Heart & Soul Hospice Inc.

“Condition of Participation: Core Services 418.64 is not met.Based on observation, record review and interview, the hospice failed to routinely provide substantially all core services directly by hospice employees consistent with acceptable standards of practice; such as nursing services, medical social services, and counseling for any Patients on services or admitted to the hospice, in that: •The hospice did not provide confirmation that current nurses, social workers, and counsellors were available to provide services and oversight to patients for care.The hospice failed to provide nursing care and services by or under the supervision of a registered nurse and failed to ensure nursing services met the needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessments. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm nursing services were being provided to patients. Refer to L0591.The hospice failed to ensure medical social services were provided to patients and their families by a qualified social worker, under the direction of a physician based on the patients’ and families psychosocial assessment and identified needs and acceptance of these services. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm medical social services were being provided to patients and their families. Refer to L0594. The hospice failed to provide counseling services to the patients and patients’ families to assist the patients and their families in minimizing the stress and problems that arise from terminal illness, related conditions, and the dying process. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm counseling services were being provided to patients and their families. Refer to L0595. Refer to L0591 - Nursing Services, Refer to L0594 - Medical Social Services, and Refer to L0595 – Counseling Services.”

“Condition of Participation: Organization and Administration of services §418.100 is not met. Based on records reviews and interviews, the hospice failed to organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions, in that:The hospice Administrator, Alternate Administrator, or designated agency representative failed to be available onsite during normal business hours on 06/09/2026 to provide entry to HHSC Surveyor to conduct survey to ascertain the hospice was providing care and services to its patients, caregivers, and families as required to help relieve stress associated with terminal illness and the end-of-life process. The hospice failed to primarily engage in providing the following care and services and must do so in a manner that is consistent with acceptable standards of practice: nursing service, medical services, physician services, counseling services, hospice aid, volunteer, physical therapy, occupational therapy, speech-language pathology services, short-term care, and medical services.Refer to L0652. The hospice failed to provide nursing services, physician services, and drugs and biologicals) that must be made routinely available on a 24-hour basis 7 days a week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. Refer to L0653. Refer to L0652 - ServicesRefer to L0653 Services (Nursing services, physician services, and drugs and biologicals)”

“Based on observation, records reviews, and interviews, the hospice failed to provide nursing care and services by or under the supervision of a registered nurse and failed to ensure nursing services met the needs of the Patient as identified in the Patient’s initial assessment, comprehensive assessment, and updated assessments.In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to SR onsite and did not return SR’s calls to confirm nursing services were being provided to Patients. This failure hindered HHSC Survey process and could place hospice Patients and their families at risk of not having their medical and/or nursing needs identified and met by a qualified registered nurse. Findings include: Record Reviews: Record review of 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 06/08/2026 revealed the hospice’s name, address, secondary address, telephone number listed with business hours of operation as Monday to Fridays from 10:00AM to 4:00PM and Hospice CCN. Record review of IQIES (a secure, cloud-based CMS portal used by healthcare providers, state agencies, and federal surveyors. It integrates the submission of clinical patient assessments, manages facility performance data, and facilities the survey and certification process) on 06/08/2026 revealed the hospice’s name, and secondary address. Observation: On 06/09/2026 at 12:25PM, the SR arrived at the hospice’s commercial business location as listed in TULIP to conduct a re-certification, and re-licensure survey. SR to the hospice’s door at 12:33PM. Door was locked, SR rang the doorbell once; Other #1 answered the door. SR introduced self and stated purpose of the visit. Other #1 stated, “I’ve heard of that agency before, but we have been here for the past year now.” SR inquired from Other #1 at 12:35PM, what agency was currently housed here. Other #1 stated, “We are called Agency B. Would you like our business card as proof?” SR stepped into the reception area of Agency B; SR observed that the entire agency belonged to Agency B. SR received a business card from Other #1 at 12:36PM. [Hospice] was not housed at this location.During an interview with Other #1 on 06/09/2026 at 12:37PM. SR inquired from Other #1, does Agency B receive any mail for [Hospice]. Other #1 stated, “Yes we still do.” SR inquired further, what does Agency B do with the mail for the hospice. Other #1 stated, “We send it back to sender.” SR headed back to SR’s vehicle at 12:38PM unable to find the hospice at this location.06/09/2026 at 1:35PM, SR arrived at the hospice’s secondary commercial location as listed in TULIP and IQIES to conduct a re-certification, and re-licensure survey. SR into the secondary commercial location at 1:42PM. SR