Veteran Memorial Hospice

“Based on observation, record review, and interview, the hospice failed to be primarily engaged in providing nursing services, medical social services and counseling services to 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.This failure places any patients at risk of not receiving effective oversight for pain and symptom management, at risk of not having their nursing needs met or their services not being appropriately supervised, at risk of not having psychosocial assessments to help identify issues or assist with facilitating the patient’s care and treatment in their end of life, and places potential patients and families at risk of not receiving the support services needed during the patients’ end of life 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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to surveyor onsite and did not return surveyors calls to confirm nursing services were being provided to patients.Refer to L0591 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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to the 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 not having their psychosocial needs identified and met by a qualified social worker.Refer to L0594 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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to the 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.Refer to L0595 Refer to L0591 - Nursing Services, Refer to L0594 - Medical Social Services, and Refer to L0595 - COUNSELING SERVICES.”

“Based on records reviews and interviews, the hospice failed to maintain, organize, manage, and administer its resources to provide hospice care and services to the patients, caregivers, and families necessary to alleviate stress associated with 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 05/13/2026 and 05/14/2026 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.This failure could place hospice patients, caregivers, and their families at risk of not receiving the care and services they need to effectively manage pain and symptoms and other related stress associated with terminal illness, the end-of-life process and family bereavement. Based on records reviews and interviews, the hospice governing body failed to assume full legal authority and responsibility for the management of the hospice agency, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. In that the hospice governing body or the hospice Administrator failed to ensure the hospice agency was opened during normal business hours on 05/13/2026 and 05/14/2026. This failure hindered 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.Refer to L0651 Refer to L0651- GOVERNING BODY AND ADMINISTRATOR”

“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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to surveyor onsite and did not return surveyors calls to confirm nursing services were being provided to patients. Findings include:Review of hospice’s account page in Texas Unified license Information Portal (TULIP – is 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 05/12/2026 at 8:13am revealed hospice A’s contact information as: Hospice’s address A. Hospice’s phone Number as Telephone 1, hospice’s operational hours as 9am – 3pm. Monday through Friday and Hospice CCN. Further review of hospice’s TULIP account revealed hospice’s patients census was 12 as of 07/28/2025.Review of the Hospice’s IQIES account on 05/12/2026 revealed hospice’s address was same as shown in hospice’s TULIP account and the hospice CCN was the same also.Review of the CMS Care Compare website on 05/12/2026 revealed that hospice A had average daily census of 3 patients and the hospice provided the core hospice services to patients in their residents. Observation: On 05/13/2026 at 12:06p.m. Surveyor arrived at hospice A’s (address A) and found hospice’s door locked with a notice posted by the side of the door that stated that hospice A had relocated to a new location (Address B) under a new Name (Hospice B). Surveyor went to location (Address B) and found a notice on the door with the name “Hospice B”. During interview with the Administrator of Hospice B at Address B on 05/13/2026 at 2:43pm, the Administrator confirmed that they recently changed hospice’s name from Hospice A to Hospice B. Surveyor asked when the change was made and the reason for the change. The Administrator stated that hospice B was recently purchased from the previous owner, but she did not know the full details of the sale, but hospice B’s Chief Financial Officer (CFO) would know the full details of the transaction. During interview with hospice B’s CFO on 05/13/2026 at 2:50pm, the CFO confirmed hospice’s former name as Hospice A, but they changed the hospice’s name to hospice B and relocated Hospice B after the purchase from the previous owner in February 2026. The CFO also informed Surveyor that the previous owner (who is also the Administrator of Hospice A) owned other agencies that he still retained ownership of. Surveyor requested the CFO of Hospice B to call the previous owner of Hospice B for interview. The CFO stated that she had texted him 05/13/2026 at 2:45pm but he did not respond. Surveyor then requested Hospice B’ CFO to call the previous owner of hospice B and not send a text. Hospice B’s CFO then called the previous owner of hospice B on 05/13/2026 at 2:58pm, there was no response, left a voicemail requesting a call back. The previous owner/Administrator did not call back while the Surveyor was present. Observation: On 05/14/2026 at 9:48am the Surveyor went back to Hospice A’s location listed in IQIES/TULIP to search for Hospice A. Surveyor walked through the hospice’s designated suite number listed in TULIP but could not find hospice A at the location (Address A) listed in TULIP. Interview: Surveyor called the hospice A’s phone number listed in Tulip (Telephone 1) on 05/14/2026 at 10:11am and 11:24am and 12: 13pm to notify Hospice A’s Administrator and Alternate Administrator of her arrival at the hospice’s location, but was unable to leave voice messages as the phone notification stated the recipient mailbox was full and could not accept any messages, but if the Surveyor wanted to send a call back phone number to the recipient(Hospice Administrator/Alternate Administrator) by pressing the # sign and the Surveyor’s phone number would be automatically sent. So, Surveyor did as she was prompted three different times but did not receive any call back from the administrator. Neither Hospice’s Administrator nor the Alternate Administrator called the Surveyor back by the end of the business day.Surveyor waited at the hospice A’s location for two hours as required and left the location at 12:23pm unable to conduct a survey to ascertain whether hospice Nursing staff were routinely providing core services to hospice patients as required by regulations.Surveyor sent the hospice A’s Administrator and Alternate Administrator via email the letter of inability to conduct a federal survey on 05/19/2026 at 5:29pm.”

