Henderson County Health Department Hospice

“Based on document review and interview, the Hospice failed to ensure medical record content requirements were met for 14 of 14 patients, by having incomplete or missing clinical notes, and untimely entry of clinical notes per policy and accepted standards of practice. Findings include: Throughout the survey, 100 Clinical Notes were reviewed, with 97 Clinical Notes not being completed on the same day as the patient visit, as required by policy. 12 Initial Comprehensive Assessment visits were completed, with documentation for 11 assessments not being completed within 48 hours of the patient visit, as required by policy. 5 Hospice Update and Follow-up visits were completed, with none of the documentation being completed within 48 hours of the patient visits, as required by policy. One RN Supervisory Visit was completed, with entry to the Electronic Health Record (EHR) occurring greater than 90 days after the completion of the supervisory visit.The EHR for Pt #2 was reviewed beginning on 7/28/26. The Clinical Notes for 9/22/25, 9/26/25, 9/29/25, 10/2/25, 10/3/25, and 10/5/25 were initiated in the EHR, and signed as completed, but had incomplete assessment information entered. Additional documentation was requested from the Director of Nursing (E #1), who presented paper notes titled “Skilled Nursing Visit Report” dated “9-22,” “9-2-25,” “9-29-25,” “10-2,” A sticky note was present on the 9/22 paper note that stated “Unable to locate 10-2 and 10-5 notes.” It was noted on 7/29/26, that complete Clinical Notes for 10/2/25, and 10/5/25 were now present and complete in the EHR. The EHR for Pt #5 was reviewed beginning on 7/28/26. The Clinical Notes for dates 1/15/25, 1/17/25 and 1/23/25 were initiated in the EHR and signed as completed, but had incomplete assessment information entered. A copy of the incomplete EHR Clinical Notes for these dates was requested of E #1 on 7/29/2026, but not provided. It was noted later in the day on 7/29/2026, that the Clinical Notes for 1/15/25, 1/17/25 and 1/23/25 were now completed in the EHR.The EHR for Pt #10 was reviewed beginning on 7/28/26. The Initial Comprehensive Assessment note was initiated in the EHR and signed as complete, but had incomplete assessment information entered. The Clinical Notes for 12/24/24, 12/28/24 and 12/30/24 were initiated in the EHR and signed as complete, but had incomplete assessment information entered. It was noted on 7/30/26, that the Initial Comprehensive Assessment note, and the Clinical Notes for 12/24/24, 12/28/24, and 12/30/24 were now completed in the EHR.The Policy titled “Clinical Documentation” (Date of Implementation: January 1, 2026. Previous version requested but not available) states, “...Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into clinical record within seven days after the care has been provided... “The Policy titled “Initial and Comprehensive Assessment Policy” (Date of Implementation: 1/1/2026. Previous version requested but not available) states, “...The hospice registered nurse must complete an initial assessment within 48 hours after the election of hospice care...(d) Standard: Update of the comprehensive assessment...The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.An interview was conducted with the Office Manager (E #3) on 7/29/26 at approximately 12:45 PM. During discussion, E #3 stated the agency has “had an ongoing issue with (E #1) getting notes entered on time.” E #3 stated E #1 was struggling through a personal tragedy “last year”, that affected her performance, but further stated “but this was happening before that, too...several years.”An interview was conducted with the Director of Nursing (E #1) on 7/29/26 at approximately 3:30 PM. E #1 verified she had been completing the entry of patient visit notes that were being reviewed during the survey, while the survey was underway.An interview was conducted with the Licensed Practical Nurse (E #4) on 7/30/2026 at approximately 2:30 PM. During discussion regarding the timeline expectation for clinical documentation of patient visits to be entered into the EHR, E #4 stated, “As far as I know, it’s never been discussed. When I started, we were on paper. We went electronic about 4 years ago, and as far as I know, it’s never been discussed, or I just don’t remember if it was.”An interview was conducted with the Administrator (E #2) on 7/31/2026 at approximately 10:30 AM. During discussion regarding the timeline expectation for entry completion for Comprehensive Assessments, Hospice Updates, and Clinical Notes, E #2 referred to the policies, and clarified that the policy verbiage of “complete an initial assessment within 48 hours,” and “the assessment update must be accomplished...no less frequently than every 15 days,” includes the completion of documentation in the EHR.”