observed at 1:45PM that black and silver colored directory did not contain [Hospice] as one of its listed businesses at this secondary commercial location. SR introduced self at 1:46PM and stated that SR was looking for suite 610 C to Other #2 at the information desk. Other #2 stated, “Good Afternoon. We don’t have a 610 C. The only suites that have letters to their numbers are the 630 suites.” SR thanked Other #2 for Other #2’s time and inquired if SR could witness whether the suite was housed at this location. Other #2 stated, “That is fine.” During an internal health department inspection on 06/09/26 at 1:49PM to 1:56PM of the 6th floor. SR toured the entire 6th floor twice; SR observed proper signage of businesses visibly posted on the 6th floor doors. However, SR was unable to find a suite at the number of 610 C. SR left to the secondary commercial building garage parking lot at 2:02PM to call the hospice from SR’s vehicle. Unable to find the hospice at this secondary location.SR called the hospice’s main number at 2:14PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. If the ADM and/or the Alt ADM were available for survey to be conducted to please contact the SR once the ADM and/or Alt ADM received this message. SR also stated that the timeframe for the survey to be conducted will lapse as of 2:25PM.Timeframe for the survey to be conducted lapsed at 2:25PM. SR called the hospice’s main number at 2:29PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. SR stated that the timeframe for the survey to be conducted as lapsed as of 2:25PM that the hospice would automatically be cited from administrative penalties to license revocation and that the hospice would receive a 2567 and/or 3724 within 10 business days and/or more. SR would also send Memo Letters 2023 to the hospice via email later today that explained the inability to conduct a survey. SR also stated if the ADM and/or Alt ADM had any further questions to please call the SR for more information. Interviews: On 06/09/2026, SR received a call from an unidentified and unknown number from Phone #1 at 2:36PM. Caller introduced self and stated purpose of the call was to speak with SR regarding [Hospice]. Caller identified self as LNC, and that LNC was representing [Hospice]’s interests. During a phone interview with LNC on 06/09/2026 at 2:37PM. LNC explained to SR the Hospice’s situation; LNC stated that, “[Hospice] ADM called LNC earlier today when ADM received SR’s message and reached out to LNC to explain that ADM was not available but if LNC could reach out to the SR for the ADM instead. The situation is that the hospice was in the process of rectifying the 855A Application because the hospice made a mistake but is working on it. In between, trying to fix the 855A Application; the hospice’s CHAP accreditation status expired, and I think that’s why state somehow got the hospice instead. At that exact time, we were trying to work still on the 855A; somehow the hospice’s PTAN number was deactivated. CMS deactivated it. So, the license is still good, but the PTAN number we are trying to work on fixing. Then crazy enough, if it wasn’t already crazy was that the ADM was going through a lot of legal actions with ownership situation. It’s honestly been a lot.” SR inquired from the LNC, why did CMS deactivate the PTAN. LNC stated, “Because apparently the Hospice had not been billing for the services, but the ADM was trying to get everything in order. In fact, we are currently at Address A right now. On the voicemail you left; if the hospice decides to say… not conduct the survey, we will just get administrative penalties correct? Because, if that’s the case, then we would be okay with that.” SR informed the LNC at 2:39PM that the timeframe for the survey to be conducted lapsed as of 2:25PM, and for the LNC along with the ADM and/or Alt ADM to reference the SR’s pervious voicemails placed on the hospice’s voicemail for more information. SR also informed the LNC that it was up to the administrative reviewers to decide what penalties would apply. SR waited at the hospice’s secondary location and met the required timeframe of 2 hours. Additional time of 22 minutes was given for the ADM and/or Alt ADM to contact the SR back. However, no call back was received from the ADM and/or Alt ADM on 06/09/2026 and/or after 06/09/2026. SR left the secondary location at 2:47PM unable to conduct the re-certification and re-licensure survey. SR was unable to ascertain whether hospice nursing staff were routinely providing core services to hospice patients as required by regulations. During a phone interview with LNC on 06/09/2026 at 4:26PM. SR inquired from LNC, if the ADM was available for the survey to be conducted and why the ADM was not at the location listed in TULIP. LNC stated, “The ADM called me earlier in the afternoon as I said before, he [ADM] had received your call that he was actually not available because he currently had been under anesthesia for a dental procedure.” SR inquired further from the LNC, if the ADM was not available; was the Alt ADM available for the survey to be conducted and why was the Alt ADM not at the location listed in TULIP. LNC stated, “I not going to lie, I am not sure why the Alt ADM was not available; I would have to look at the demographics for this hospice. But again, the Alt ADM should have been at Address A. Is it possible, if I can call you back to give you that information?” – Although, LNC stated that LNC would call SR back with demographic information; callback was not received on 06/09/2026 and/or after 06/09/2026 with an update. – SR emailed MEMO 2023 – 01 Inability to Access Records or Perform a Survey by Texas Health and Human Services, and MEMO 2023 – 01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services to the agency’s main email of [Email XXXX] at 4:54PM. SR did not receive an email back from the hospice confirming receipt on 06/09/2026 and/or after 06/09/2026.”