“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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to the 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 not having their psychosocial needs identified and met by a qualified social worker. Findings include:Review of hospice’s account page in Texas Unified license Information Portal (TULIP – is 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 05/12/2026 at 8:13am revealed hospice A’s contact information as: Hospice’s address A. Hospice’s phone Number as Telephone 1, hospice’s operational hours as 9am – 3pm. Monday through Friday and Hospice CCN. Further review of hospice’s TULIP account revealed hospice’s patients census was 12 as of 07/28/2025.Review of the Hospice’s IQIES account on 05/12/2026 revealed hospice’s address was same as shown in hospice’s TULIP account and the hospice CCN was the same also.Review of the CMS Care Compare website on 05/12/2026 revealed that hospice A had average daily census of 3 patients and the hospice provided the core hospice services to patients in their residents. Observation: On 05/13/2026 at 12:06p.m. Surveyor arrived at hospice A’s (address A) and found hospice’s door locked with a notice posted by the side of the door that stated that hospice A had relocated to a new location (Address B) under a new Name (Hospice B). Surveyor went to location (Address B) and found a notice on the door with the name “Hospice B”. During interview with the Administrator of Hospice B at Address B on 05/13/2026 at 2:43pm, the Administrator confirmed that they recently changed hospice’s name from Hospice A to Hospice B. Surveyor asked when the change was made and the reason for the change. The Administrator stated that hospice B was recently purchased from the previous owner, but she did not know the full details of the sale, but hospice B’s Chief Financial Officer (CFO) would know the full details of the transaction. During interview with hospice B’s CFO on 05/13/2026 at 2:50pm, the CFO confirmed hospice’s former name as Hospice A, but they changed the hospice’s name to hospice B and relocated Hospice B after the purchase from the previous owner in February 2026. The CFO also informed Surveyor that the previous owner (who is also the Administrator of Hospice A) owned other agencies that he still retained ownership of. Surveyor requested the CFO of Hospice B to call the previous owner of Hospice B for interview. The CFO stated that she had texted him 05/13/2026 at 2:45pm but he did not respond. Surveyor then requested Hospice B’ CFO to call the previous owner of hospice B and not send a text. Hospice B’s CFO then called the previous owner of hospice B on 05/13/2026 at 2:58pm, there was no response, left a voicemail requesting a call back. The previous owner/Administrator did not call back while the Surveyor was present. Observation: On 05/14/2026 at 9:48am the Surveyor went back to Hospice A’s location listed in IQIES/TULIP to search for Hospice A. Surveyor walked through the hospice’s designated suite number listed in TULIP but could not find hospice A at the location (Address A) listed in TULIP. Interview: Surveyor called the hospice A’s phone number listed in Tulip (Telephone 1) on 05/14/2026 at 10:11am and 11:24am and 12: 13pm to notify Hospice A’s Administrator and Alternate Administrator of her arrival at the hospice’s location, but was unable to leave voice messages as the phone notification stated the recipient mailbox was full and could not accept any messages, but if the Surveyor wanted to send a call back phone number to the recipient(Hospice Administrator/Alternate Administrator) by pressing the # sign and the Surveyor’s phone number would be automatically sent. So, Surveyor did as she was prompted three different times but did not receive any call back from the administrator. Neither Hospice’s Administrator nor the Alternate Administrator called the Surveyor back by the end of the business day.Surveyor waited at the hospice A’s location for two hours as required and left the location at 12:23pm unable to conduct a survey to ascertain whether hospice counseling staff were routinely providing core services to hospice patients and families as required by regulations.Surveyor sent the hospice A’s Administrator and Alternate Administrator via email the letter of inability to conduct a federal survey on 05/19/2026 at 5:29pm.”

