Southlake Hospice Care Inc.

“Based on record review and interview, the agency failed to designate a Medical Director for the hospice agency. This failure could place the agency’s patients at risk of inadequate care. The findings included: Record review of personnel records revealed the agency had no record of a Medical Director. Employee file provided by Admin revealed an expired contract for the MD who was presented. The employee file revealed an “Agreement for Professional Services Medical Director” agreement with MD dated July 1, 2024 with a contract termination date of June 31, 2025. The contract was signed by MD on 6/24/2024. A phone call with MD on 6/30/2026 at 2:15 p.m. was made. MD stated that he was the prior MD for the agency but placed his resignation with the agency in October of 2025. Surveyor asked if MD was able to provide the Surveyor with a copy of the email. MD stated that he would send the email immediately and expressed concern that he continued to be represented as the MD of this agency. During an interview on 6/30/2026 at 2:30 p.m. with the Admin, the conversation with MD was addressed and resignation email presented. The Admin stated that he was told by the Alt Admin that MD was going to be the current MD but they were in the process of locating a different medical director because the agency didn’t have any active patients since November 2025. Surveyor requested the name and contact information for the physician they were actively recruiting to verify that a job offer was being discussed. During an interview on 6/30/2026 at 2:45 p.m. with MD B, MD B stated that the agency approached him regarding the position of medical director, but he has not confirmed the position. The agency had a policy titled, “Physician Services and Medical Director Roles and Responsibilities,” dated 2/2025, read in part, “Hospice will provide qualified physician and Medical Director Services…the hospice medical director, physician…are responsible for the palliation and management of terminal illness and conditions related to the terminal illness…””

“Based on record review, and interview, the hospice failed to ensure that the agency Social Worker met professional qualification requirements in that: The agency failed to ensure that the agency’s Social Worker had a master’s degree of social work. This failure placed clients at risk of receiving services from personnel who were not qualified. Findings included: During record review of employee files on 6/29/2026, SW employee file, date of hire 6/1/2026, revealed a bachelor’s degree in social work received in 1992. A phone call to SW on 6/30/2026 at 3:40 p.m. was attempted to verify educational history. A voicemail was left with the purpose of the call and a return number. The phone call was not returned. In an exit conference with the Admin and Alt Admin on 6/30/2026 at 4:00 p.m., Surveyor asked if they were aware of the social worker requirement was to hold a master’s degree. Admin stated he wasn’t aware that she only had a bachelor’s degree. Survey asked if a master’s level social worker was employed with the agency to which Admin stated there was not. Admin stated he was responsible for hiring her and that he understood the regulatory requirement. Review of agency policy titled “Psychosocial Services”, dated 06/2026, read in part, “…[agency name] will provide psychosocial services by qualified social workers… under the direction of a physician and in accordance to plan of care.””

“Based on observation, record review and interview the agency failed to enforce it’s written policy to ensure that the agency met the Clinical Laboratory Improvement Act (regulations that establish standards for all laboratory testing to ensure accurate, reliable, and timely test results) concerning certification of a clinical laboratory in that: The agency failed to maintain a CLIA certification while performing laboratory testing on 1 of 4 (Pt #4) patients reviewed. This failure placed patients at risk of receiving inaccurate or unreliable laboratory test results and resulted in noncompliance with 42 United States Code (USC) §263a. Findings include: Upon entry to the agency on 6/16/2026, Surveyor located a license issued to the agency for Hospice services. No CLIA certificate waiver was observed upon entry. Surveyor asked Admin if the agency had a CLIA waiver and he stated he believed they had one but was unable to locate the waiver once asked. Record review of Pt #4’s medical record revealed a start of care date of 11/14/2024 with a primary hospice diagnosis of cerebrovascular disease (a condition that affects blood flow to the brain). The medical record revealed blood and urine collected on 2/19/2025 with an ordering physician listed as hospice MD. Review of QCOR (Quality, Certification, and Oversight Reports), a database used to look up CLIA laboratories, revealed no active CLIA waiver for this agency listed. During an interview with agency Admin and Alt Admin on 6/30/2026 at approximately 4:15 p.m., surveyor asked about the agency collecting blood and urine for testing without a CLIA waiver. Admin stated he wasn’t sure if the agency had a CLIA waiver at the time of testing because he was new to the agency. Admin stated he was in the process of applying for a CLIA waiver. Alt Admin accepted responsibility for now having a CLIA waiver. Review of agency policy titled “Waived Testing”, revised January 2023, read in part, “…[agency name] will perform permitted laboratory tests in the home… will apply for and maintain a CLIA waiver on file…”.”