“Based on observation, records reviews, and interviews, the hospice failed to ensure medical social services were provided to patients and their families by a qualified social worker, under the direction of a physician based on the Patients’ and families identified needs. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm medical social services were being provided to patients and their families. This failure hindered HHSC Survey process and could place hospice Patients and their families at risk of not having their psychosocial needs identified and met by a qualified social worker. Findings include: Record Reviews: Record review of TULIP on 06/08/2026 revealed the hospice’s name, address, secondary address, telephone number listed with business hours of operation as Monday to Fridays from 10:00AM to 4:00PM and Hospice CCN. Record review of IQIES on 06/08/2026 revealed the hospice’s name, and secondary address. Observation: On 06/09/2026 at 12:25PM, the SR arrived at the hospice’s commercial location as listed in TULIP to conduct a re-certification, and re-licensure survey. SR to the hospice’s door at 12:33PM. Door was locked, SR rang the doorbell once; Other #1 answered the door. SR introduced self and stated purpose of the visit. Other #1 stated, “I’ve heard of that agency before, but we have been here for the past year now.” SR inquired from Other #1 at 12:35PM, what agency is currently housed here. Other #1 stated, “We are called Agency B. Would you like our business card as proof?” SR stepped into the reception area of Agency B; SR observed that the entire agency belonged to Agency B. SR received a business card from Other #1 at 12:36PM. [Hospice] was not housed at this location.During an interview with Other #1 on 06/09/2026 at 12:37PM. SR inquired from Other #1, does Agency B receive any mail for [Hospice]. Other #1 stated, “Yes we still do.” SR inquired further, what does Agency B do with the mail for the hospice. Other #1 stated, “We send it back to sender.” SR headed back to SR’s vehicle at 12:38PM unable to find the hospice at this location.06/09/2026 at 1:35PM, SR arrived at the hospice’s secondary commercial location as listed in TULIP and IQIES to conduct a re-certification, and re-licensure survey. SR into the secondary commercial location at 1:42PM. SR observed at 1:45PM that black and silver colored directory did not contain [Hospice] as one of its listed businesses at this secondary commercial location. SR introduced self at 1:46PM and stated that SR was looking for suite 610 C to Other #2 at the information desk. Other #2 stated, “Good Afternoon. We don’t have a 610 C. The only suites that have letters to their numbers are the 630 suites.” SR thanked Other #2 for Other #2’s time and inquired if SR could witness whether the suite was housed at this location. Other #2 stated, “That is fine.” During an internal health department inspection on 06/09/26 at 1:49PM to 1:56PM of the 6th floor. SR toured the entire 6th floor twice; SR observed proper signage of businesses visibly posted on the 6th floor doors. However, SR was unable to find a suite at the number of 610 C. SR left to the secondary commercial building garage parking lot at 2:02PM to call the hospice from SR’s vehicle. Unable to find the hospice at this secondary location.SR called the hospice’s main number at 2:14PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. If the ADM and/or the Alt ADM were available for survey to be conducted to please contact the SR once the ADM and/or Alt ADM received this message. SR also stated that the timeframe for the survey to be conducted will lapse as of 2:25PM.Timeframe for the survey to be conducted lapsed at 2:25PM. SR called the hospice’s main number at 2:29PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. SR stated that the timeframe for the survey to be conducted as lapsed as of 2:25PM that the hospice would automatically be cited from administrative penalties to license revocation and that the hospice would receive a 2567 and/or 3724 within 10 business days and/or more. SR would also send Memo Letters 2023 to the hospice via email later today that explained the inability to conduct a survey. SR also stated if the ADM and/or Alt ADM had any further questions to please call the SR for more information. Interviews: On 06/09/2026, SR received a call from an unidentified and unknown number from Phone #1 at 2:36PM. Caller introduced self and stated purpose of the call was to speak with SR regarding [Hospice]. Caller identified self as LNC, and that LNC was representing [Hospice]’s interests. During a phone interview with LNC on 06/09/2026 at 2:37PM. LNC explained to SR the Hospice’s situation; LNC stated that, “[Hospice] ADM called LNC earlier today when ADM received SR’s message and reached out to LNC to explain that ADM was not available but if LNC could reach out to the SR for the ADM instead. The situation is that the hospice is in the process of rectifying the 855A Application because the hospice made a mistake but is working on it. In between, trying to fix the 855A Application; the hospice’s CHAP accreditation status expired, and I think that’s why state somehow got the hospice instead. At that exact time, we were trying to work still on the 855A; somehow the hospice’s PTAN number was deactivated. CMS deactivated it. So, the license is still good, but the PTAN number were trying to work on fixing. Then crazy enough, if it wasn’t already crazy is that the ADM is going through a lot of legal actions with ownership