Phoenix Home Care and Hospice

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate/updated medication profile in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Medication List and Monitoring,” last reviewed 09/01/2024, showed in part: - The hospice will review, monitor, and maintain a current, accurate list of all prescription and over the counter (OTC) medications, herbal remedies and other alternative treatments that could affect drug therapy taken by the patient; and - The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 09/06/2024 with a terminal diagnosis of malignant neoplasm of the right kidney (kidney cancer that spread to other areas of the body). The patient had additional diagnoses of an infrarenal abdominal aortic aneurism (a ballooning of the wall in the abdominal aorta, below the kidney), surgical repair of a fractured left femur from a fall on 09/03/2024, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood) and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in his/her home with help from family members and paid caregivers. Observation on 01/14/2025 at 10:30 AM, showed the following discrepancies between the providers medication profile and the patients home medications: - The providers medication profile showed acetaminophen (a non-narcotic pain reliever) 325 milligrams (mg), take two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen that showed the dosage was 500 mg tablets, and the patient stated that they took two tablets two times a day; - The providers medication profile showed nitroglycerin sublingual tablets 0.4 mg take one tablet every five minutes as needed for chest pain. May take up to three doses. The patient stated that they were not taking this medication; - The providers medication profile showed Benadryl (brand) Allergy tablet 25 mg take one tab every eight hours as needed. The patient stated that they were not taking this medication; - The providers medication profile showed FML Liquifilm (brand) (steroid eye drops) 0.1% solution, use one drop two times daily. The patient stated that they were not taking this medication; - The providers medication profile showed azelastine nasal solution 137 micrograms (mcg) (for seasonal allergies), use two sprays into each nostril two times daily. The patient stated that they were not taking this medication; - The patient had a bottle of calcium 333 mg, magnesium 133 mg and zinc 5 mg with vitamin D-3 5 mcg supplement, take one tablet up to three times daily. The providers medication profile did not include this medication; - The patient had a bottle of vitamin E 268 mg, take one daily. The providers medication profile did not include this medication; - The patient had a bottle of iron complex (vitamin C 60 mg, folate 400 mcg, vitamin B-12 80 mcg, iron 25 mg, L-histidine 100 mg), take one capsule daily. The providers medication profile did not include this medication; and - The patent had a bottle of vitamin D-3, 125 mcg, take one daily. The providers medication profile did not include this medication. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that he/she would expect the clinician to maintain an accurate and updated medication list and the clinician should review medications at least for every interdisciplinary group meeting. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Observation on 01/14/2025 at 12:15 PM, showed the following discrepancies between the providers medication profile and the patients facility medications: - The LTCF treatment administration record (TAR) showed lorazepam (antianxiety) 0.25 milligram (mg) / milliliter (ml), give 0.25 ml by mouth every 2 hours as needed for anxiety/increased restlessness. The providers medication profile showed 0.25 ml under the tongue every 4 hours as needed for agitation/anxiety; - The LTCF TAR showed apply skin prep (skin protectant) to stasis ulcer to anterior left lower extremity (LLE) daily until resolved every day shift. The providers medication profile did not include this medication; - The LTCF TAR showed apply skin prep to bilateral heels twice daily for skin integrity every shift. The providers medication profile did not include this medication; - The LTCF medication administration record (MAR) showed hydroxyzine (anti itching) 25 mg by mouth every 4 hours as needed for itching. The providers medication profile did not include this medication; and - The LTCF medication administration record (MAR) showed cetirizine (allergies) 10 mg tablet, give one tablet by mouth one time a day for allergies. The providers medication profile did not include this medication;”

