Eternal Faith Hospice

“Based on observation, record review, and interview, the hospice failed to maintain compliance with this Condition of Participation to provide all core services directed by the hospice consistent with acceptable standards of practice to include nursing services, medical social services and counseling services to any patients on services or admitted to the hospice in that: 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 when the hospice failed to provide entry to HHSC surveyor during attempted survey on 8/18/26. (Refer to L 0591) 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, and based on the patients’ psychosocial assessment and the patients’ and families identified needs and acceptance of services, when the hospice failed to provide HHSC surveyor entry during attempted survey on 8/18/26. (Refer to L 0594)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 when the hospice failed to provide HHSC surveyor entry during attempted survey on 8/18/26. (Refer to L 595) FindingsRefer to L0591- Nursing servicesRefer to L0594 - Medical Social ServicesRefer to L0595 - Counseling Services”

“Based on records reviews and interviews, the hospice failed to maintain compliance with this Condition of Participation 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 failed to be engaged in providing nursing services, medical social services, physician services, counseling services including spiritual counseling, dietary counseling, and bereavement counseling, hospice aide, volunteer, and homemaker services, physical therapy, occupational therapy, and speech-language pathology services, short-term inpatient care, medical supplies (including drugs and biologicals) and medical appliances in accordance with acceptable standards, when the hospice failed to provide entry to HHSC surveyor during attempted survey on 8/18/26. (Refer to L0652) The hospice failed to make nursing services, physician services, drugs and biologicals routinely available to patients on a 24-hour basis 7 days a week and other covered services must be made available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family, when the hospice failed to provide entry to HHSC surveyor during attempted survey on 8/18/26. (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 8/18/2026 at Address A and the hospice failed to provide entry to HHSC to survey and ensure agency compliance with this regulation. This failure places patients at risk of not having their nursing needs met or their services not being appropriately supervised and places potential patients and families at risk of not receiving the support services needed during the patients’ end of life. Review of hospice’s account page in Texas Unified license Information Portal (TULIP - a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 08/18/2026 at 8:00am revealed hospice Agency’s contact information as: Hospice A’s address, Hospice’s phone# A, Hospice’s operational hours as 11am – 5pm. Monday through Friday and Hospice CCN. The hospice as an ADS in Address# B and a Phone# B.Further review of the agency’s information revealed Deemed Status expired on 8/14/2026.Review of the Hospice’s IQIES account on 8/18/2026 revealed hospice’s CCN and address was same as shown in Hospice’s TULIP account.An observation on 8/18/2026 at 11:10 AM revealed that the agency’s address was located in a professional building at Address A. Upon arrival, the surveyor observed a large white banner hanging on the building that read, “office space for lease.” The surveyor proceeded to walk to the main door of the office and knocked on the glass door three times. The door was locked, and there was no name or signage indicating the presence of the agency. Furthermore, no furniture could be seen inside, and no lights could be observed from the outside.On 8/18/2026 at 11:20 AM, the surveyor called the agency’s Phone #A as indicated in TULIP. A female individual answered the call and introduced herself as the office manager. The surveyor stated the purpose of the call and asked for the administrator. Office Manager #1 stated that she was the manager of the location at Address B and not at Address A but noted that she would reach out to the staff at Address A because they might have been out in the community conducting visits. The surveyor stated that the office appeared to be permanently closed and even had a lease sign hanging on the building. Office Manager #1 did not respond to the statement directly but instead stated that she would either return the surveyor’s call herself or have another person do so.On 8/18/2026 at 11:55 AM, the Hospice Agency’s Regional Vice President of Operations (VP) called the surveyor. He stated that he had been informed that a state surveyor was at Address A attempting to conduct a survey, and he noted that the office “was not doing business anymore.” When the surveyor asked what had happened to the patients and the staff at Address A, VP stated that he would find out. He added that he was currently in the area and could meet the surveyor in 30 minutes. He further noted that he would not be able to let the surveyor inside the office because it was closed. The surveyor agreed to the meeting.An interview was conducted on 8/18/2026 at approximately 12:30 PM on the sidewalk beside Address A. During the interview, VP stated that the agency’s office at Address A had been no longer in business since March of 2026, and that there were no patients. VP added that the agency had been unable to change the location because the agency’s account in PECOS (which is the secure online database and management system operated by CMS) had been locked since December of 2025. VP further noted that agency Address A and Address B were supposed to have been merged into a single office. The agency had tried to notify HHSC, but because the PECOS account was locked out, it did not allow them to change the address. When the surveyor asked for the contact information of the Administrator and Alternate Administrator listed on the agency’s TULIP account, VP stated that they no longer worked for the company. VP did not state the exact date the administrative staff had left the agency, but added that, as of that moment, the agency was in the process of replacing them.On 8/18/2026 at around 12:50 pm the surveyor handed the letters of Inability to Perform a Federal and State Survey by an HHSC representative and had VP signed the “Acknowledgement of Receipt” forms. Surveyor informed VP that surveyor will still be in the area until about 1:10 pm to wait for the 2 hours arrival window.Surveyor left the location Address A at 1:10 PM unable to conduct a recertification survey, and therefore was unable to determine whether nursing care and hospice services were provided by or under the supervision of a registered nurse, and whether the nursing needs of hospice patients were identified and met through the initial, comprehensive, and updated assessments.””

