Star of Texas Hospice and Palliative Care LLC

“It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include the generic, trade, or brand name of the medication, as well as the amount dispensed, and directions for use, including route, rate, frequency, and method of administration. This standard was not met as evidenced by clinical record review and interview. In 3 of 8 (38%) clinical records reviewed revealed that the agency did not ensure that medication orders contained medication name, dose, and frequency Clinical Record 1: Plan of care dated 12/18/2023 - 3/26/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. Clinical Record 2: Plan of care dated 12/30/2023- 3/28/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. Clinical Record 3: Plan of care dated 12/30/2023- 3/28/2024 included an order for Laxative/Enema of choice PRN. There is no drug name, route, dose, or frequency ordered. In an interview on 1/19/2024, the administrator confirmed that the plan of care included the language laxative of choice and enema of choice but argued that it should not be a finding because it was like a standing order from the physician.”

“It is required that each patient’s individualized written plan of care reflects patient and family goals. Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Includes all services necessary for the palliation and management of the terminal illness, including the following: Intervention to manage pain and symptoms; measurable outcomes anticipated from implementing and coordinating the plan of care; Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 3 (67%) clinical and home records reviewed revealed that the agency did not ensure that the patient representatives had a copy and clear understanding of the patient’s plan of care. Home Visit 2: During the home visit noted that the patient notebook contained a form “Hospice Initial Plan of Care/Physician Order.” This form was a printed form that had Laxative of Choice checked and Foley Catheter PRN checked and was not consistent with the plan of care in the clinical record. The patient folder did not contain a plan of care that identified individualized patient goals. The plan of care in the clinical record dated 12/30/23 - 3/28/24 included interventions for fall risk, pain, and diabetes which were not included in the plan of care in the patient’s home. The clinical record contained no evidence that the plan of care reflected the patient or family goals and the plan of care in the clinical record was not in the patient home. Home Visit 3: During the home visit noted that the patient notebook contained a form “Hospice Initial Plan of Care/Physician Order.” This form was a printed form that had Laxative of Choice checked and Foley Catheter PRN checked and was not consistent with the plan of care in the clinical record. The patient folder did not contain a plan of care that identified individualized patient goals. Plan of care dated 12/30/23 -3/28/2024 included individualized interventions to address weakness, potential pain, and nutrition. The care plan in the home did not include these individualized interventions. Clinical supervisor present during the home visit on 1/18/2024 and confirmed that the patient care plans in the home were not consistent with physician-ordered care plans and were not written appropriately with patient’s individualized goals. An interview with the Administrator and Director of Clinical Services was conducted on 1/18/2024. The Director of Nursing stated she didn’t know how that form could have gotten into the patient chart.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that the plan of care was specific to the patient’s needs and notified the aide of important precautions. Clinical Record 1: SN assessment dated 12/28/2023 revealed that the patient can only eat semi-solid foods and has difficulty swallowing foods. The HHA plan of care created by the RN on 12/28/2023 did not address the patient’s diet feeding or swallowing precautions. In an interview on 1/18/2023, the administrator confirmed that the patient’s diet and feeding precautions were not addressed in the HHA plan of care.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group. This standard was not met as evidenced by clinical record review and interview. In 3 of 7 (43%) clinical records reviewed with a hospice aide revealed that the agency did not ensure that the aide followed the care plan as ordered. Clinical Record 1: The start of care was Thursday 12/28/2023. Agency visit week Sunday through Saturday. HHA Care Plan form dated 12/28/2023 included an aide frequency that stated, 1 wk 1, 2 wk 2, and then 3 x week. However, the physician order dated 12/28/23 and updated 12/29/2023 contained orders for HHA 3/week. Aide visits were completed on 12/29/2023 as the only visit for the week of 12/28/23 -12/30/23. Week of December 31, 2023 - 1/6/2024 the HHA completed visits on 1/2/24 and 1/4/24 but not three times as the physician ordered. There were no missed visit notes or communication to the physician related to the reduced number of HHA visits in the clinical record. Clinical Record 4: AIde care plan dated 12/28/2023 read Aide frequency 3 x weekly. Plan of care dated 12/28/2023 read Hospice Aide 3/wk. No HHA visits and no missed visits documented for aide 12/28/2023 -12/30/2023. Agency visit week Sunday through Saturday. Clinical Record 6: Plan of care dated 10/20/2022 - 1/17/2023 and signed by the physician on 4/18/2023 contains an order for aide 3 x week. The week starting 10/20/2022 and ending on 10/22/2022, the patient was seen by the aide one time on 10/21/2022. There are no missed visit notes or evidence of communication with the physician to explain missed visits. The Director of Nursing and Administrator stated in an interview on 1/18/2024, “Can’t we have leniency since it is obviously just how we put it in the computer.””

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 3 of 3 (100%) revocation clinical records reviewed revealed that the agency did not ensure that a discharge summary was provided to the attending physician. Clinical Record 6: The clinical record contains a discharge note on 10/6/2023 indicating that the caregiver requested revocation to seek treatment at a hospital. The record does not include evidence that a discharge summary was sent to the physician. There is no evidence that the agency attempted to identify a community physician. Clinical Record 7: The clinical record contains a discharge note on 10/6/2023 indicating that the caregiver requested revocation to seek treatment at a hospital. The record does not include evidence that a discharge summary was completed or was sent to the physician. Clinical Record 8: Clinical record contains a discharge note revealing that patient requested revocation on 10/13/2023 to explore alternate hospices. There is no evidence in the clinical record that a discharge summary was completed and provided to the physician. In an interview with the Administrator and Director of Nursing on 1/18/2024, the administrator confirmed by looking in the EMR system that there were no discharge summaries sent to the attending physicians after patient revocations. The director of Nursing argued that the discharge notes reveal that the patients were given copies of their charts therefore this should not be a finding.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the latest physician orders and any other information that will assist in post-discharge continuity of care. This standard was not met as evidenced by clinical record review. In 3 of 3 (100%) revocation records reviewed revealed that the agency did not complete a discharge summary that included a summary of the patient stay and the plan of care. Clinical Record 6: The patient revocated services on 10/6/2023. The clinical record contains a note explaining that the agency received a call that the patient would be moving out of town. The note reads that the patient chart and med list were given to the patient. There is no discharge summary written and no documentation that a physician was provided with a discharge summary. Clinical Record 7: The patient revocated hospice services on 10/6/2023. The clinical record did not contain a discharge summary explaining the summary of care and there was no indication that a discharge summary was provided to a physician or alternate care provider. Clinical Record 8: The patient revocated on 10/13/2023. The clinical record did not contain a discharge summary explaining the summary of care and there was no indication that a discharge summary was provided to a physician or alternate care provider. In an interview on 1/17/2023, the administrator stated “Don’t these discharge notes count?” Administrator acknowledged that the discharge not in the clinical did not include all of the required components.”