“Based on policy review, record review, and interview, the hospice provider failed to develop an individualized plan of care (POC) in, one of five full records reviewed (Record/Patient #2). This deficient practice has a potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Plan of Care,” dated 05/02/2024, showed:- Each patient/client must receive an individualized POC, including any revisions or additions; - The individualized POC must include the following;*The types of supplies, and equipment required; and- The POC should list required, non-routine supplies and equipment that are medically necessary for the patient’s/client’s care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit, dated 12/30/2024, showed the registered nurse (RN) documented the patient was able to stand and transfer to a wheelchair on admission, but he/she had lost all ability to stand and was currently using a Hoyer lift (a mechanical lift used for transferring patients) for transfers to a wheelchair. Review of the interdisciplinary group (IDG) meeting, dated 12/31/2024, showed the RN IDG re-cert (recertification) details: he/she was able to stand and transfer to a wheelchair on admission, but he/she had lost all ability to stand and was currently using a Hoyer lift for transfers to a wheelchair. Observation during the home visit on 01/14/2025 at 12:15 PM, showed a low air loss mattress on the patient’s bed he/she was sitting on. During an interview during the home visit on 01/14/2025 at 12:30 PM, the patient stated that the facility staff were going to start using the Hoyer lift to take him/her to the beauty shop. Review of the patients POC, dated 01/13/2025 to 04/12/2025, failed to be individualized and show the Hoyer lift and the low air loss mattress as part of the patients durable medical equipment (DME). During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that all the patients DME should be on the patients POC.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) was updated with the correct urinary catheter size in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients with urinary catheters served by the provider. RECORD/PATIENT #1: Review of the clinical record showed the patient elected hospice on 11/27/2024 with a terminal diagnosis of malignant neoplasm of the connective and soft tissue of the left lower limb, including hip (cancer in the left leg that had spread to other parts of the body). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), chronic kidney disease, urinary retention (difficulty urinating and completely emptying the bladder), and dementia (a decline in mental capacity). The patient lived in a long-term care facility (LTCF). Review of the clinical record, showed in part: - The initial assessment, dated 11/27/2024, showed the patients genito-urinary system was assessed, the urine was dark yellow, urinary incontinence was present, and the patient had a urinary catheter (a sterile tube placed in the bladder to drain urine) and the size of the catheter was a 16 French (Fr., refers to the catheters diameter) 10 ml (milliliter) bulb (refers to the volume of fluid needed to inflate the balloon at the tip of the catheter, chosen based on the patients needs and anatomy); - The POC, dated 11/27/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter for altered bladder elimination; - A skilled nurse (SN) visit note, dated 11/28/2024, showed the catheter was changed by the LTCF nurse and the size was 16 Fr. 5 (five) ml bulb; - A SN visit note, dated 12/03/2024, showed the urinary catheter size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/04/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - SN visit notes, dated 12/06/2024, 12/10/2024 and 12/13/2024, showed the catheter size was documented as 16 Fr. 5 ml bulb; - A SN visit note, dated 12/17/2024, showed the urinary catheter was last changed on 12/17/2024 and the size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/18/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - A SN visit note, dated 12/24/2024, showed the urinary catheter was changed on 12/23/2024 and the size was 16 Fr. 5 ml bulb; - The SN visit note, dated 12/30/2024, showed the catheter size was 16 Fr. 5 ml bulb; - IDG/POC notes, dated 12/18/2024, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter size in the POC); - A SN visit note, dated 12/31/2024, showed the catheter was changed on 12/31/2024, and the size was 16 Fr. 5 ml bulb; - A SN visit note, dated 01/03/2025 at 10:50 AM, showed the catheter was changed on 01/02/2025, and the size was 16 Fr. 5 ml bulb; - A SN SOAP note (an acronym for subjective, objective, assessment, and plan; a type of structured clinical documentation), dated 01/03/2025 at 3:35 PM, showed the hospice RN responded to a call from the LTCF requesting assistance with a catheter change. The hospice RN inserted a 16 Fr. 30 ml bulb urinary catheter. The SOAP note failed to document the reason a 30 ml bulb catheter was used; - On 01/07/2025, the SN note documented the presence of a 16 Fr. 5 ml bulb urinary catheter inserted on 01/02/2025 (the note failed to document the presence of the 16 Fr. 30 ml catheter inserted on 01/03/2025); and - IDG/POC notes, dated 01/08/2025, showed an order for a 16 Fr. 10 ml bulb urinary catheter (the IDG failed to update the catheter bulb size in the POC). Observation on 01/14/2025 at 1:00 PM, during the patients home visit, showed the patients urinary catheter size was 16 Fr. 30 ml bulb. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that he/she would expect the clinician to accurately document the catheter size and the IDG to update the POC with the correct catheter size.