situation. It’s honestly been a lot.” SR inquired from the LNC, why did CMS deactivate the PTAN. LNC stated, “Because apparently the Hospice had not been billing for the services. But the ADM is trying to get everything in order. In fact, we are currently at Address A right now. On the voicemail you left; if the hospice decides to say… not conduct the survey, we will just get administrative penalties correct? Because, if that’s the case, then we would be okay with that.” SR informed the LNC at 2:39PM that the timeframe for the survey to be conducted lapsed as of 2:25PM, and for the LNC along with the ADM and/or Alt ADM to reference the SR’s pervious voicemails placed on the hospice’s voicemail for more information. SR also informed the LNC that it is up to the administrative reviewers to decide what penalties would apply. SR waited at the hospice’s secondary location and met the required timeframe of 2 hours. Additional time of 22 minutes was given for the ADM and/or Alt ADM to contact the SR back. However, no call back was received from the ADM and/or Alt ADM on 06/09/2026 and/or after 06/09/2026. SR left the secondary location at 2:47PM unable to conduct the re-certification and re-licensure survey. SR was unable to ascertain whether hospice social workers were routinely providing core medical social services to hospice patients and families as required by regulations.During a phone interview with LNC on 06/09/2026 at 4:26PM. SR inquired from LNC, if the ADM was available for the survey to be conducted and why the ADM was not at the location listed in TULIP. LNC stated, “The ADM called me earlier in the afternoon as I said before, he [ADM] had received your call that he was actually not available because he currently had been under anesthesia for a dental procedure.” SR inquired further from the LNC, if the ADM was not available; was the Alt ADM available for the survey to be conducted and why was the Alt ADM not at the location listed in TULIP. LNC stated, “I not going to lie, I am not sure why the Alt ADM was not available; I would have to look at the demographics for this hospice. But again, the Alt ADM should have been at Address A. Is it possible, if I can call you back to give you that information?” – Although, LNC stated that LNC would call SR back with demographic information; callback was not received on 06/09/2026 and/or after 06/09/2026 with an update. – SR emailed MEMO 2023 – 01 Inability to Access Records or Perform a Survey by Texas Health and Human Services, and MEMO 2023 – 01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services to the agency’s main email of [Email XXXX] at 4:54PM. SR did not receive an email back from the hospice confirming receipt on 06/09/2026 and/or after 06/09/2026.”

“Based on observation, records reviews, and interviews, the hospice failed to provide counseling services to the Patients and Patients’ families to assist the Patients and their families in minimizing the stress and problems that arise from terminal illness, related conditions, and the dying process. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm counseling services were being provided to patients and their families. This failure hindered HHSC Survey process and could place hospice patients and their families at risk of enormous stress related to terminal illness, related conditions, and the dying process. Findings include: Record Reviews: Record review of TULIP on 06/08/2026 revealed the hospice’s name, address, secondary address, telephone number listed with business hours of operation as Monday to Fridays from 10:00AM to 4:00PM and Hospice CCN. Record review of IQIES on 06/08/2026 revealed the hospice’s name, and secondary address. Observation: On 06/09/2026 at 12:25PM, the SR arrived at the hospice’s commercial location as listed in TULIP to conduct a re-certification, and re-licensure survey. SR to the hospice’s door at 12:33PM. Door was locked, SR rang the doorbell once; Other #1 answered the door. SR introduced self and stated purpose of the visit. Other #1 stated, “I’ve heard of that agency before, but we have been here for the past year now.” SR inquired from Other #1 at 12:35PM, what agency is currently housed here. Other #1 stated, “We are called Agency B. Would you like our business card as proof?” SR stepped into the reception area of Agency B; SR observed that the entire agency belonged to Agency B. SR received a business card from Other #1 at 12:36PM. [Hospice] was not housed at this location.During an interview with Other #1 on 06/09/2026 at 12:37PM. SR inquired from Other #1, does Agency B receive any mail for [Hospice]. Other #1 stated, “Yes we still do.” SR inquired further, what does Agency B do with the mail for the hospice. Other #1 stated, “We send it back to sender.” SR headed back to SR’s vehicle at 12:38PM unable to find the hospice at this location.06/09/2026 at 1:35PM, SR arrived at the hospice’s secondary commercial location as listed in TULIP and IQIES to conduct a re-certification, and re-licensure survey. SR into the secondary commercial location at 1:42PM. SR observed at 1:45PM that black and silver colored directory did not contain [Hospice] as one of its listed businesses at this secondary commercial location. SR introduced self at 1:46PM and stated that SR was looking for suite 610 C to Other #2 at the information desk. Other #2 stated, “Good Afternoon. We don’t have a 610 C. The only suites that have letters to their numbers are the 630 suites.” SR thanked Other #2 for Other #2’s time