“Based on observation, records reviews, and interviews, the hospice failed to provide medical social services by or under the supervision of a social worker and failed to ensure social 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 8/18/2026 at Address A and the hospice failed to provide entry to HHSC to survey and ensure agency compliance with this regulation. This failure places patients at risk of not having their social services met or their services not being appropriately supervised and places potential patients and families at risk of not receiving the psychosocial services needed during the patients’ end of life. Review of hospice’s account page in Texas Unified license Information Portal (TULIP - a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 08/18/2026 at 8:00am revealed hospice Agency’s contact information as: Hospice A’s address, Hospice’s phone# A, Hospice’s operational hours as 11am – 5pm. Monday through Friday and Hospice CCN. The hospice as an ADS in Address# B and a Phone# B.Further review of the agency’s information revealed Deemed Status expired on 8/14/2026.Review of the Hospice’s IQIES account on 8/18/2026 revealed hospice’s CCN and address was same as shown in Hospice’s TULIP account.An observation on 8/18/2026 at 11:10 AM revealed that the agency’s address was located in a professional building at Address A. Upon arrival, the surveyor observed a large white banner hanging on the building that read, “office space for lease.” The surveyor proceeded to walk to the main door of the office and knocked on the glass door three times. The door was locked, and there was no name or signage indicating the presence of the agency. Furthermore, no furniture could be seen inside, and no lights could be observed from the outside.On 8/18/2026 at 11:20 AM, the surveyor called the agency’s Phone #A as indicated in TULIP. A female individual answered the call and introduced herself as the office manager. The surveyor stated the purpose of the call and asked for the administrator. Office Manager #1 stated that she was the manager of the location at Address B and not at Address A, but noted that she would reach out to the staff at Address A because they might have been out in the community conducting visits. The surveyor stated that the office appeared to be permanently closed and even had a lease sign hanging on the building. Office Manager #1 did not respond to the statement directly but instead stated that she would either return the surveyor’s call herself or have another person do so.On 8/18/2026 at 11:55 AM, the Hospice Agency’s Regional Vice President of Operations (VP) called the surveyor. He stated that he had been informed that a state surveyor was at Address A attempting to conduct a survey, and he noted that the office “was not doing business anymore.” When the surveyor asked what had happened to the patients and the staff at Address A, VP stated that he would find out. He added that he was currently in the area and could meet the surveyor in 30 minutes. He further noted that he would not be able to let the surveyor inside the office because it was closed. The surveyor agreed to the meeting.An interview was conducted on 8/18/2026 at approximately 12:30 PM on the sidewalk beside Address A. During the interview, VP stated that the agency’s office at Address A had been no longer in business since March of 2026, and that there were no patients. VP added that the agency had been unable to change the location because the agency’s account in PECOS (which is the secure online database and management system operated by CMS) had been locked since December of 2025. VP further noted that agency Address A and Address B were supposed to have been merged into a single office. The agency had tried to notify HHSC, but because the PECOS account was locked out, it did not allow them to change the address. When the surveyor asked for the contact information of the Administrator and Alternate Administrator listed on the agency’s TULIP account, VP stated that they no longer worked for the company. VP did not state the exact date the administrative staff had left the agency, but added that, as of that moment, the agency was in the process of replacing them.On 8/18/2026 at around 12:50 pm the surveyor handed the letters of Inability to Perform a Federal and State Survey by an HHSC representative and had VP signed the “Acknowledgement of Receipt” forms. Surveyor informed VP that surveyor will still be in the area until about 1:10 pm to wait for the 2 hours arrival window.Surveyor left the location Address A at 1:10 PM unable to conduct a recertification survey and therefore unable to verify if the Hospice routinely provides substantially all core services in a manner consistent with acceptable standards of practice including nursing services, medical social services and counseling.””