“Based on document review and interview, the Hospice failed to ensure proper authentication of clinical notes for patient visits for 14 of 14 patients, through entry and editing of visit notes into the electronic medical record, that are outside of policy and accepted standards of practice. Findings include: The EHR for Pt #2 was reviewed beginning on 7/28/26. The Clinical Notes for 9/22/25, 9/26/25, 9/29/26, 10/2/25, 10/3/25, and 10/5/25 were initiated in the EHR, and signed as completed, but had incomplete assessment information entered. Additional documentation was requested from the Director of Nursing (E #1), who presented paper notes titled “Skilled Nursing Visit Report” dated “9-22,” “9-2-25,” “9-29-25,” “10-2,” A sticky note was present on the 9/22 paper note that stated “Unable to locate 10-2 and 10-5 notes.” It was noted on 7/29/26, that complete Clinical Notes for 10/2/25, and 10/5/25 were present in the EHR. An entry history audit was requested for the Clinical Notes dated 10/2/25 and 10/5/25 and completed by the Administrator (E #2). The entry history document noted the Clinical Notes for 10/2/2025 and 10/5/2025 were edited with a large amount of new documentation by the Director of Nursing, (E #1), beginning on 7/28/26 at 3:40 PM for the 10/2/25 note and beginning on 7/29/26 at 6:18 AM for the 10/5/2025. In comparison of the information on the paper document dated “10-2”, and the EHR document for 10/2/25, the information was not consistent.The EHR for Pt #5 was reviewed beginning on 7/28/26. The Clinical Notes for dates 1/15/25, 1/17/25 and 1/23/25 were initiated in the EHR and signed as completed, but had incomplete assessment information entered. A copy of the incomplete EHR Clinical Notes for these dates was requested on 7/29/2026, but not provided. It was noted later in the day on 7/29/2026, that the Clinical Notes for 1/15/25, 1/17/25 and 1/23/25 were now completed in the EHR. An entry history audit was requested for the notes dated 1/15/25, 1/17/25 and 1/23/25, and completed by E #2. The entry history document noted the Clinical Notes for 1/15/25, 1/17/25 and 1/23/25 were edited with a large amount of new documentation by E #1, beginning on 7/28/2026 at 2:20 PM for the 1/15/25 note, beginning on 7/28/26 at 7:31 PM for the 1/17/25 note, and beginning on 7/28/26 at 3:27 PM for the 1/23/25 note.The EHR for Pt #10 was reviewed beginning on 7/28/26. The Initial Comprehensive Assessment note for 12/23/24 was initiated in the EHR and signed as complete, but had incomplete assessment information entered. The Clinical Notes for 12/24/24, 12/28/24 and 12/30/24 were initiated in the EHR and signed as complete, but had incomplete assessment information entered. It was noted on 7/30/26, that the Initial Comprehensive Assessment note, and the Clinical Notes for 12/24/24, 12/28/24, and 12/30/24 were now completed in the EHR. An entry history audit was requested for the notes dated 12/23/24, 12/24/24, 12/28/24, and 12/30/24, and completed by E #2. The entry history document noted the Initial Comprehensive Assessment for 12/23/24 and Clinical Notes for 12/23/24, 12/24/24, 12/28/24, and 12/30/24 were edited with a large amount of new documentation by E #1, beginning on 7/28/2026 at 2:37 PM for the 12/23/24 Initial Comprehensive Assessment note, beginning on 7/28/26 at 10:18 PM for the 12/24/24 Clinical Note,beginning on 7/29/26 at 11:17 AM for the 12/28/24 Clinical Note, and beginning on 7/29/26 at 11:23 AM for the 12/30/24 Clinical Note.The Policy titled “Clinical Documentation” (Date of Implementation: January 1, 2026. Previous version requested but not available) states, “...Documentation of services ordered on the plan of care will be completed the day service is rendered and incorporated into clinical record within seven days after the care has been provided... “The Policy titled “Initial and Comprehensive Assessment Policy” (Date of Implementation: 1/1/2026. Previous version requested but not available) states, “...The hospice registered nurse must complete an initial assessment within 48 hours after the election of hospice care...(d) Standard: Update of the comprehensive assessment...The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.An interview was conducted with the Office Manager (E #3) on 7/29/26 at approximately 12:45 PM. During discussion, E #3 stated the agency has “had an ongoing issue with (E #1) getting notes entered on time.” E #3 stated E #1 was struggling through a personal tragedy “last year”, that affected her performance, but further stated “but this was happening before that, too...several years.”An interview was conducted with the Director of Nursing (E #1) on 7/29/26 at approximately 3:30 PM. E #1 verified she had been completing the entry of patient visit notes that were being reviewed during the survey, while the survey was underway. E #1 noted she found the paper documentation for visits completed with Pt. #2 for 10/2/25 and 10/5/25 after presenting the surveyors with the other paper notes that included the sticky note stating “Unable to locate 10-2 and 10-5 notes.” When the paper documentation of the 10/2/25 and 10/5/25 visit notes was requested