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) necessary to meet the needs of the patients in three of five full records reviewed (Record/Patient #2, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. Findings Included: Review of the providers policy titled, “;Plan of Care,” dated 03/07/2022, showed the POC will include all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 04/12/2024 with a terminal diagnosis of dementia (decline in mental capacity), and secondary diagnoses which included, heart failure, and anemia (a blood disorder that occurs when the body doesn’t have enough red blood cells to carry oxygen throughout the body). The patient resided in a long-term care facility (LTCF). Observation during the home visit on 01/14/2025 at 11:30 AM, showed a wheeled walker in the patients room labeled with the patients name. Review of the patients plan of care dated 01/03/2025 failed to show the wheeled walker as part of the patients DME. During an interview during the home visit on 01/14/2025 at 11:50 AM, Licensed Practical Nurse (LPN) D stated that the patient has had the wheeled walker since admission to the LTCF. During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that the patients wheeled walker should be included as DME on the patients POC. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 11/23/2024 with a terminal diagnosis of malignant neoplasm of the lung (lung cancer), and secondary diagnoses which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the body), and heart failure. The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit dated 12/23/2024 showed staff documented a cane, a scooter, and a Rollator (mobility aid that helps people with walking difficulties) as part of the patients DME. Review of the patients plan of care dated 01/03/2025 failed to show the patients cane, scooter, and rollator as part of the patients DME. During an interview conducted on 01/16/2024 at 12:20 PM, the providers administrator stated that all the patients DME should be on the patients POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 10/15/2024 with a terminal diagnosis of atherosclerotic heart disease (a condition that occurs when plaque builds up in the arteries and hardens, narrowing the blood vessels), type II diabetes (a group of diseases that results in too much sugar in the blood) with peripheral neuropathy (weakness, numbness, and pain from nerve damage), hypertension (elevated blood pressure) and chronic kidney disease (loss of kidney function). The patient resided in a long-term care facility (LTCF). Review of the skilled nurse visit dated 12/30/2024 showed the registered nurse (RN) documented the patient was able to stand and transfer to a wheelchair on admit, now he/she has lost all ability to stand and is a Hoyer lift for transfers to a wheelchair. Review of the interdisciplinary group (IDG) meeting dated 12/31/2024 showed the RN IDG re-cert details: he/she was able to stand and transfer to a wheelchair on admit, now he/she has lost all ability to stand and is a Hoyer lift for transfers to a wheelchair. Review of the patients plan of care dated 01/13/2025 to 04/12/2025 failed to show a Hoyer lift as part of the patients durable medical equipment (DME). During an interview during the home visit on 01/14/2025 at 12:30 PM, the patient stated that the facility staff were going to start using the Hoyer lift to take her to the beauty shop.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff followed established policies and procedures for reporting missing narcotic medication in one of four home visit interviews conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the hospice providers undated policy titled, “;Home Use and Disposal of Control Substances Policy,” located in the document titled, “;Patient Handbook,” showed in part: - The registered nurse (RN) case manager or designee identifies and documents any misuse of controlled substances and notifies the attending or hospice physician, the pharmacist, and the director of hospice services for further intervention; and - An incident report is completed for suspected or actual diversion of controlled substances and the interdisciplinary group (IDG), in consultation with the hospice physician, the patients attending physician (if there is one) and the pharmacist determines the appropriate course of action, including reporting the diversion to the appropriate authorities. RECORD/PATIENT #3: Review of the clinical record showed the patient elected hospice on 09/06/2024 with a terminal diagnosis of malignant neoplasm of the right kidney (kidney cancer that spread to other areas of the body). The patient had additional diagnoses of an infrarenal abdominal aortic aneurysm (a ballooning of the wall in the abdominal aorta, below the kidney), surgical repair of a fractured left femur from a fall on 09/03/2024, chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes (a group of diseases that results in too much sugar in the blood) and hypertensive chronic kidney disease (impaired kidney function caused by high blood pressure). The patient lived in his/her home with help from family members and paid caregivers. Observation on 01/14/2025 at 10:30 AM, showed the patient had a locked box that contained Norco 5/325 milligrams (mg) (hydrocodone 5 mg / Acetaminophen 