Lighthouse Hospice Care LLC

“Based on record review, observation, and interview, the hospice’s governing body failed to appoint a qualified Administrator and/or qualified Alternate Administrator that would be responsible for the day-to-day operation of the hospice for 1 of 9 personnel records reviewed. This failure placed the hospice at actual risk of inadequate organizational structure, inadequate operational planning, and the inability for the hospice to comply with federal and state regulations and guidelines to ensure measurable outcomes and objectives were being met. Findings Record ReviewsRecord review of TULIP on 04/22/2026 revealed the hospice’s address to be [Address A] (as listed in TULIP (is 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)). As listed in TULIP revealed who the ADM, Alt ADM, SUP Nurse, and the Alt SUP Nurse were. Along with the hospice’s business hours were from Mondays to Fridays 11AM to 6PM and the hospice’s main number. Record review of Intake #1081817 during pre-survey preparation on 04/22/2026 revealed that COMP alleged that the hospice moved from Address A to Address B without notifying the state even when COMP suggested for the hospice to notify the state of the change. COMP also alleged that the COMP was unsure how the hospice was being run and who oversaw the hospice. Record review of Staff A/N.O.’s PR on 04/27/2026 showed a job application of 10/09/2025 that the employee was hired on 10/14/2025 for the job position of Alt ADM, and job description was signed for the same date of 10/14/2025. Resume in the PR revealed that Staff A/N.O. had been a manager with [Business A] for 8 years, gaining customer experience for the business sector. Further review of PR revealed that Staff A/N.O.’s highest education was 1 year in college for associate’s degree in computer analytics at [Business B]. In Staff A/N.O.’s entire PR there was no documented evidence; That Staff A/N.O. was a qualified Administrator or Alternate Administrator. PR did not contain any experience in management in any healthcare related setting. PR did not contain initial 8 administrative clock hours for year 2025 before Staff A/N.O. started working as an administrator. ObservationOn 04/22/2026 at 12:27PM; SR arrived at Address A’s commercial building location. On 04/22/2026 at 12:36PM; SR arrived at suite 440 (as listed in TULIP). Door was locked with another business name (not associated with the hospice) listed on the door. SR knocked on door and no staff member answered the door. On 04/22/2026 at 12:43PM; SR left Address A’s commercial building location (unable able to find hospice at listed suite of 440). On 04/22/2026 at 1:03PM; SR arrived at Address B’s commercial building location (not listed in TULIP). SR arrived at suite 618 on 04/22/2026 at 1:10PM; SR observed that the door sign listed [Hospice] on the suite’s door; the door was locked with the lights off. SR knocked on the door, and no staff member of the hospice answered the door. SR also observed on the door sign an alternative phone number (not listed in TULIP) to contact staff after hours of operation. SR called hospice’s [Alt #] provided on the hospice’s door sign on 04/22/2026 at 1:18pm. Interviews Unable to do an interview with the complainant prior to the complaint survey as the complainant was anonymous. During an telephone interview on 04/22/2026 at 1:19PM with Other #1/Investor. SR explained the purpose of the visit was to conduct a recertification and re-licensure survey with a complaint investigation, and to see if ADM and/or Alt ADM was available for survey to be conducted. Other #1/Investor stated, “No they are not there right now. They are currently on the field; I believe there should be a sign on the door that they will not be available today. Don’t y’all let us know if y’all are coming? I mean… I must check and see. When did you get there? Also, what location are you at?” During an interview on 04/22/2026 at 3:10PM with the Staff A/N.O. SR inquired from Staff A/N.O., if the ADM and/or the Alt ADM were available for the complaint survey to be conducted. Staff A/N.O. identified self has the “ADM” and the Owner of the hospice. SR inquired from the Staff A/N.O., when the Change of Ownership (CHOW) occurred. Staff A/N.O. stated, “In January.” SR inquired further was it (CHOW) updated in TULIP along with the Change in ADM(s). Staff A/N.O. stated, “Yes all of that was updated in TULIP.” SR Requested verbally from the Staff A/N.O; the TULIP Application for Change of ADM on 04/22/2026 at 3:11PM. Staff A/N.O. verbalized understanding stating, “Okay I will get that for you.” -Although, Staff A/N.O. verbalized understanding and stated that Staff A/N.O. would obtain the Change of ADM application for the SR. The request was not furnished during entrance, during the survey, during exit and/or after exit.