Hospice Home Care LLC

“Based on clinical record review and personnel interview, it was determined the Agency failed to complete a Psychosocial Assessment as part of the Initial Comprehensive Assessment within 5 days after the election of Hospice services in 1 (#6) of 27 (#1 - #27) clinical records reviewed. This failed practice had the potential to affect all admissions to the Agency in that, there could be a delay in identification of psychosocial needs and could place patient and/or family at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. Review of clinical record #6 with a SOC (start of care) of 07/31/24 revealed a patient with a diagnosis of Hypertensive Chronic Kidney Disease (CKD), stage 5- End Stage Renal Disease (ESRD). A document titled “Visit Note Report” dated 08/06/24 revealed the initial visit from the Medical Social Worker (MSW) was completed on day 6 (1 day past the 5-day requirement). On 08/09/24, the Regional Clinical/Executive Director was asked to provide any additional documentation regarding the late visit and no further information was provided.”

“Based on record review and interview, the Agency failed to ensure oxygen was on the medication profile 3 (#1, #7, and #26, ) of 17 (#1-#4, #7- #10, #12, #14, #16, #17, #19, #21, #22, #25, and #26) and it was checked for actual or potential drug interactions of 8 (#1-#4, #7, #8, #19, #26, ) of 17 (#1- #4, #7-#10, #12, #14, #16, #17, #19, #21, #22, #25, and #26) patients that utilize oxygen. This failed practice had the potential to affect all patients on the current census who have orders for oxygen as there may be a drug interaction not identified in a timely manner. The findings follow: Review of clinical record # 1 with a start of care date of 07/11/24 revealed a patient with a diagnosis of Alzheimer’s disease. A document titled, “Hospice Certification and Plan of Care” with a certification period of 07//24 to 10/08/24 contained orders, “...O2 [oxygen] 2-4L [Liters] PRN [as needed] SOB [shortness of breath], HYPOXIA ...” A physician narrative signed and dated 07/24/24 documented, “...oxygen dependent at 2.5L via nasal canula...” Oxygen is not on the list of medications on the Hospice Certification and Plan of Care nor on the 07/24/24 Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Report. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #2 with a start of care date of 06/28/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) with exacerbation. A document titled, “Hospice Certification and Plan of Care” with a certification period of 06/28/24 to 09/25/24 contained orders, “...O2 2-4L PRN SOB, HYPOXIA. Medications...Oxygen 3 Liters continuous...” A physician’s narrative signed and dated 07/10/24 documented, “...requiring 3.5L via nasal cannula continuously...” There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #3 with a start of care date of with a start of care date of 06/22/24 revealed a patient with a diagnosis of Hypertensive Heart Disease. A document titled, “Hospice Certification and Plan of Care” with a certification period of 06/22/24 to 09/19/24 contained orders,”...O2 2-4L PRN SOB, HYPOXIA... Medications...Oxygen 1-5 liter daily shortness of breath via NC or MASK...” A physician’s narrative signed and dated 06/26/24 documented, “... Now requiring supplemental oxygen at 3 LPM [Liters per minute] ...” Registered Nurse (RN) Client Coordination Note Reports dated 07/17/24, 07/27/24, 08/01/24, and 08/07/24 documented the use of O2 2.5 Liters. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #4 with a start of care date of 06/19/24 revealed a patient with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. A document titled, “Hospice Certification and Plan of Care” with a certification period of 06/19/24 to 09/16/24 contained orders, “...Ox-Oxygen 1-4 Liters PRN dyspnea via NC or mask...” A physician’s narrative signed and dated 07/02/24 documented, “...She utilizes supplemental oxygen prn at 2 Liters...” There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #7 with a start of care date of 07/19/24 revealed a patient with a diagnosis of Monoplegia of upper limb following Cerebral Infarction. A document titled, “Hospice Certification Plan of Care” with a certification period of 07/19/24 to 09/16/24 contained orders, “...O2 2-4L PRN SOB, HYPOXIA...” Review of a document titled “Vital SIGNS Report” revealed patient on Oxygen 4L (7/24/24), 5L (08/01/24), and 8L (08/07/24). The Medication section of the Hospice Certification Plan of Care, nor the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 08/02/24 included the medication Oxygen. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #8 with a start of care date of 06/28/24 revealed a patient with a diagnosis of Malignant Neoplasm of Unspecified partial Right Bronchus or Lung. A document titled, “Hospice Certification and Plan of Care” with a certification period of 06/28/24 to 09/25/24 contained orders, “...O2 2-4L PRN SOB, HYPOXIA...” The Vital Signs section of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 07/31/24 documented patient using oxygen 3L on 06/28/24, 07/30/24, and 07/31/24; and using 2.5L on 07/18/24 and 07/23/24. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. Review of clinical record #19 with a start of care date of 11/13/22 revealed a patient with a diagnosis of Hypertensive Heart and Chronic Kidney Disease without Heart Failure. The documents titled, “Client Medication Report” and “Hospice IDG Comprehensive Assessment and Plan of Care Update Report” noted “...Medication List...Oxygen 3 Liter dyspnea apply via NC PRN...” On 08/07/24 at 11:30 a.m., the resident was observed lying in bed with oxygen set at 5L BNC (by nasal cannula). Review of clinical record #26 with a start of care of 05/23/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A document titled, “HOSPICE CERTIFICATION AND PLAN OF CARE” with a certification period of 05/23/24 to 08/20/24 contained orders, “...O2 (oxygen) 2-4L (liters) PRN (as needed) SOB (Shortness of breath), HYPOXIA, MAY HAVE O2 CONCENTRATOR”. Review of a document titled “Vital SIGNS Report” revealed patient “ON OXYGEN 2L” on visits 05/23/24, 05/24/24, 05/28/24, 05/30/24, and 06/05/24. Review of a form titled; “Client Medication Report” failed to include the medication Oxygen. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. An interview on 08/09/24 at 11:00 a.m. with the Agency Personnel #1 confirmed that Oxygen was not included on the medication profile and not checked for actual or potential drug interactions for #26. Agency Personnel #1 was unaware the computer program did not include oxygen in its medication interactions review.”