and inquired if SR could witness whether the suite was housed at this location. Other #2 stated, “That is fine.” During an internal health department inspection on 06/09/26 at 1:49PM to 1:56PM of the 6th floor. SR toured the entire 6th floor twice; SR observed proper signage of businesses visibly posted on the 6th floor doors. However, SR was unable to find a suite at the number of 610 C. SR left to the secondary commercial building garage parking lot at 2:02PM to call the hospice from SR’s vehicle. Unable to find the hospice at this secondary location.SR called the hospice’s main number at 2:14PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. If the ADM and/or the Alt ADM were available for survey to be conducted to please contact the SR once the ADM and/or Alt ADM received this message. SR also stated that the timeframe for the survey to be conducted will lapse as of 2:25PM.Timeframe for the survey to be conducted lapsed at 2:25PM. SR called the hospice’s main number at 2:29PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. SR stated that the timeframe for the survey to be conducted as lapsed as of 2:25PM that the hospice would automatically be cited from administrative penalties to license revocation and that the hospice would receive a 2567 and/or 3724 within 10 business days and/or more. SR would also send Memo Letters 2023 to the hospice via email later today that explained the inability to conduct a survey. SR also stated if the ADM and/or Alt ADM had any further questions to please call the SR for more information. Interviews: On 06/09/2026, SR received a call from an unidentified and unknown number from Phone #1 at 2:36PM. Caller introduced self and stated purpose of the call was to speak with SR regarding [Hospice]. Caller identified self as LNC, and that LNC was representing [Hospice]’s interests. During a phone interview with LNC on 06/09/2026 at 2:37PM. LNC explained to SR the Hospice’s situation; LNC stated that, “[Hospice] ADM called LNC earlier today when ADM received SR’s message and reached out to LNC to explain that ADM was not available but if LNC could reach out to the SR for the ADM instead. The situation is that the hospice is in the process of rectifying the 855A Application because the hospice made a mistake but is working on it. In between, trying to fix the 855A Application; the hospice’s CHAP accreditation status expired, and I think that’s why state somehow got the hospice instead. At that exact time, we were trying to work still on the 855A; somehow the hospice’s PTAN number was deactivated. CMS deactivated it. So, the license is still good, but the PTAN number were trying to work on fixing. Then crazy enough, if it wasn’t already crazy is that the ADM is going through a lot of legal actions with ownership situation. It’s honestly been a lot.” SR inquired from the LNC, why did CMS deactivate the PTAN. LNC stated, “Because apparently the Hospice had not been billing for the services. But the ADM is trying to get everything in order. In fact, we are currently at Address A right now. On the voicemail you left; if the hospice decides to say… not conduct the survey, we will just get administrative penalties correct? Because, if that’s the case, then we would be okay with that.” SR informed the LNC at 2:39PM that the timeframe for the survey to be conducted lapsed as of 2:25PM, and for the LNC along with the ADM and/or Alt ADM to reference the SR’s pervious voicemails placed on the hospice’s voicemail for more information. SR also informed the LNC that it is up to the administrative reviewers to decide what penalties would apply. SR waited at the hospice’s secondary location and met the required timeframe of 2 hours. Additional time of 22 minutes was given for the ADM and/or Alt ADM to contact the SR back. However, no call back was received from the ADM and/or Alt ADM on 06/09/2026 and/or after 06/09/2026. SR left the secondary location at 2:47PM unable to conduct the re-certification and re-licensure survey. SR was unable to ascertain whether hospice counseling staff were routinely providing core services to hospice patients and families as required by regulations.During a phone interview with LNC on 06/09/2026 at 4:26PM. SR inquired from LNC, if the ADM was available for the survey to be conducted and why the ADM was not at the location listed in TULIP. LNC stated, “The ADM called me earlier in the afternoon as I said before, he [ADM] had received your call that he was actually not available because he currently had been under anesthesia for a dental procedure.” SR inquired further from the LNC, if the ADM was not available; was the Alt ADM available for the survey to be conducted and why was the Alt ADM not at the location listed in TULIP. LNC stated, “I not going to lie, I am not sure why the Alt ADM was not available; I would have to look at the demographics for this hospice. But again, the Alt ADM should have been at Address A. Is it possible, if I can call you back to give you that information?” – Although, LNC stated that LNC would call SR back with demographic information; callback was not received on 06/09/2026 and/or after 06/09/2026 with an update. – SR emailed MEMO 2023 – 01 Inability to Access Records or Perform a Survey by Texas Health and Human Services, and MEMO 2023 – 01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services to the agency’s main email of [Email XXXX] at 4:54PM. SR did not receive an email back from the hospice confirming receipt on 06/09/2026 and/or after 06/09/2026.”

