based on record review and interview, the agency failed to take into consideration an initial bereavement assessment of the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that could impact their ability to cope with the patient’s death in that the hospice did no conduct an initial bereavement assessment for 6 (#4, #6, #7, #8, #9, #11) of 14 patient records reviewed. The failure placed the patients’ family or other individuals at risk that appropriate bereavement services would not be provided which could result in complicated grief or inadequate coping. Patient #4:Record review of Patient #4’s clinical record revealed an Initial Plan of Care dated 11/30/2023 to 2/27/2024. The Plan of Care indicated that Patient #4 was admitted to services on 11/30/2023. The Plan of Care indicated listed Congestive Heart Failure (heart unable to pump blood to meet the body’s needs) as the terminal diagnosis. Patient #4’s record did not contain an initial bereavement assessment. Patient #6:Record review of Patient #6’s clinical record revealed an Initial Plan of Care dated 3/7/2025 to 6/4/2025. The Plan of Care indicated that Patient #6 was admitted to the agency’s services on 3/7/2025. The Plan of Care did not list the terminal diagnosis but the narrative portion indicated that Patient #6 had a stroke (loss of blood flow to part of the brain which causes brain damage). Patient #6’s record did not contain an initial bereavement assessment. Patient #7:Record review of Patient #7’s clinical record revealed an Initial Plan of Care dated 8/27/2024 to 11/24/2024. The Plan of Care indicated that Patient #7 started on the agency’s service on 8/27/2024The Plan of Care listed Unspecified (congestive) Heart Failure (heart unable to pump blood to meet the body’s needs) as the terminal diagnosis. Patient #7’s record did not contain an initial bereavement assessment. Patient #8:Record review of Patient #8’s clinical record revealed a Plan of Care dated 9/25/2024 to 12/23/2024. The Plan of Care indicated that Patient #8 started on the agency’s services on 9/25/2025. The Plan of Care listed Cerebral Infarction (stroke) as the terminal diagnosis. Patient #8’s clinical record did not contain an initial bereavement assessment. Patient #9:Record review of Patient #9’s clinical record revealed a Plan of Care dated 9/24/2024 to 12/22/2024. The Plan of Care indicated that Patient #9 started on the agency’s services on 9/24/2024. The Plan of Care listed Alzheimer’s Disease (progressive, fatal brain disorder causing memory loss, confusion, and other cognitive decline) as the terminal diagnosis. Patient #9’s clinical record did not contain an initial bereavement assessment. Patient #11:Record review of Patient #11’s clinical record revealed an Initial Plan of Care dated 1/23/2024. The Plan of Care indicated that Patient #11 started on the agency’s services on 1/23/2024. The Plan of Care did not list Patient #11’s terminal diagnosis. Patient #11’s clinical record did not contain an initial bereavement assessment. During an interview on 6/9/2025 at 3:23 p.m. with the Supervising Nurse, the surveyor discussed the initial bereavement assessments were not done. The Supervising Nurse informed the surveyor that the bereavement assessments were not done if the Chaplain did not go. The Supervising Nurse informed the surveyor that some of the patients had declined Chaplain services. The Supervising Nurse informed the surveyor that Patient #4’s initial bereavement assessment should have been done by the previous staff, prior to their acquisition of the company. The Supervising Nurse did not state how it could affect the agency’s patients. The Supervising Nurse stated, “We didn’t realize we had to do an initial bereavement assessment.” During an interview on 6/10/2025 at 1:45 p.m. with the Administrator, Supervising Nurse, and Administrative Assistant, the surveyor reviewed the finding. The agency did not produce any evidence that would change the finding. The surveyor asked if there were any dispute to the finding, the Administrator and Supervising Nurse stated, “No.” Review of the agency’s policy titled “Bereavement,” labeled PC.130, dated 9/1/2024 read in part; “I. Purpose To ensure appropriate bereavement services are provided to Hospice family members, caregivers, and other bereaved persons. II. To facilitate a normal grieving process by providing counseling, coping strategies, and caring interventions to families and/or caregivers. Policy...Procedure I. The Hospice will perform an initial bereavement assessment of the needs of the patient’s family and other care individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death as part of the Initial Comprehensive Assessment. A. The bereavement assessment will be completed by the Hospice’s spiritual counselor, social worker (SW), and/or the registered nurse (RN)...””