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure the plans of care were specific and individualized relative to social work for 4 (#1, #2, #6, and #27) and spiritual needs for 9 (#1, #2, #6, #8, #18- #20, #24, and #27) of 27 (#1 -#27) clinical records reviewed. This failed practice could result in potential harm for all patients on the census that chose to participate with social work and chaplain services in that they would not have specific needs addressed while under their care. Findings follow: Review of clinical records #1, #2, #6, and #27 revealed the identical care plan was written for each of the patients and was not patient specific. Each were written as below: Hospice Plan of Care, “...Hospice Medical Social Work [MSW]... MSW-Hospice I: [Intervention] Encourage patient/Family for readiness to discuss end of life issues, fears and concerns related to the dying process I[Intervention] Instruct Patient/ Family for signs/ symptoms of depression. Communicate to physician change in depression status I: [Intervention] Instruct Patient/Family signs/symptoms of stress and how to manage stress appropriately I: [Intervention] Instruct Patient/Family on support and acceptance techniques I: [Intervention] Initiate referral to mental health professional if mental illness identified G: [Goal] Patient/ Caregiver(s) has decreased fear/anxiety regarding death and dying process G: [Goal] Patient’s stress/anxiety is reduced to level of comfort...” Review of clinical records #1, #2, #6, #8, #18-#20, #24, and #27 revealed the identical care plan was written for each of the patients and was not patient specific. Each were written as below: Hospice Plan of Care Report for (# Hospice Plan of Care, “.... Hospice Chaplain...” Coping... I: [Intervention] Encourage patient/family for readiness to discuss end of life issues, fears and concerns related to the dying process I: [Intervention] Encourage patient/family for readiness to discuss end of life issues, fears and concerns related to the dying process ...G: [Goal] Patient/Caregiver(s) has decreased fear/anxiety regarding death and dying process...””