“Based on records reviews and interviews, the hospice failed to primarily be engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice: nursing services, medical services, physician services, counseling services, hospice aide, volunteer, physical therapy, occupational therapy, speech-language pathology services, short-term inpatient care, and medical services. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm care and services were being provided to patients and their families. This failure hindered the HHSC Survey process and could place hospice Patients and their families at risk of not having their medical, nursing, counseling, hospice aide, volunteer, physical therapy, occupational therapy, speech-language pathology services, short-term inpatient care needs identified and met by qualified healthcare clinicians and other hospice personnels. Findings include: Record Reviews: Record review of TULIP on 06/08/2026 revealed the hospice’s name, address, secondary address, telephone number listed with business hours of operation as Monday to Fridays from 10:00AM to 4:00PM and Hospice CCN. Further review of hospice’s TULIP account revealed hospice’s Patients census was 5 and PAS active client census was 0 as of 12/06/2025. Record review of IQIES on 06/08/2026 revealed the hospice’s name, secondary address, and the hospice CCN was the same also. Observation: On 06/09/2026 at 12:25PM, the SR arrived at the hospice’s commercial business location as listed in TULIP to conduct a re-certification, and re-licensure survey. SR to the hospice’s door at 12:33PM. Door was locked, SR rang the doorbell once; Other #1 answered the door. SR introduced self and stated purpose of the visit. Other #1 stated, “I’ve heard of that agency before, but we have been here for the past year now.” SR inquired from Other #1 at 12:35PM, what agency was currently housed here. Other #1 stated, “We are called Agency B. Would you like our business card as proof?” SR stepped into the reception area of Agency B; SR observed that the entire agency belonged to Agency B. SR received a business card from Other #1 at 12:36PM. [Hospice] was not housed at this location.During an interview with Other #1 on 06/09/2026 at 12:37PM. SR inquired from Other #1, does Agency B receive any mail for [Hospice]. Other #1 stated, “Yes we still do.” SR inquired further, what does Agency B do with the mail for the hospice. Other #1 stated, “We send it back to sender.” SR headed back to SR’s vehicle at 12:38PM unable to find the hospice at this location.06/09/2026 at 1:35PM, SR arrived at the hospice’s secondary commercial location as listed in TULIP and IQIES to conduct a re-certification, and re-licensure survey. SR into the secondary commercial location at 1:42PM. SR observed at 1:45PM that black and silver colored directory did not contain [Hospice] as one of its listed businesses at this secondary commercial location. SR introduced self at 1:46PM and stated that SR was looking for suite 610 C to Other #2 at the information desk. Other #2 stated, “Good Afternoon. We don’t have a 610 C. The only suites that have letters to their numbers are the 630 suites.” SR thanked Other #2 for Other #2’s time and inquired if SR could witness whether the suite was housed at this location. Other #2 stated, “That is fine.” During an internal health department inspection on 06/09/26 at 1:49PM to 1:56PM of the 6th floor. SR toured the entire 6th floor twice; SR observed proper signage of businesses visibly posted on the 6th floor doors. However, SR was unable to find a suite at the number of 610 C. SR left to the secondary commercial building garage parking lot at 2:02PM to call the hospice from SR’s vehicle. Unable to find the hospice at this secondary location.SR called the hospice’s main number at 2:14PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. If the ADM and/or the Alt ADM were available for survey to be conducted to please contact the SR once the ADM and/or Alt ADM received this message. SR also stated that the timeframe for the survey to be conducted will lapse as of 2:25PM.Timeframe for the survey to be conducted lapsed at 2:25PM. SR called the hospice’s main number at 2:29PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. SR stated that the timeframe for the survey to be conducted as lapsed as of 2:25PM that the hospice would automatically be cited from administrative penalties to license revocation and that the hospice would receive a 2567 and/or 3724 within 10 business days and/or more. SR would also send Memo Letters 2023 to the hospice via email later today that explained the inability to conduct a survey. SR also stated if the ADM and/or Alt ADM had any further questions to please call the SR for more information. Interviews: On 06/09/2026, SR received a call from an unidentified and unknown number from Phone #1 at 2:36PM. Caller introduced self and stated purpose of the call was to speak with SR regarding [Hospice]. Caller identified self as LNC, and that LNC was representing [Hospice]’s interests. During a phone interview with LNC on 06/09/2026 at 2:37PM. LNC explained to SR the Hospice’s situation; LNC stated that, “[Hospice] ADM called LNC earlier today when ADM received SR’s message and reached out to LNC to explain that ADM was not available but if LNC could reach out to the SR for the ADM instead. The situation is that the hospice was in the process of rectifying the 855A Application because the hospice made a mistake but is working on it. In between, trying to fix the 855A Application; the hospice’s CHAP accreditation status expired, and I think that’s why state somehow got the hospice instead. At that exact time, we were trying to work still on the 855A; somehow the hospice’s PTAN number was deactivated. CMS deactivated it. So, the license is still good, but the PTAN number we are trying to work on fixing. Then crazy