“Based on record review and interview, the hospice failed to have individuals that provided hospice aide services, complete a competency evaluation where tasks listed at 42 Code of Federal Regulations Chapter 418, at 418.76(b)(3), (iii), (ix), (x), and (xi) were evaluated by observation of the aide’s performance of the tasks with a patient or pseudo-patient for 2 (Hospice Aide D and Hospice Aide E) of 2 hospice aides where their personnel records were reviewed. The failure placed patients at risk of receiving inadequate or unsafe care from the hospice aides. The 42 Code of Federal Regulations Chapter 418 at 418.76 (b)(3), (i), (iii), (ix), (x) and (xi) listed the following tasks that a registered nurse must observe an aide perform were: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other hospice staff; . . . (iii) Reading and recording temperature, pulse, and respiration; . . . (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include— (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning...” Hospice Aide D:Review of Hospice Aide D’s personnel record revealed an application for employment for a hospice aide that was dated 8/29/2024. Hospice Aide D listed previous employment under work history with a hospice agency, and two hospitals. The personnel record contained an orientation checklist dated 8/29/2024. The personnel record contained a job description for a hospice aide that was signed by Hospice Aide D on 8/28/2024. Hospice Aide D’s personnel record did not contain an evaluation by observation of Hospice Aide D performing the tasks for reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that included a bed bath; sponge, tub, and shower bath; Hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. Hospice Aide E:Review of Hospice Aide E’s personnel record revealed an application for employment for a certified nurse aide. The application was not dated but indicated that Hospice Aide E was available to begin work on 3/10/2025. Hospice Aide E listed previous employment under work history with two home health agencies. The personnel record contained an orientation checklist dated 3/10/2025. The personnel record contained a job description for a hospice aide that was signed by Hospice Aide E on 3/10/2025. Hospice Aide E’s personnel record did not contain an evaluation by observation of Hospice Aide E performing the tasks for reading and recording temperature, pulse, and respiration; appropriate and safe techniques in performing personal hygiene and grooming tasks that included a bed bath; sponge, tub, and shower bath; Hair shampooing in sink, tub, and bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer techniques and ambulation; and normal range of motion and positioning. Home visits and interviews were conducted on 6/5/2025 to with Patient #6, #12, and #13 Patient #6’s Family Member informed the surveyor that Hospice Aide E visited Patient #6 on Monday, Wednesday, and Fridays. Patient #6’s Family Member informed the surveyor that Hospice Aide E bathed and shampooed Patient #6. Patient #6’s Family Member and Patient #6 informed the surveyor that Hospice Aide E did a good job. Patient #12 informed the surveyor that Hospice Aide D provided services three times a week. Patient #13’s Family Member informed the surveyor that Hospice Aide E provided services on Monday, Wednesday, and Fridays. Patient #13’s family member informed the surveyor that Hospice Aide E bathed Patient #13. During an interview on 6/10/2025 at 12:58 p.m. with the Supervising Nurse, the surveyor requested the hospice aide competency evaluations when they were hired. The surveyor requested the portion of the competency evaluation that was observation of the aide performing the tasks on a patient or pseudo-patient. The Supervising Nurse stated, “We haven’t done that when they (aides) first started with us. I didn’t know it was something we had to do. We haven’t done that.” The surveyor asked how the agency would know if the aides were competent in those tasks. The Supervising Nurse informed the surveyor that the task evaluation was done orally. During an interview on 6/10/2025 at 1:45 p.m. with the Administrator, Supervising Nurse, and Administrative Assistant, the surveyor reviewed the finding. The agency did not produce any evidence that would change the finding. The surveyor asked if there were any dispute to the finding, the Administrator and Supervising Nurse stated, “No.” Review of the agency’s policy titled “Hospice Aide/Homemaker Competency Evaluation,” labeled HR.45, and dated 9/1/2024 read in part; “To establish the competency evaluation for both written and skill demonstration for hospice aides...Definition I. Pseudo-patient means a person trained to participate in a role-play situation, or a computer-based mannequin device. A pseudo-patient must be capable of responding to and interacting with the hospice aide trainee and must demonstrate the general characteristics of the primary patient population serviced by the Hospice in key areas such as age, frailty, functional status, cognitive status and care goals...Policy I. The Hospice will ensure that each hospice aide successfully completes a hospice aide skills and competency evaluation in accordance with federal and state laws and regulations prior to the aide performing care independently. A. The competency evaluation must be performed by a registered nurse (RN) in consultation with other skilled professionals, as appropriate...Procedure I. Hospice Aides...1. The following subject areas must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient: a. communication, including the ability to read, write, and verbally report clinical information to patients, representatives and caregivers, and other Hospice staff; b. reading and recording temperature, pulse, and respiration; c. Appropriate and safe techniques in performing personal hygiene and grooming tasks, including: (1). bed bath, (2) Sponge, tub, or shower bath, (3) Hair shampooing in sink, tub, and bed, (4) Nail and skin care, (5) Oral hygiene, (6) Toileting and elimination, (7) Normal range of motion and positioning, and (8) Safe transfer techniques and ambulation...””