Arkansas Hospice, Inc.

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for one (#6) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: A review of clinical record #6, with a start of care date of 04/03/25, revealed a patient diagnosed with Amyotrophic Lateral Sclerosis. On a form titled “Visit Note Report” and dated 04/07/25 the Skilled Nurse documented the patient was currently utilizing oxygen. Review of a form titled “Vital Signs Report” revealed the patient “ON OXYGEN” 23 out of 25 visits dated 04/03/25-06/24/25. Review of a form titled “Client Medication Report” did not reflect oxygen as part of the patient’s active medications. There was no documentation in the chart to indicate that oxygen had been checked for actual or potential drug interactions.During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions. Specifically, oxygen was not listed on the medication profile and had not been assessed for drug interactions.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to include critical Foley catheter management details in the individualized plan of care for one (#19) of five (#1, #10, #11, #16, and #19) clinical records reviewed with catheter orders. Specifically, the plan did not specify the appropriate catheter size nor the replacement frequency. This failure had the potential to impact all patients currently on census with catheter orders and increased the risk of preventable harm (e.g., trauma, infection). Findings follow: A review of clinical record #19, with a start of care date of 09/05/24, revealed a patient diagnosed with Malignant Neoplasm of Gallbladder. Review of a form titled “Visit Note Report” and dated 09/10/24 the Skilled Nurse documented “16 FR (French) FOLEY CATH (catheter) INSERTED”. On a document titled “IDG SUMMARY REPORT” and dated 09/12/24 changes to the plan of care since admission include “FOLEY”. Foley catheter orders did not include catheter size, balloon volume, frequency for catheter changes, or clear parameters regarding catheter maintenance. During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1 and #2 confirmed the plan of care did not include specific and individualized foley catheter orders.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure that the Interdisciplinary Group (IDG) updated and coordinated individualized plans of care in response to changes in the condition or needs of the patient in fifteen (#1 - #11, #14, and #17 - #19) of nineteen (#1 - #19) clinical records reviewed. This failure of the IDG to comprehensively assess, coordinate, and revise the plan of care in a timely manner placed all patients currently on census of unmet clinical, emotional, and comfort care needs. Findings follow: A review of clinical record #1, with a start of care (SOC) date of 04/28/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. Review of the Interdisciplinary Group (IDG) Summary dated 05/08/25 revealed the Registered Nurse (RN) left blank the “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION” and the Social Worker left blank “PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT.”A review of clinical record #2, with a SOC date of 05/29/25, revealed a patient diagnosed with Senile Degeneration of Brain. Review of the IDG Summary dated 06/05/25 revealed the RN left blank the “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION”A review of clinical record #3, with a SOC date of 06/02/05, revealed a patient diagnosed with Chronic Obstructive Pulmonary Disease. Despite physician orders dated 06/18/25 for new medications (Aspirin and Cetrizine), review of the IDG Summary dated 06/19/25 revealed the RN documented “CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE.”A review of clinical record #4, with a SOC date of 06/02/25, revealed a patient diagnosed with Congestive Heart Failure. Despite documented unmanaged pain and physician orders for Lyrica on 06/03/25 review of the IDG Summary dated 06/05/25 revealed the RN left blank the “PROBLEMS IDENTIFIED AT ADMISSION” and documented “CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE.”A review of clinical record #5, with a SOC of 05/29/25, revealed a patient diagnosed with Malignant Neoplasm of Stomach. Review of the IDG Summary dated 06/05/25 revealed the RN left blank “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION.”A review of clinical record #6, with a SOC date of 04/03/25, revealed a patient diagnosed with Amyotrophic Lateral Sclerosis. Review of the IDG Summary dated 04/10/25 revealed the RN left blank “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION” and the Social Worker left blank “PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT.”A review of clinical record #7, with a SOC of 06/12/25, revealed a patient diagnosed with Cirrhosis of Liver. Documentation of paracentesis (a medical procedure where a needle or catheter is inserted into the abdominal cavity to drain excess fluid) performed 06/17/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented “PROBLEMS IDENTIFIED AT ADMISSION: NONE” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NO CHANGES TO POC.”A review of