“Based on observation, records reviews, and interviews, the hospice failed to provide counselling to the patients and patient’s family and failed to ensure counselling 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 8/18/2026 at Address A and the hospice failed to provide entry to HHSC to survey and ensure agency compliance with this regulation. This failure places patients at risk of not having their counselling services met or their services not being appropriately supervised and places potential patients and families at risk of not receiving the counselling needed during the patients’ end of life. Review of hospice’s account page in Texas Unified license Information Portal (TULIP - a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 08/18/2026 at 8:00am revealed hospice Agency’s contact information as: Hospice A’s address, Hospice’s phone# A, Hospice’s operational hours as 11am – 5pm. Monday through Friday and Hospice CCN. The hospice as an ADS in Address# B and a Phone# B.Further review of the agency’s information revealed Deemed Status expired on 8/14/2026.Review of the Hospice’s IQIES account on 8/18/2026 revealed hospice’s CCN and address was same as shown in Hospice’s TULIP account.An observation on 8/18/2026 at 11:10 AM revealed that the agency’s address was located in a professional building at Address A. Upon arrival, the surveyor observed a large white banner hanging on the building that read, “office space for lease.” The surveyor proceeded to walk to the main door of the office and knocked on the glass door three times. The door was locked, and there was no name or signage indicating the presence of the agency. Furthermore, no furniture could be seen inside, and no lights could be observed from the outside.On 8/18/2026 at 11:20 AM, the surveyor called the agency’s Phone #A as indicated in TULIP. A female individual answered the call and introduced herself as the office manager. The surveyor stated the purpose of the call and asked for the administrator. Office Manager #1 stated that she was the manager of the location at Address B and not at Address A, but noted that she would reach out to the staff at Address A because they might have been out in the community conducting visits. The surveyor stated that the office appeared to be permanently closed and even had a lease sign hanging on the building. Office Manager #1 did not respond to the statement directly but instead stated that she would either return the surveyor’s call herself or have another person do so.On 8/18/2026 at 11:55 AM, the Hospice Agency’s Regional Vice President of Operations (VP) called the surveyor. He stated that he had been informed that a state surveyor was at Address A attempting to conduct a survey, and he noted that the office “was not doing business anymore.” When the surveyor asked what had happened to the patients and the staff at Address A, VP stated that he would find out. He added that he was currently in the area and could meet the surveyor in 30 minutes. He further noted that he would not be able to let the surveyor inside the office because it was closed. The surveyor agreed to the meeting.An interview was conducted on 8/18/2026 at approximately 12:30 PM on the sidewalk beside Address A. During the interview, VP stated that the agency’s office at Address A had been no longer in business since March of 2026, and that there were no patients. VP added that the agency had been unable to change the location because the agency’s account in PECOS (which is the secure online database and management system operated by CMS) had been locked since December of 2025. VP further noted that agency Address A and Address B were supposed to have been merged into a single office. The agency had tried to notify HHSC, but because the PECOS account was locked out, it did not allow them to change the address. When the surveyor asked for the contact information of the Administrator and Alternate Administrator listed on the agency’s TULIP account, VP stated that they no longer worked for the company. VP did not state the exact date the administrative staff had left the agency, but added that, as of that moment, the agency was in the process of replacing them.On 8/18/2026 at around 12:50 pm the surveyor handed the letters of Inability to Perform a Federal and State Survey by an HHSC representative and had VP signed the “Acknowledgement of Receipt” forms. Surveyor informed VP that surveyor will still be in the area until about 1:10 pm to wait for the 2 hours arrival window.Surveyor left the location Address A at 1:10 PM unable to conduct a recertification survey and therefore unable to verify if the Hospice made counseling services available to the patient and family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process.””