325 mg) take one tablet every eight hours as needed for pain. Per an interview conducted during observation, the patient and the patients daughter stated that the staff were addressing his/her pain needs and the only time he/she had a problem with the provider was when he/she “;first started hospice”. He/she had a different nurse who also had a second nurse “;training” with them and while one nurse wrapped his/her feet, the other nurse counted his/her narcotics. The patient and daughter both stated that, sometime after that visit, they noticed the narcotic pain medications (Norco 5/325 mg) were missing. They reported the missing narcotics to the provider and another bottle was brought to the home. The patient was taking Tylenol (acetaminophen 500 mg) for pain and was not taking the Norco. On 01/14/2025 at 2:00 PM, this surveyor requested information regarding the investigation into the missing narcotics and the policies and procedures the provider had in place for the discovery of missing narcotics in the home. The administrator stated that he/she would have to look in the patients file and see what he/she could find. On 01/14/2025 at approximately 3:30 PM, the administrator produced the following: - A document titled, “;Incident Report,” that showed the incident occurred on 02/06/2024 at 2:00 PM and the witness was (licensed practical nurse A, LPN-A). Details included “;medication bottle missing from the home see note attached” and the response to the incident was two attempts to call the patient both resulted in an inability to leave a message due to full voice mailbox and called and left message for daughter with no returned call. The incident note showed documentation that the patients daughter was notified on 02/05/2024 at 4:00 PM (one day before the medication was discovered to be missing). The RN coordinator was notified on 02/09/ (no year entered) (three days following the discovery). The incident report was completed by (registered nurse C, RN-C) on 02/08/2024; and - A typed document on plain white paper that showed (named nurse A) “;made a skilled nursing visit on 2/6/25 (date of occurrence was 02/06/2024) and documented that (he/she) was unable to find Norco bottle during (his/her) skilled nursing visit.” (Registered nurse B, RN-B) “;made (his/her) skilled nursing visit and contacted this nurse (RN-C) that the Norco was no longer present in the home as the patient was unable to find it. It was discussed that the patient has 24/7 (referring to 24 hour a day, seven days a week) care with family and paid caregivers present. (RN-B) contacted (named physician) who re-ordered the medication to be replaced. It was discussed that a lockbox be placed in the home and all narcotics be placed in the box and the key kept with the patient. (RN-B) ordered the Norco to be refilled and discussed with the patient and (named daughter) that the medications to be placed in the lockbox on arrival and the key kept in a safe place. Both patient and daughter verbalize understanding. This nurse communicated with the daughter regarding the medications missing. (He/she) reports they have multiple caregivers in the home 24/7 and is unable to pinpoint who would have taken the medications however feels certain the patient or (named provider) was not responsible for taking the medications.” The document was signed by (RN-C) on 02/08/2024. Review of the skilled nursing visit made by (LPN-A), dated 02/06/2024, showed the following entry: “;No refills needed at this time Xanax (a narcotic for anxiety) 13 tabs (tablets) unable to locate Norco.” The note failed to show documentation that anyone was notified of the missing narcotic pain medication. Review of the skilled nursing visit made by (RN-B), dated 02/09/2024, showed/ the following entry: “;No refills needed at this time Xanax 10 tabs (tablets) Norco 325/5 mg (5/325 mg) 30 tabs (tablets) – placed in locked box.” The note also showed two keys were in the patients possession and two more keys were placed in the kitchen cupboard. The patient verbalized an understanding on the use of the lock box. Review of the IDG meeting notes, dated 02/21/2024, failed to show documentation regarding the missing narcotics. During an interview on 01/15/2025 at 3:00 PM, the administrator stated that the policy located in the patient handbook was a current policy for the provider and he/she confirmed the incident report and attached document were written at the time of the incident. He/she would look for further documentation that showed the missing narcotics were discussed in the IDG meeting with the medical director and pharmacist or any reports made to the authorities. During an interview on 1/15/2024 at 3:45 PM, the administrator stated that he/she remembered discussing the missing narcotics in IDG, but nothing was written down in the IDG meeting notes. He/she did not have any documentation to show the missing narcotics were discussed with the hospice physician and pharmacist and they did not report the missing narcotics to any law enforcement officials. He/she stated that they should have documented the occurrence and reported the incident to the proper authorities per the providers policy.”