clinical record #8, with a SOC of 06/04/25, revealed a patient diagnosed with Malignant Neoplasm Unspecified. Review of the IDG Summary dated 06/05/25 revealed the RN left blank “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION” A review of clinical record #9, with a SOC of 04/08/25, revealed a patient diagnosed with Unspecified Protein-Calorie Malnutrition. Documentation of orders dated 04/09/25 for pain management and wound care. Review of the IDG Summary dated 04/10/25 revealed the RN documented “CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NO CHANGES.”A review of clinical record #10, with a SOC of 06/12/25, revealed a patient diagnosed with Senile Degeneration of Brain. Documentation of a fall and multiple skin tears with new wound orders dated 06/13/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented “PROBLEMS IDENTIFIED AT ADMISSION: NONE” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION: NONE.”A review of clinical record #11, with a start of care date of 04/14/25, revealed a patient diagnosed with Nonalcoholic Steatohepatitis (NASH). Review of the IDG Summary dated 04/10/25 revealed the RN left blank the “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION” and the Social Worker left blank “PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT.”A review of clinical record #14, with a SOC of 07/02/24, revealed a patient diagnosed with Heart Failure. Documentation of new orders for wound care dated 06/13/25. Review of the IDG Summary dated 06/19/25 revealed the RN documented “CHANGES TO PLAN OF CARE SINCE LAST IDG: NO CHANGES.”A review of clinical record #17, with a SOC date of 06/14/24, revealed a patient diagnosed with Alzheimer’s Disease. Review of the IDG Summary dated 06/20/24 revealed the RN left blank the “PROBLEMS IDENTIFIED AT ADMISSION” and “CHANGES TO THE PLAN OF CARE SINCE ADMISSION.”A review of clinical record #18, with a SOC date of 11/18/24, revealed a patient diagnosed with Malignant Neoplasm of Brain. Review of the IDG Summary dated 11/21/24 revealed the RN documented “PROBLEMS IDENTIFIED AT ADMISSION: NONE” and the Social Worker left blank “PSYCHOSOCIAL PROBLEMS IDENTIFIED AT EVALUATION VISIT.”A review of clinical record #19, with a SOC date of 09/05/24, revealed a patient diagnosed with Malignant Neoplasm of Gallbladder. Review of IDG Summary dated revealed the RN documented “PROBLEMS IDENTIFIED AT ADMISSION: NONE.” All IDG meeting minutes included a directive to “SEE IDG NOTE ADDENDUM FOR ANY CHANGES IDENTIFIED DURING REVIEW.” None of the nineteen records reviewed contained and IDG note addendum, indicating a systemic failure to document required care planning updates. During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1 and #2 confirmed the agency failed to document updates to the plan of care in response to new or ongoing clinical needs.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in two (#8 and #11) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: A review of clinical record #8, with a start of care date of 06/04/25, revealed a patient diagnosed with Malignant Neoplasm Unspecified. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with certification dates of 06/01/25 to 09/01/25 revealed orders for a Skilled Nurse (SN) visit two times per week and as needed effective 06/08/25. SN visit documented 06/16/25. One missed SN visit week 06/15/25-06/21/25.A review of clinical record #11, with a start of care date of 04/14/25, revealed a patient diagnosed with Nonalcoholic Steatohepatitis (NASH). Review of a document titled “Order Number: 395005” and dated 04/25/25 revealed orders for a SN visit three times a week. SN visits documented 05/05/25 and 05/09/25. One missed SN visit week 05/04/25-05/10/25.During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed the SN missed visits.”

“Based on a review of clinical records and staff interviews, it was determined that the agency failed to supervise and assess the quality of care and services through on-site Supervisory Aide Visits (SAV) every 14 days in two (#1 and #9) of fifteen (#1, #3, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, and #18) clinical records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: A review of clinical record #1, with a start of care date of 04/28/25, revealed a patient diagnosed with Malignant Neoplasm of Prostate. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 04/28/2025 to 07/26/2025 revealed orders for a HA. Supervisory aide visits conducted 05/12/25 and 05/27/25 (One day past the required14-day time frame).A review of clinical record #9, with a start of care date of 04/08/25, revealed a patient diagnosed with Unspecified Protein-Calorie Malnutrition. Review of a document titled “HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 04/08/2025 to 07/06/2025 revealed orders for a HA. Supervisory aide visits conducted 05/13/25 and 05/28/25 (One day past the required14-day time frame).During an interview on 06/27/25 at 2:00 PM, Agency Personnel #1and #2 confirmed the Registered Nurse failed to conduct Supervisory Aide Visits every fourteen days as required.”