enough, if it wasn’t already crazy was that the ADM was going through a lot of legal actions with ownership situation. It’s honestly been a lot.” SR inquired from the LNC, why did CMS deactivate the PTAN. LNC stated, “Because apparently the Hospice had not been billing for the services, but the ADM was trying to get everything in order. In fact, we are currently at Address A right now. On the voicemail you left; if the hospice decides to say… not conduct the survey, we will just get administrative penalties correct? Because, if that’s the case, then we would be okay with that.” SR informed the LNC at 2:39PM that the timeframe for the survey to be conducted lapsed as of 2:25PM, and for the LNC along with the ADM and/or Alt ADM to reference the SR’s pervious voicemails placed on the hospice’s voicemail for more information. SR also informed the LNC that it was up to the administrative reviewers to decide what penalties would apply. SR waited at the hospice’s secondary location and met the required timeframe of 2 hours. Additional time of 22 minutes was given for the ADM and/or Alt ADM to contact the SR back. However, no call back was received from the ADM and/or Alt ADM on 06/09/2026 and/or after 06/09/2026. SR left the secondary location at 2:47PM unable to conduct the re-certification and re-licensure survey. SR was unable to ascertain whether hospice nursing staff were routinely providing core services to hospice patients as required by regulations. During a phone interview with LNC on 06/09/2026 at 4:26PM. SR inquired from LNC, if the ADM was available for the survey to be conducted and why the ADM was not at the location listed in TULIP. LNC stated, “The ADM called me earlier in the afternoon as I said before, he [ADM] had received your call that he was actually not available because he currently had been under anesthesia for a dental procedure.” SR inquired further from the LNC, if the ADM was not available; was the Alt ADM available for the survey to be conducted and why was the Alt ADM not at the location listed in TULIP. LNC stated, “I not going to lie, I am not sure why the Alt ADM was not available; I would have to look at the demographics for this hospice. But again, the Alt ADM should have been at Address A. Is it possible, if I can call you back to give you that information?” – Although, LNC stated that LNC would call SR back with demographic information; callback was not received on 06/09/2026 and/or after 06/09/2026 with an update. – SR emailed MEMO 2023 – 01 Inability to Access Records or Perform a Survey by Texas Health and Human Services, and MEMO 2023 – 01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services to the agency’s main email of [Email XXXX] at 4:54PM. SR did not receive an email back from the hospice confirming receipt on 06/09/2026 and/or after 06/09/2026.”

“Based on observation, records reviews, and interviews, the hospice failed to provide nursing services, physician services, and drugs and biologicals) that must be made routinely available on a 24-hour basis 7 days a week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family. In that, an attempted visit was made on 06/09/2026 at the hospice’s physical location as listed in IQIES that indicated the hospice is operational and able to bill for services rendered, the hospice ADM and Alt ADM were not available to surveyor onsite and did not return surveyor’s calls to confirm care and services were being provided to patients and their families. This failure hindered the HHSC Survey process to ascertain the hospice agency was operational and providing care and services to Hospice Patients in compliance with established rules and it could place patients at risk of receiving substandard care and services. Findings include: Record Reviews: Record review of TULIP on 06/08/2026 revealed the hospice’s name, address, secondary address, telephone number listed with business hours of operation as Monday to Fridays from 10:00AM to 4:00PM and Hospice CCN. Record review of IQIES on 06/08/2026 revealed the hospice’s name, and secondary address. Observation: On 06/09/2026 at 12:25PM, the SR arrived at the hospice’s commercial business location as listed in TULIP to conduct a re-certification, and re-licensure survey. SR to the hospice’s door at 12:33PM. Door was locked, SR rang the doorbell once; Other #1 answered the door. SR introduced self and stated purpose of the visit. Other #1 stated, “I’ve heard of that agency before, but we have been here for the past year now.” SR inquired from Other #1 at 12:35PM, what agency was currently housed here. Other #1 stated, “We are called Agency B. Would you like our business card as proof?” SR stepped into the reception area of Agency B; SR observed that the entire agency belonged to Agency B. SR received a business card from Other #1 at 12:36PM. [Hospice] was not housed at this location.During an interview with Other #1 on 06/09/2026 at 12:37PM. SR inquired from Other #1, does Agency B receive any mail for [Hospice]. Other #1 stated, “Yes we still do.” SR inquired further, what does Agency B do with the mail for the hospice. Other #1 stated, “We send it back to sender.” SR headed back to SR’s vehicle at 12:38PM unable to find the hospice at this location.06/09/2026 at 1:35PM, SR arrived at the hospice’s secondary commercial location as listed in TULIP and IQIES to conduct a re-certification, and re-licensure survey. SR into the secondary commercial location at 1:42PM. SR observed at 1:45PM that black and silver colored directory did not contain [Hospice] as one of its listed businesses at this secondary commercial location. SR introduced self at 1:46PM and stated that SR was looking for suite 610 C to Other #2 at the information desk. Other #2 stated, “Good Afternoon. We don’t have a 610 C. The only suites that have letters to their numbers are the 630 suites.” SR