Nightingale Hospice Care of Texas Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice services. CLINICAL RECORD 4: The patient elected the hospice benefit on 09/23/2025. The nurse documented the initial nursing assessment on 09/23/2025. The initial spiritual assessment was completed on 09/30/2025. The initial psychosocial assessment dated 09/30/2025 included documentation “Missed visit due to cancellation of care.” The spiritual assessment and psychosocial assessment, as part of the initial comprehensive assessment, were not completed within 5 days of the election of benefit. During an interview with the Director of Nursing (Personnel Record 8) on 05/21/2026, she stated they have self-identified this issue and are now completing admission audits to be sure that initial visits are completed in a timely manner.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure the patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/16/2025. The clinical record included a Physical Therapy (PT) evaluation dated 05/01/2026, with a plan for PT x 2 visits to be performed for caregiver education. One visit was planned for the week of 05/11/2026 and one visit for the week of 05/25/2026. The plan of care did not include interventions for caregiver education, the PT planned interventions, and the frequency of services. During an interview on 05/21/2026, the Director of Nursing (Personnel Record 8) stated that updating the plan of care with changes is an ongoing performance improvement project, and they will continue to provide education to the clinical staff.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with bereavement services applicable, the agency did not ensure a bereavement plan of care was developed that included the types of bereavement services being offered and the frequency of service delivery. CLINICAL RECORD 11: The patient elected the hospice benefit on 05/21/2025 and the patient’s date of death was 06/01/2025. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services being offered and the frequency of service delivery. The clinical record did contain bereavement tasks assigned to the Bereavement Coordinator (BC), and the tasks were being completed in a timely manner, with mailings on 07/03/2025 (letter), 09/05/2025 (letter), 11/28/2025 (letter), 03/02/2026 (letter), and a phone call on 03/24/2026 (invitation to memorial service). CLINICAL RECORD 12: The patient elected the hospice benefit on 08/07/2025 and the patient’s date of death was 01/08/2026. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services being offered and the frequency of service delivery. The discharge summary contained the documentation “referred for bereavement follow-up: YES,” but no bereavement plan of care was documented in the clinical record. During an interview on 05/21/2026, the Director of Nursing (Personnel Record 8) and the Bereavement Coordinator (Personnel Record 4) stated they are still learning the bereavement documentation in the current electronic medical record (EMR). The Director of Nursing stated that they will be scheduling education with the vendor for education on how to fully utilize their current EMR.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide completed appropriate records of service. CLINICAL RECORD 7: Clinical record review revealed two hospice aide visit notes dated 03/25/2026 and 03/27/2026 with documentation of the date and the time in and time out, however there was no documentation of the aide services provided during the visits. During an interview on 05/21/2026, the Director of Nursing (Personnel Record 8) stated that they did not realize that the aide’s documentation had been left blank, and when she discussed it with the aide, she reported that it was when they were having an issue with the electronic medical record, and she forgot to report it.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice did not ensure volunteers provided administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours. The agency provided report with volunteer hours included documentation of volunteer percentage for: May 2025 1.15%, June 2025 2.52%, July 2025 9.31%, August 2025 2.67%, September 1.60%, October 2025 2.14%, November 2025 2.78%, December 2025 3.53%, January 2026 2.42%, February 2026 2.66%, March 2026 3.10%, and April 2026 3.42%, with an annual percentage of 3.108%. The agency did not meet the 5% requirement within the last year. During an interview on 05/21/2026, the Director of Nursing (Personnel Record 8) stated that they have been working on trying to recruit volunteers and utilize volunteers more to increase their volunteer percentage. The document review of the volunteer hours revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This was evidenced by the volunteer percentage as follows: May 2025 1.15%, June 2025 2.52%, July 2025 9.31%, August 2025 2.67%, Septemeber 1.60%, October 2025 2.14%, November 2025 2.78%, December 2025 3.53%, January 2026 2.42%, February 2026 2.66%, March 2026 3.10%, and April 2026 3.42% which is annual percentage of 3.108%, which is less than the 5% requirement.”