“Based on clinical record review and personnel interview, it was determined the Agency failed to ensure the plan of care for aide services was complete and accurate for 2 (#3 and #20) of 21 (#1-5, 8-10, 12-15, 17, 19-23, 25-27) clinical records reviewed who had aide services scheduled. The failed practice had the potential to affect all patients on census that have aide services scheduled in that the aide would not have specific instructions on what services to provide for the patient. Findings follow: 1. Review of clinical record #3 with a start of care date of 06/22/24 revealed a patient with a diagnosis of Hypertensive Heart Disease. The Hospice Certification and Plan of Care with a certification period of 06/22/24 to 09/19/24 noted Hospice Aide visits 2 times a week for 13 weeks. Additionally, this document revealed, “...Functional Limitations: Bowel/Bladder (Incontinence); Endurance; Dyspnea with Minimal Exertion...” A physician’s narrative signed and dated 06/26/24 documented, “... Incontinent of bowel and bladder, and bedbound. Max [Maximum] assist [assistance] with all ADL’s [Activities of Daily Living] ...” a. A document titled, “Aide Care Plan Report” revealed, “...Effective Date of Current Aide Care Plan: 06/22/24... ADL SERVICES Bathing (Bed/Bath) ...Every Visit...” b. There were no further instructions in the Aide Care Plan to address the other Activities of Daily Living (ADL’s). 2. Review of clinical record #20 with a start of care date of 02/14/24 revealed a patient with a diagnosis of Senile degeneration of the Brain. The Hospice Certification and Plan of Care with a certification period of 02/14/24 - 05/13/24 notes Hospice Aide visits 1 week the first week, then 2 times a week for 12 weeks. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 07/31/24 documented Hospice Aide visits effective 08/12/24 2 times a week for 8 weeks then 1 time a week for 1 week. Additionally, the IDG and Plan of Care Update Report dated 07/31/24 documented, “...Hospice Physician...Details... He requires assistance with bathing, dressing, continence, toileting and transfers...” a. The Aide Care Plan Report with a care episode period of 05/14/24 to 08/11/24 documented, “...Stand-by assistance with ambulation, Bathing (tub bath/shower), dressing...” b. There were no instructions in the Aide Care Plan for incontinence, nail care or shaving. 3. On 08/09/24 the Regional Clinical Director was asked to provide any further information regarding the missing details on the aide care plans and none was provided.”

“Based on clinical record review and personnel interview, it was determined the Agency did not ensure all orders were complete and accurate for 1 of 1 (#3) record reviewed who had pressure ulcers. This failed practice could result in potential harm for all patients on census in that the agency did not obtain individual and specific orders to address the patient’s specific needs. Findings follow: Review of clinical record #3 revealed a patient with a SOC dated 06/22/24 and a diagnosis of Hypertensive Heart Disease. Client Coordination Note Reports dated 07/17/24, 07/27/24, and 08/02/24 documented, “Facility treatment nurse [Name] reports pt [patient] has a friction/shear/moisture wound on buttocks measuring 4cm x 0.25cm, covered with duoderm and collagen, SNF [Skilled Nursing Facility] change dressing Q [every] 3 days...” The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 07/24/24 documented, “.... Registered Nurse...Facility treatment nurse [Name] reports pt [patient] has a friction/shear/moisture wound on buttocks measuring 4cm x 0.25cm, covered with duoderm and collagen, SNF [Skilled Nursing Facility] change dressing Q [every] 3 days...” There was no order noted for wound treatment and there were no wound assessment records in the chart. On 08/09/24 the Regional Clinical Director was asked to provide a physician’s order for wound treatment and wound assessments. The Regional Clinical Director confirmed these were not in the clinical record.”