- During an interview on 04/22/2026 at 3:12PM with the Staff A/N.O. SR inquired from Staff A/N.O., are you the new owner for the hospice. Staff A/N.O. explained that Staff A/N.O was the new owner and that Ex-DON/ Ex-ADM was the ADM and the DON before [Ex-DON/ Ex-ADM] abruptly left on 04/20/2026. Staff A/N.O also explained that [Ex-DON/ Ex-ADM] was the one that called in the complaint because [Ex-DON/ Ex-ADM] told Staff A/N.O before [Ex-DON/ Ex-ADM] left that Staff A/N.O could not be an ADM due to Staff A/N.O’s lack of education and/or not having any healthcare related clinical experience. During an interview on 04/22/2026 at 3:16PM with the Staff A/N.O. SR inquired from Staff A/N.O., what was your highest level of education. Staff A/N.O. stated, “I have two years college. I have my associates, but I don’t have a degree.” SR inquired further from Staff A/N.O., what was your associates degree in and. Staff A/N.O. stated, “Computer analyst” she added that she did not have any management experience in a healthcare related field. During an entrance conference interview on 04/22/2026 at 3:43PM. SR inquired with Staff A/N.O. why was the hospice located here. Staff A/N.O. stated, “[Ex- ADM/ Ex- Owner] had it (the hospice) first and then we (New Owners (Staff A/N.O. and Other #1/Investor) had it second but there was a lockout. But any who, we are here because this place is very close to my home.” SR inquired further from Staff A/N.O., was it reported in TULIP. Staff A/N.O. stated, “Yes the new address is reported in TULIP.” -Although, Staff A/N.O. stated it was reported in TULIP; there was no documented evidence in any of the TULIP applications that change of address was updated to reflect the current location at Address B. - During an entrance conference interview on 04/22/2026 at 3:47PM. SR inquired from Staff A/N.O., who was the ADM. Staff A/N.O. stated, “We (hospice) don’t have an ADM at this time; although, we are looking.” SR inquired further from Staff A/N.O., who is the Alt ADM. Staff A/N.O. stated, “I am the Alt ADM.” SR inquired even further, when did the Ex- Alt ADM/ Ex- SUP Nurse leave the hospice. Staff A/N.O. stated, “I don’t know none of them people.” SR inquired about Staff A/N.O., who is the SUP Nurse. Staff A/N.O. stated, “As of right now there’s not a SUP Nurse. But I will have one tomorrow and she is coming today to do an application to be the SUP Nurse.” During an entrance conference interview on 04/22/2026 at 3:49PM. SR inquired from Staff A/N.O. when was the agency bought? Staff A/N.O. stated, “the first week of November. I believe November 11th or something like that?” During an entrance conference interview on 04/22/2026 at 4:00PM. SR clarified from Staff A/N.O, so there was not an ADM and you are the “Alt ADM” but you don’t seem too sure of the basic information of the hospice. Staff A/N.O. stated, “Well this is all new for me, and I am not really sure what I am supposed to be doing but I am willing to learn.” During an interview on 04/23/2026 at 4:05PM. SR inquired from Staff A/N.O., how did you get this position of “ADM”. Staff A/N.O stated, “I used to be called like something lower than a CNA (Certified Nurse Assistant). Like I was doing provider services at one point. So, I was approached by [Other #2] who was a nurse from [Business C] that wanted me to be in this position because she still had stuff going on as a nurse with [Business C]. So, [Ex- ADM/ Ex- Owner] and [Other #2] told me to try this out, which is what I am currently doing now. I have experience as a provider as well as a Business A customer service person. But this is my first time doing this. Before I came on; [Other #2] hired on [Ex-DON/ Ex-ADM] to help me become a better ADM. Because she has experience in that department. But like I said, she (Ex-DON/ Ex-ADM) up and quit on us just like that.” During an interview with Staff A/N.O. on 04/27/2026 at 12:09PM. SR inquired from Staff A/N.O., can you tell me why TULIP was not updated to reflect the new location of the hospice. Staff A/N.O. stated, “I said before [Ex-DON/ Ex-ADM] just quit on us. So, we couldn’t just do it. We didn’t expect you to come through as fast as you did. That’s why we haven’t got time to do so. We’re