“Based on observation, records reviews, and interviews, the hospice failed to be engaged in providing Nursing services, Medical social services, Physician services, Counseling services including spiritual counseling, dietary counseling, and bereavement counseling, Hospice aide, volunteer, and homemaker services, Physical therapy, occupational therapy, and speech-language pathology services, Short-term inpatient care, Medical supplies (including drugs and biologicals) and medical appliances in accordance with acceptable standards. In that:An attempted visit was made on 8/18/2026 at Address A and the hospice failed to provide entry to HHSC to survey and ensure agency compliance with this regulation. This failure hindered HHSC Survey process and placed hospice patients at risk of receiving substandard hospice care and services. Review of hospice’s account page in Texas Unified license Information Portal (TULIP - a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 08/18/2026 at 8:00am revealed hospice Agency’s contact information as: Hospice A’s address, Hospice’s phone# A, Hospice’s operational hours as 11am – 5pm. Monday through Friday and Hospice CCN. The hospice as an ADS in Address# B and a Phone# B.Further review of the agency’s information revealed Deemed Status expired on 8/14/2026.Review of the Hospice’s IQIES account on 8/18/2026 revealed hospice’s CCN and address was same as shown in Hospice’s TULIP account.An observation on 8/18/2026 at 11:10 AM revealed that the agency’s address was located in a professional building at Address A. Upon arrival, the surveyor observed a large white banner hanging on the building that read, “office space for lease.” The surveyor proceeded to walk to the main door of the office and knocked on the glass door three times. The door was locked, and there was no name or signage indicating the presence of the agency. Furthermore, no furniture could be seen inside, and no lights could be observed from the outside.On 8/18/2026 at 11:20 AM, the surveyor called the agency’s Phone #A as indicated in TULIP. A female individual answered the call and introduced herself as the office manager. The surveyor stated the purpose of the call and asked for the administrator. Office Manager #1 stated that she was the manager of the location at Address B and not at Address A, but noted that she would reach out to the staff at Address A because they might have been out in the community conducting visits. The surveyor stated that the office appeared to be permanently closed and even had a lease sign hanging on the building. Office Manager #1 did not respond to the statement directly but instead stated that she would either return the surveyor’s call herself or have another person do so.On 8/18/2026 at 11:55 AM, the Hospice Agency’s Regional Vice President of Operations (VP) called the surveyor. He stated that he had been informed that a state surveyor was at Address A attempting to conduct a survey, and he noted that the office “was not doing business anymore.” When the surveyor asked what had happened to the patients and the staff at Address A, VP stated that he would find out. He added that he was currently in the area and could meet the surveyor in 30 minutes. He further noted that he would not be able to let the surveyor inside the office because it was closed. The surveyor agreed to the meeting.An interview was conducted on 8/18/2026 at approximately 12:30 PM on the sidewalk beside Address A. During the interview, VP stated that the agency’s office at Address A had been no longer in business since March of 2026, and that there were no patients. VP added that the agency had been unable to change the location because the agency’s account in PECOS (which is the secure online database and management system operated by CMS) had been locked since December of 2025. VP further noted that agency Address A and Address B were supposed to have been merged into a single office. The agency had tried to notify HHSC, but because the PECOS account was locked out, it did not allow them to change the address. When the surveyor asked for the contact information of the Administrator and Alternate Administrator listed on the agency’s TULIP account, VP stated that they no longer worked for the company. VP did not state the exact date the administrative staff had left the agency, but added that, as of that moment, the agency was in the process of replacing them.On 8/18/2026 at around 12:50 pm the surveyor handed the letters of Inability to Perform a Federal and State Survey by an HHSC representative and had VP signed the “Acknowledgement of Receipt” forms. Surveyor informed VP that surveyor will still be in the area until about 1:10 pm to wait for the 2 hours arrival window.Surveyor left the location Address A at 1:10 PM unable to conduct a recertification survey “and therefore unable to verify that the Hospice was primarily engaged in providing the following care and services and in a manner that is consistent with accepted standards of practice: (i) Nursing services. (ii) Medical social services. (iii) Physician services. (iv) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling. (v) Hospice aide, volunteer, and homemaker services. (vi) Physical therapy, occupational therapy, and speech-language pathology services. (vii) Short-term inpatient care. (viii) Medical supplies (including drugs and biologicals) and medical appliances.””