“Based on clinical record review and personnel interview, it was determined that the plan of care was not specific and individualized for 3 (#1, #2, #8 ) of 17 (#1- #4, #7-#10, #12, #14, #16, #17, #19, #21, #22, #25, and #26) clinical records reviewed who had oxygen in use, for 1 of 1 (#1) clinical records reviewed who had an order for enteral feeding, and 1 of 1 (#8) clinical records reviewed who had an order for a PleurX drainage tube. This failed practice could result in potential harm for all patients on census in that the agency did not have an individualized care plan to address the patient’s specific needs. Findings follow: A. Oxygen Use: 1. Review of Clinical Record #1 with a SOC date of 07/11/24 revealed a patient with a diagnosis of Alzheimer’s disease. A Client Coordination Note Report dated 07/11/24 documented, “...She is on O2 [oxygen] @ 2.5L [liters]...” The Hospice POC (Plan of Care) Report did not include a care plan for oxygen use. Oxygen was not listed on the medication list as part of the Hospice Certification and Plan of Care dated 07/11/24 - 10/08/24. 2. Review of Clinical Record #2 with a SOC date of 06/28/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. The Hospice Certification and Plan of Care dated 06/28/24 - 09/25/24 documented oxygen 3L continuous in the medication list. The physician’s narrative dated 07/10/24 documented, “...Over the past month she has gone from wearing oxygen just at night to now requiring 3.5L via nasal cannula continuously...She is an active smoker and continues to smoke 1/2 pack a day...” a. The Hospice POC Report documented, “...Need for O/A [Observation/Assessment] of respiratory status I: [Intervention] Assess respiratory status. G: [Goal] Patient’s respiratory status is stabilized to comfort within realms of disease...” b. The Hospice POC Report did not include a care plan regarding the home safety with the use of oxygen and also continuing to smoke cigarettes 1/2 pack a day. 3. Review of Clinical Record #8 with a SOC date of 06/28/24 revealed a patient with a diagnosis of Malignant Neoplasm of right bronchus or Lung. A Visit Note Report dated 06/28/24 documented, “Pt on 2–3 liters O2...” The Hospice POC Report documented, “...Need for O/A of Respiratory Status I: [Intervention] Assess Respiratory Status. G: [Goal] Patient’s respiratory status is stabilized to comfort within realms of disease... “ The Plan of Care did not include the specifics of oxygen use, including home safety related to the use of oxygen. B. Enteral Feeding: Review of Clinical Record #1 with a SOC date of 07/11/24 revealed a patient with a diagnosis of Alzheimer’s disease. A Client Coordination Note Report dated 07/11/24 documented, “... Admission Summary...Entered by... Registered Nurse... Peg [Percutaneous Endoscopic Gastrostomy) tube in which she receives continuous TF [tube feeding] of Nutren @55ml [milliliter]/ hr [hour]...” The Hospice Certification and Plan of Care with a certification period of 07/11/24 - 10/08/24 did not include the tube feeding and documented, “.... Nutritional Requirements... NPO [Nothing by mouth] ...” The Hospice POC (Plan of Care) Report included a nutrition care plan in reference to a patient that takes in food by mouth rather than NPO (Nothing by mouth) and the enteral feeding as ordered. Additionally, the Hospice POC report documented a care plan for a colostomy rather than a gastrostomy tube for feeding. Patient #1 did not have a colostomy. C. PleurX drainage tube: Review of Clinical Record #8 with a SOC date of 06/28/24 revealed a patient with a diagnosis of Malignant Neoplasm of right bronchus or Lung. A Visit Note Report dated 06/28/24 documented, “...Pt has plural [PleurX] drain on upper right side of ribs, which requires to be drained every 3 days, Significant Other provides this for pt...” The Hospice POC Report documented, “...Need for O/A of Respiratory Status I: [Intervention] Assess Respiratory Status. G: [Goal] Patient’s respiratory status is stabilized to comfort within realms of disease... “ There were no details regarding the care of and tasks for the PleurX drain including prevention of infection, dressing change, emptying the drain, when to contact the physician. D. On 08/09/24 the Regional Clinical Director was asked to provide any further information, and none was provided.”