during the interview, E #1 stated she shredded the documents, as that is their process to document visit notes in the EHR and then shred the paper documents. When asked why she would shred the visit notes that had specifically been requested during the survey, E #1 stated “I just didn’t think about it. Stupidity, I guess.” When asked why she did not present the paper notes for 10/2/25 and 10/5/25 to the surveyor when she found them later in the day on 7/28/25, E #1 stated “I didn’t know you were still here.” When asked if she checked if the surveyor was still on site, E #1 stated “No.” When asked why she was entering the visit notes during the survey, when the visits had taken place several months ago, E #1 stated, “I was trying to cover myself. I didn’t want you to know I wasn’t very efficient.”An interview was conducted with the Registered Nurse (E #5) on 7/29/2026 at approximately 3:30 PM, E #5 stated they use the paper titled “Skilled Nursing Visit Report” “as a worksheet” and “after some time” after entering the notes in the EHR, they will shred the “Skilled Nursing Visit Report” documents.An interview was conducted with the Licensed Practical Nurse (E #4) on 7/30/2026 at approximately 2:30 PM. During discussion regarding the timeline expectation for clinical documentation of patient visits to be entered into the EHR, E #4 stated, “As far as I know, it’s never been discussed. When I started, we were on paper. We went electronic about 4 years ago, and as far as I know, it’s never been discussed, or I just don’t remember if it was.”An interview was conducted with the Administrator (E #2) on 7/31/2026 at approximately 10:30 AM. During discussion regarding the timeline expectation for entry completion for Comprehensive Assessments, Hospice Updates, and Clinical Notes, E #2 referred to the policies, and clarified that the policy verbiage of “complete an initial assessment within 48 hours,” and “the assessment update must be accomplished...no less frequently than every 15 days,” includes the completion of documentation in the EHR. E #2 went on to state she was unaware of the nursing documentation practice of taking written notes, initiating the notes in the computer, signing them as complete, and entering them at a later time, stating “I don’t understand why they’re doing that when we are giving them laptops and (internet) hotspots to take to the (patient) homes to do their documentation.” During discussion regarding previous versions of policies, E #1 stated E #3 discarded the previous versions of the policies once the new versions were implemented.”

“Based on document review and interview, it was determined that in 4 of 14 patients, the Hospice failed to ensure drug disposal was conducted per policy. 1.Pt #9 Start of Care (SOC) 4/28/25. Date of death 5/1/25. Diagnosis: Chronic systolic (congestive) heart failure. The record was reviewed on 7/29/26. The “Hospice Medication Profile” dated 4/28/25 indicated the following medications: Morphine Sulfate (Concentrate) 100MG/5ML and Lorazepam 2MG/ML. The record lacked documentation that the medications were disposed of after the patient had expired on 5/1/25.Pt #10 SOC 12/23/24. Date of Death 1/1/25. Diagnosis: Chronic combined systolic and diastolic heart failure. The record was reviewed on 7/29/26. The “Hospice Medication Profile” dated 12/23/24 indicated the following medications: Oxycodone HCL 5 mg Tab, Oxycodone-Acetaminophen 5/325 Tab, Lorazepam 2mg/ML, Morphine sulfate (Concentrate) 100MG/5ML. The record lacked documentation that the medications were disposed of after the patient had expired on 1/1/25.Pt #11 SOC 9/16/24. Date of Death 9/23/24. Diagnosis: Chronic Kidney Disease, stage 4. The record was reviewed on 7/29/26. The “Hospice Medication Profile” dated 9/16/24 indicated the following medications: Morphine Sulfate (Concentrate) 100MG/ML and Lorazepam 2MG/ML. The record lacked documentation that the medications were disposed of after the patient had expired on 9/23/24.Pt #14 SOC 6/5/24. Date of Death 6/9/24. Diagnosis: Malignant neoplasm of prostate. The record was reviewed on 7/29/26. The “Hospice Medication Profile” dated 6/5/24 indicated the following medications: Morphine Sulfate (Concentrate) 100MG/5ML and Lorazepam 2MG/ML. The record lacked documentation that the medications were disposed of after the patient had expired on 6/9/24.2. The policy titled “Controlled Drug Disposal” (Date of Implementation 1/1/2026) was reviewed on 7/29/26. A request was made for the previous policy. The previous policy could not be found. The policy required, “When a patient no longer requires the controlled drug, the nurse will inform the family of the need to destroy the remaining medication. The method of how the medication was destroyed, along with the name of the medication, the dosage, and the amount of the drug, will be documented, and a witness will be present, and a signature will be obtained.”3. On 7/29/2026 at approximately 3:30 PM, an interview was conducted with the administrator (E#2). E#2 reviewed Pt’s records for Pt #9, Pt#10, Pt #12, and Pt #14. E#2 verbally agreed that the records lacked documentation of the medication disposal.”