still working on all of it right now. We discharged the patients because [Ex-DON/ Ex-ADM] haven’t been seeing them or was coming by. So that’s what we’re doing now updating it (the rosters) on our end. So that’s what made me come here today to the office initially, but I wasn’t expecting to see you here. We thought we had more than enough time to find another ADM. I just happened to find a new DON now.” SR inquired further from Staff A/N.O., what was the reason that the change of ADM(s) was not updated in TULIP; when the hospice realized that the [Ex-DON/ Ex-ADM] was not coming back to the hospice. Staff A/N.O stated, “it wasn’t done in TULIP because we were waiting, like waiting to find a position for the administrator.” During an interview with Staff A/N.O. on 04/27/2026 at 12:13PM. SR inquired from Staff A/N.O., why was the new location not updated in TULIP. Staff A/N.O. stated, “The location should have been updated from Address A. Yeah. So, so from Address A to Address C And then of course, we updated from Address C to here and this was when all this. All this chaos came about.” During an interview with Staff A/N.O. on 04/27/2026 at 12:16PM. SR inquired from Staff A/N.O., who was responsible for ensuring that the location and the change in administrators were inputted into TULIP accordingly. Staff A/N.O. stated, “Ex-DON/ Ex-ADM. It’s supposed to be Ex-DON/ Ex-ADM, but now, since this came on me, now I have to be the one right now.” SR inquired further from Staff A/N.O., who was responsible right now since Ex-DON/ Ex-ADM was longer at this hospice. Staff A/N.O. stated, “It would be me right now.” During an interview with Staff A/N.O. on 04/27/2026 at 12:19PM. SR inquired from Staff A/N.O., can you tell me what your roles and responsibilities were as an administrator. Staff A/N.O stated, “To make sure the patient binders are complete. Make sure that the employees are doing what they supposed to do. Make sure I communicate with the doctor, make sure have the notes are all in the binder within the required timeframe. All the reason I do that is because that’s what [Ex-DON/ Ex-ADM] was talking about before she left. Make sure that the office runs like it is supposed to be run.” During an interview with Staff A/N.O. on 04/28/2026 at 2:51PM. SR inquired from Staff A/N.O., who was the hospice’s Governing Body? Staff A/N.O. stated, “Myself, Staff B, Staff C, and the MD.” -Although, Staff A/N.O. explained who was in the governing body. Staff A/N.O. was unsure as to the functions (roles and responsibilities) of the governing body.- Record review of the hospice’s policy manual entitled, “Governing Body” last revised 11/2025 pages 1 to 3 reads in part, “… Purpose: To outline the roles and responsibilities of the Governing Body. Policy: The Governing Body will assume full legal authority, responsibility and accountability for the operation of [Hospice]. The Governing Body of [Hospice] will serve as the governing authority for the home care program, which will function according to [Hospice]’s bylaws… Procedure… 7. The Governing Body will assist with development and approve strategic, marketing, and operational plans. 8. The Governing Body will appoint a qualified Executive Director/Administrator and establish procedures of systematic communication between the two…” Record review of hospice policy entitled, “Job Title/Position: Executive Director/Administrator” with a revised date of 11/2025 reads in part, “Reports to the Governing Body… The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy… Essential Job Functions/Responsibilities: Operational planning and budgeting.Ensuring organizational compliance with legal, regulatory and accreditation requirements… Monitoring business operations to insure financial stability… Evaluating hospice services and personnel using measurable outcomes and objectives… Monitoring operational progress toward accomplishing operational and strategic goals… Ensuring standards of ethical business and clinical practice are maintained… Position Qualifications: A bachelor’s degree in business administration, master’s degree in health care or related field preferred. Three (3) to five (5) years’ experience in health care management. Demonstrates an ability to supervise and direct professional and administrative personnel. Has an ability to deal tactfully with the community. Has knowledge of corporate business management. Understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group. Intimate knowledge of Medicare Hospice Certification.””