“Based on observation, clinical record review and personnel and facility staff interview, it was determined the Agency failed to ensure a Skilled Nursing Facility (SNF) physician’s change of medication order was approved by the hospice agency prior to the change for 1 of 1 (#20) SNF patients as observed during a home visit review. This failed practice had the potential to affect all patients on census that reside in a skilled nursing facility. Findings follow: Review of clinical record #20 with a SOC date of 02/14/24 revealed a patient with a diagnosis of Senile Degeneration of the Brain. On 08/07/24 at 10:45 a.m., during a medication list reconciliation with the SNF nurse and the hospice nurse, it was determined there were two medications on the hospice current medication list (Atorvastatin and Lisinopril) that were discontinued on 04/29/24 by the SNF physician. The notation in the SNF medical record noted the hospice agency case manager was called but there was no answer. On 08/09/24 the Regional Clinical Director was informed of the findings and there was no additional information provided.”

“Based on observation, clinical record review and personnel interviews, it was determined the Agency failed to demonstrate coordination of care and services for 2 of 2 (#19 and #20) patients who were visited at a long-term care facility. The failed practice had the potential to affect all patients on census that reside in a long-term care facility in that medications and other care and services may be inaccurate and subsequently, the physician’s prescribed medical regimen not followed. Findings follow: Review of clinical record #19 with a start of care date of 11/13/22 revealed a patient with a diagnosis of Hypertensive Heart Disease and Chronic Kidney Disease (CKD) without Heart Failure. On 08/07/24 at 11:30 a.m., the patient was visited and the facility records reviewed. The facility nurse was not able to locate the current/ updated Hospice plan of care. The medication list reconciled against the facility’s medication list did not match. There were 11 medications on the Agency’s “Client Medication Report” for patient #19 that were not on the facility medication list. There was one (1) medication on the facility medication list for patient #19 that was not on the Agency’s Medication list. The Agency’s hospice nurse asked the facility nurse about the patient’s order for Potassium. The facility nurse stated, “she hasn’t been on that for a while.” Review of clinical record #20 with a start of care date of 02/14/24 revealed a patient with a diagnosis of Senile Degeneration of the Brain. On 08/07/24 at 10:20 a.m., the patient was visited and the facility records reviewed. The facility nurse was not able to locate the current/updated Hospice plan of care or any progress notes. The entire binder was not located at the facility. The medication list reconciled against the facility’s medication list did not match. There were 5 medications on the Agency’s “Client Medication Report” for patient #20 that were not on the facility medication list. There was one (1) medication on the facility medication list for patient #19 that was not on the Agency’s Medication list. The Agency’s hospice nurse was asked about the Hospice Binder with the updated care plans, admission paperwork, progress notes, etc. She stated, “They should have their binder.” The hospice agency’s nurse asked about Tramadol that was ordered 07/09/24. The facility nurse found the medication in the narcotic lock box, but it was not on the patient’s list of physician’s orders and therefore, not on the patient’s medication list (Medication Administration Record-MAR) at the skilled facility.”

“Based on personnel record review and staff interview it was determined the agency failed to submit criminal history check applications to the Arkansas State Police as required by the laws of the State of Arkansas in Act 762 of 2009, Ark. Code Ann. § 20-38-101 et seq. and did not receive Arkansas Department of Health letters of determination in 6 (#2, #3, #5, #6, #7, and #8) out of 10 (#1-#10) unlicensed professional records reviewed. This failed practice could pose a risk to the safety and well-being of all patients on census and jeopardize the trust and security of all patients in their final moments. Findings follow: Rules and Regulations for Conducting Criminal History Records Checks for Home Health, Hospice and Private Care Agencies in Arkansas require that each hospice applicant or employee must complete a state criminal history check upon hire and no less than time every five years unless the applicant or employee is licensed as a professional as outlined in A.C.A. §17-27-101. Completed applications for criminal history records are to be submitted by the agency to the Arkansas State Police. Upon receiving the results of the state criminal history records check and the national criminal history records check, Health Facility Services will issue a letter of determination whether the employee of a service provider is or is not disqualified for employment. Review of Agency personnel records #2, #3, #5, #6, #7, and #8 did not contain Arkansas State Police criminal background checks or Arkansas Department of Health (ADH) letters of determination An interview on 08/09/24 at 11:00 AM with Agency Personnel #1 confirmed personnel records listed above did not contain Arkansas State Police criminal background checks or ADH letters of determination.”