“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 05/13/2026 and 05/14/2026 at the hospice physical location listed in IQIES with an active CCN that indicated the hospice is operational and able to bill for services rendered, the hospice Administrator and Alternate Administrator were not available to the 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:Review of hospice’s account page in Texas Unified license Information Portal (TULIP – is 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 05/12/2026 at 8:13am revealed hospice A’s contact information as: Hospice’s address A. Hospice’s phone Number as Telephone 1, hospice’s operational hours as 9am – 3pm. Monday through Friday and Hospice CCN.Further review of hospice’s TULIP account revealed hospice’s patients census was 12 as of 07/28/2025.Review of the Hospice’s IQIES account on 05/12/2026 revealed hospice’s address was same as shown in hospice’s TULIP account and the hospice CCN was the same also.Review of the CMS Care Compare website on 05/12/2026 revealed that hospice A had average daily census of 3 patients and the hospice provided core hospice services to patients in their residents. Observation: On 05/13/2026 at 12:06p.m. Surveyor arrived at hospice A’s (address A) and found hospice’s door locked with a notice posted by the side of the door that stated that hospice A had relocated to a new location (Address B) under a new Name (Hospice B). Surveyor went to location (Address B) and found a notice on the door with the name “Hospice B”. During interview with the Administrator of Hospice B at Address B on 05/13/2026 at 2:43pm, the Administrator confirmed that they recently changed hospice’s name from Hospice A to Hospice B. Surveyor asked when the change was made and the reason for the change. The Administrator stated that hospice B was recently purchased from the previous owner, but she did not know the full details of the sale, but hospice B’s Chief Financial Officer (CFO) would know the full details of the transaction. During interview with hospice B’s CFO on 05/13/2026 at 2:50pm, the CFO confirmed hospice’s former name as Hospice A, but they changed the hospice’s name to hospice B and relocated Hospice B after the purchase from the previous owner in February 2026. The CFO also informed Surveyor that the previous owner (who is also the Administrator of Hospice A) owned other agencies that he still retained ownership of. Surveyor requested the CFO of Hospice B to call the previous owner of Hospice B for interview. The CFO stated that she had texted him 05/13/2026 at 2:45pm but he did not respond. Surveyor then requested Hospice B’ CFO to call the previous owner of hospice B and not send a text. Hospice B’s CFO then called the previous owner of hospice B on 05/13/2026 at 2:58pm, there was no response, left a voicemail requesting a call back. The previous owner/Administrator did not call back while the Surveyor was present. Observation: On 05/14/2026 at 9:48am the Surveyor went back to Hospice A’s location listed in IQIES/TULIP to search for Hospice A. Surveyor walked through the hospice’s designated suite number listed in TULIP but could not find hospice A at the location (Address A) listed in TULIP. Interview: Surveyor called the hospice A’s phone number listed in Tulip (Telephone 1) on 05/14/2026 at 10:11am and 11:24am and 12: 13pm to notify Hospice A’s Administrator and Alternate Administrator of her arrival at the hospice’s location, but was unable to leave voice messages as the phone notification stated the recipient mailbox was full and could not accept any messages, but if the Surveyor wanted to send a call back phone number to the recipient(Hospice Administrator/Alternate Administrator) by pressing the # sign and the Surveyor’s phone number would be automatically sent. So, Surveyor did as she was prompted three different times but did not receive any call back from the administrator. Neither Hospice’s Administrator nor the Alternate Administrator called the Surveyor back by the end of the business day.Surveyor waited at the hospice A’s location for two hours as required and left the location at 12:23pm unable to conduct a survey to ascertain whether hospice counseling staff were routinely providing core services to hospice patients and families as required by regulations.Surveyor sent the hospice A’s Administrator and Alternate Administrator via email the letter of inability to conduct a federal survey on 05/19/2026 at 5:29pm.”