“Based on observation, records reviews, and interviews, the hospice failed to ensure nursing services, physician services, drugs and biologicals routinely available to patients on a 24-hour basis 7 days a week. In that: An attempted visit was made on 8/18/2026 at Address A and the hospice failed to provide entry to HHSC to survey and ensure agency compliance with this regulation. This failure hindered HHSC Survey process and placed hospice patients at risk of receiving substandard hospice care and services. Review of hospice’s account page in Texas Unified license Information Portal (TULIP - a database utilized by the State of Texas to maintain licensing, demographic information, complaints, and self-reported incidents for home health and hospice agencies) on 08/18/2026 at 8:00am revealed hospice Agency’s contact information as: Hospice A’s address, Hospice’s phone# A, Hospice’s operational hours as 11am – 5pm. Monday through Friday and Hospice CCN. The hospice as an ADS in Address# B and a Phone# B.Further review of the agency’s information revealed Deemed Status expired on 8/14/2026.Review of the Hospice’s IQIES account on 8/18/2026 revealed hospice’s CCN and address was same as shown in Hospice’s TULIP account.An observation on 8/18/2026 at 11:10 AM revealed that the agency’s address was located in a professional building at Address A. Upon arrival, the surveyor observed a large white banner hanging on the building that read, “office space for lease.” The surveyor proceeded to walk to the main door of the office and knocked on the glass door three times. The door was locked, and there was no name or signage indicating the presence of the agency. Furthermore, no furniture could be seen inside, and no lights could be observed from the outside.On 8/18/2026 at 11:20 AM, the surveyor called the agency’s Phone #A as indicated in TULIP. A female individual answered the call and introduced herself as the office manager. The surveyor stated the purpose of the call and asked for the administrator. Office Manager #1 stated that she was the manager of the location at Address B and not at Address A, but noted that she would reach out to the staff at Address A because they might have been out in the community conducting visits. The surveyor stated that the office appeared to be permanently closed and even had a lease sign hanging on the building. Office Manager #1 did not respond to the statement directly but instead stated that she would either return the surveyor’s call herself or have another person do so.On 8/18/2026 at 11:55 AM, the Hospice Agency’s Regional Vice President of Operations (VP) called the surveyor . He stated that he had been informed that a state surveyor was at Address A attempting to conduct a survey, and he noted that the office “was not doing business anymore.” When the surveyor asked what had happened to the patients and the staff at Address A, VP stated that he would find out. He added that he was currently in the area and could meet the surveyor in 30 minutes. He further noted that he would not be able to let the surveyor inside the office because it was closed. The surveyor agreed to the meeting.An interview was conducted on 8/18/2026 at approximately 12:30 PM on the sidewalk beside Address A. During the interview, VP stated that the agency’s office at Address A had been no longer in business since March of 2026, and that there were no patients. VP added that the agency had been unable to change the location because the agency’s account in PECOS (which is the secure online database and management system operated by CMS) had been locked since December of 2025. VP further noted that agency Address A and Address B were supposed to have been merged into a single office. The agency had tried to notify HHSC, but because the PECOS account was locked out, it did not allow them to change the address. When the surveyor asked for the contact information of the Administrator and Alternate Administrator listed on the agency’s TULIP account, VP stated that they no longer worked for the company. VP did not state the exact date the administrative staff had left the agency, but added that, as of that moment, the agency was in the process of replacing them.On 8/18/2026 at around 12:50 pm the surveyor handed the letters of Inability to Perform a Federal and State Survey by an HHSC representative and had VP signed the “Acknowledgement of Receipt” forms. Surveyor informed VP that surveyor will still be in the area until about 1:10 pm to wait for the 2 hours arrival window.Surveyor left the location Address A at 1:10 PM unable to conduct a recertification survey and therefore unable to verify that nursing services, physician services, and drugs and biologicals (as specified in §418.106) were made routinely available on a 24-hour basis 7 days a week and other covered services were made available on a 24-hour basis when reasonable and necessary to meet the needs of the patient and family.””