thanked Other #2 for Other #2’s time and inquired if SR could witness whether the suite was housed at this location. Other #2 stated, “That is fine.” During an internal health department inspection on 06/09/26 at 1:49PM to 1:56PM of the 6th floor. SR toured the entire 6th floor twice; SR observed proper signage of businesses visibly posted on the 6th floor doors. However, SR was unable to find a suite at the number of 610 C. SR left to the secondary commercial building garage parking lot at 2:02PM to call the hospice from SR’s vehicle. Unable to find the hospice at this secondary location.SR called the hospice’s main number at 2:14PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. If the ADM and/or the Alt ADM were available for survey to be conducted to please contact the SR once the ADM and/or Alt ADM received this message. SR also stated that the timeframe for the survey to be conducted will lapse as of 2:25PM.Timeframe for the survey to be conducted lapsed at 2:25PM. SR called the hospice’s main number at 2:29PM; call went straight to voicemail. Voicemail stated, “Thank you for calling [Hospice]. Please leave a brief message and your name and number after this beep.” SR introduced self and stated purpose of visit was to conduct a re-licensure and re-certification survey that the SR arrived at the commercial location as listed in TULIP at 12:25PM. SR stated that the timeframe for the survey to be conducted as lapsed as of 2:25PM that the hospice would automatically be cited from administrative penalties to license revocation and that the hospice would receive a 2567 and/or 3724 within 10 business days and/or more. SR would also send Memo Letters 2023 to the hospice via email later today that explained the inability to conduct a survey. SR also stated if the ADM and/or Alt ADM had any further questions to please call the SR for more information. Interviews: On 06/09/2026, SR received a call from an unidentified and unknown number from Phone #1 at 2:36PM. Caller introduced self and stated purpose of the call was to speak with SR regarding [Hospice]. Caller identified self as LNC, and that LNC was representing [Hospice]’s interests. During a phone interview with LNC on 06/09/2026 at 2:37PM. LNC explained to SR the Hospice’s situation; LNC stated that, “[Hospice] ADM called LNC earlier today when ADM received SR’s message and reached out to LNC to explain that ADM was not available but if LNC could reach out to the SR for the ADM instead. The situation is that the hospice was in the process of rectifying the 855A Application because the hospice made a mistake but is working on it. In between, trying to fix the 855A Application; the hospice’s CHAP accreditation status expired, and I think that’s why state somehow got the hospice instead. At that exact time, we were trying to work still on the 855A; somehow the hospice’s PTAN number was deactivated. CMS deactivated it. So, the license is still good, but the PTAN number we are trying to work on fixing. Then crazy enough, if it wasn’t already crazy was that the ADM was going through a lot of legal actions with ownership situation. It’s honestly been a lot.” SR inquired from the LNC, why did CMS deactivate the PTAN. LNC stated, “Because apparently the Hospice had not been billing for the services, but the ADM was trying to get everything in order. In fact, we are currently at Address A right now. On the voicemail you left; if the hospice decides to say… not conduct the survey, we will just get administrative penalties correct? Because, if that’s the case, then we would be okay with that.” SR informed the LNC at 2:39PM that the timeframe for the survey to be conducted lapsed as of 2:25PM, and for the LNC along with the ADM and/or Alt ADM to reference the SR’s pervious voicemails placed on the hospice’s voicemail for more information. SR also informed the LNC that it was up to the administrative reviewers to decide what penalties would apply. SR waited at the hospice’s secondary location and met the required timeframe of 2 hours. Additional time of 22 minutes was given for the ADM and/or Alt ADM to contact the SR back. However, no call back was received from the ADM and/or Alt ADM on 06/09/2026 and/or after 06/09/2026. SR left the secondary location at 2:47PM unable to conduct the re-certification and re-licensure survey. SR was unable to ascertain whether hospice nursing staff were routinely providing core services to hospice patients as required by regulations. During a phone interview with LNC on 06/09/2026 at 4:26PM. SR inquired from LNC, if the ADM was available for the survey to be conducted and why the ADM was not at the location listed in TULIP. LNC stated, “The ADM called me earlier in the afternoon as I said before, he [ADM] had received your call that he was actually not available because he currently had been under anesthesia for a dental procedure.” SR inquired further from the LNC, if the ADM was not available; was the Alt ADM available for the survey to be conducted and why was the Alt ADM not at the location listed in TULIP. LNC stated, “I not going to lie, I am not sure why the Alt ADM was not available; I would have to look at the demographics for this hospice. But again, the Alt ADM should have been at Address A. Is it possible, if I can call you back to give you that information?” – Although, LNC stated that LNC would call SR back with demographic information; callback was not received on 06/09/2026 and/or after 06/09/2026 with an update. – SR emailed MEMO 2023 – 01 Inability to Access Records or Perform a Survey by Texas Health and Human Services, and MEMO 2023 – 01 Inability to Access Records or Perform a Federal Survey by Texas Health and Human Services to the agency’s main email of [Email XXXX] at 4:54PM. SR did not receive an email back from the hospice confirming receipt on 06/09/2026 and/or after 06/09/2026.”