“Based on records reviews and interviews, the hospice governing body failed to assume full legal authority and responsibility for the management of the hospice agency, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. In that the hospice governing body or the hospice Administrator failed to ensure the hospice agency was opened during normal business hours on 05/13/2026 and 05/14/2026. This failure hindered 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:Review of hospice’s account page in Texas Unified license Information Portal (TULIP – is 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 05/12/2026 at 8:13am revealed hospice A’s contact information as: Hospice’s address A. Hospice’s phone Number as Telephone 1, hospice’s operational hours as 9am – 3pm. Monday through Friday and Hospice CCN. Further review of hospice’s TULIP account revealed hospice’s patients census was 12 as of 07/28/2025.Review of the Hospice’s IQIES account on 05/12/2026 revealed hospice’s address was same as shown in hospice’s TULIP account and the hospice CCN was the same also.Review of the CMS Care Compare website on 05/12/2026 revealed that hospice A had average daily census of 3 patients and the hospice provided core hospice services to patients in their residents. Observation: On 05/13/2026 at 12:06p.m. Surveyor arrived at hospice A’s (address A) and found hospice’s door locked with a notice posted by the side of the door that stated that hospice A had relocated to a new location (Address B) under a new Name (Hospice B). Surveyor went to the location (Address B) and found a notice on the door with the name “Hospice B”. During interview with the Administrator of Hospice B at Address B on 05/13/2026 at 2:43pm, the Administrator confirmed that they recently changed hospice’s name from Hospice A to Hospice B. Surveyor asked when the change was made and the reason for the change. The Administrator stated that hospice B was recently purchased from the previous owner, but she did not know the full details of the sale, but hospice B’s Chief Financial Officer (CFO) would know the full details of the transaction. During interview with hospice B’s CFO on 05/13/2026 at 2:50pm, the CFO confirmed hospice’s former name as Hospice A, but they changed the hospice’s name to hospice B and relocated Hospice B after the purchase from the previous owner in February 2026. The CFO also informed Surveyor that the previous owner (who is also the Administrator of Hospice A) owned other agencies that he still retained ownership of. Surveyor requested the CFO of Hospice B to call the previous owner of Hospice B for interview. The CFO stated that she had texted him 05/13/2026 at 2:45pm but he did not respond. Surveyor then requested Hospice B’ CFO to call the previous owner of hospice B and not send a text. Hospice B’s CFO then called the previous owner of hospice B on 05/13/2026 at 2:58pm, there was no response, left a voicemail requesting a call back. The previous owner/Administrator did not call back while the Surveyor was present. Observation: On 05/14/2026 at 9:48am the Surveyor went back to Hospice A’s location listed in IQIES/TULIP to search for Hospice A. Surveyor walked through the hospice’s designated suite number listed in TULIP but could not find hospice A at the location (Address A) listed in TULIP. Interview: Surveyor called the hospice A’s phone number listed in Tulip (Telephone 1) on 05/14/2026 at 10:11am and 11:24am and 12: 13pm to notify Hospice A’s Administrator and Alternate Administrator of her arrival at the hospice’s location, but was unable to leave voice messages as the phone notification stated the recipient mailbox was full and could not accept any messages, but if the Surveyor wanted to send a call back phone number to the recipient(Hospice Administrator/Alternate Administrator) by pressing the # sign and the Surveyor’s phone number would be automatically sent. So, Surveyor did as she was prompted three different times but did not receive any call back from the administrator. Neither Hospice’s Administrator nor the Alternate Administrator called the Surveyor back by the end of the business day.Surveyor waited at the hospice A’s location for two hours as required and left the location at 12:23pm unable to conduct a survey to ascertain whether hospice governing body/Administrator assumes full legal authority and responsibility for the management of the hospice agency to ensure the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement in accordance with acceptable standards to hospice patients as required by regulations.Surveyor sent the hospice A’s Administrator and Alternate Administrator via email the letter of inability to conduct a federal survey on 05/19/2026 at 5:29pm.”