“Based on policy review, record review, and interview, the provider failed to ensure the registered nurse (RN) updated the assigned patient care duties for the hospice aide to reflect a change in the patients condition in one of four patient records receiving aide services reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients receiving aide services from the hospice provider. Findings included: Review of the providers policy titled, “;Implementing Care and Treatment,” last reviewed 09/01/2024, showed in part: - The hospice designates a qualified RN who is a member of the interdisciplinary group (IDG), who will provide coordination of care to ensure the continuous assessment of each patients and familys needs; and - The RN will oversee the assignment of a hospice aide to a particular patient, initiating hospice aide services within the time frame to meet identified patients needs as identified in the plan of care (POC) and per physicians orders. RECORD/PATIENT #1: Review of the clinical record showed the patient elected hospice on 11/27/2024 with a terminal diagnosis of malignant neoplasm of the connective and soft tissue of the left lower limb, including hip (cancer in the left leg that had spread to other parts of the body). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), chronic kidney disease, urinary retention (difficulty urinating and completely emptying the bladder), and dementia (a decline in mental capacity). The patient lived in a long-term care facility (LTCF). Review of the hospice aide care plan, dated 11/27/2024, showed the frequency of visits was two times a week and the aide was assigned the task to assist in transfer with one person assist every visit. Review of the skilled nursing (SN) visit, dated 11/28/2024, showed the RN documented the patient was a total lift. Review of the SN visits with dates ranging from 12/13/2024 to 01/09/2025, showed the RN documented the patient was a total lift requiring two staff. Review of the aide visit notes showed the following: - On 12/13/2024, 12/17/2024, and 12/19/2024 the aide documented completion of the one-person transfer per the care plan; - On 12/26/2024 and 12/30/2024, the aide documented the one-person transfer task as “;N/A” (not applicable), due to the patient did not get out of bed and the RN case manager was notified; - On 01/02/2025, the aide documented the one-person transfer was completed; and - On 01/06/2025, the aide documented the one-person transfer as “;N/A” due to the patient was not able to get out of bed. The RN case manager was notified. Review of the RN aide supervision notes with dates ranging from 12/17/2024 to 01/07/2025, and IDG meeting notes with dates ranging from 12/04/2024 to 01/08/2025, showed the RN failed to update the hospice aide care plan to reflect the bedbound status of the patient or that the patient required a total lift of two staff members for transfers. During an interview on 01/16/2024 at 11:30 AM, the administrator stated that he/she would expect the RN case manager to update the aide care plan to reflect the change in the patient’s condition.”

“Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the hospice plan of care (POC) identified which provider was responsible for changing the urinary catheter in one of two patients that reside in a long-term care facility (LTCF) (Record/Patient #1). This deficient practice has the potential to affect all hospice patients who reside in a LTCF. Findings included: Review of the providers policy titled, “;Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities),” last reviewed 09/01/2024, showed in part: - A hospice POC will be developed based on the patient/familys needs. A copy of the POC, which includes services furnished, will be provided to the facility; and - The POC will identify the care and services that are specifically needed and identify which provider is responsible for performing the respective functions that have been agreed upon and included in the POC. RECORD/PATIENT #1: Review of the POC, dated 11/27/2024, showed in part: - An order for a Foley (brand) urinary catheter (a sterile tube placed in the bladder to drain urine) and the size of the catheter was a 16 French (Fr., refers to the catheters diameter) 10 milliliter (ml) bulb (refers to the volume of fluid needed to inflate the balloon at the tip of the catheter, chosen based on the patients needs and anatomy); and - The order showed the catheter was to be changed every 30 days and as needed for blockage or patient removal. Review of the initial assessment, dated 11/27/2024, showed the patient had a urinary catheter and was last changed at the LTCF on 10/28/2024. Review of the skilled nursing (SN) visit notes showed in part: - On 11/28/2024, registered nurse-F (RN-F) documented the catheter was changed on 11/28/2024 by (named nurse – first name only was documented). The note failed to show whether the nurse was a LTCF nurse or a hospice nurse; - On 12/17/2024, RN-F documented the catheter was changed on 12/17/2024 (19 days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 12/24/2024, RN-F documented the catheter was changed on 12/23/2024 (six days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 12/31/2024, RN-F documented the catheter was changed on 12/31/2024 (eight days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; - On 01/03/2025 at 10:50 AM, RN-F documented the catheter was changed on 01/02/2025 (two days since the previous change). The note failed to show the reason the catheter was changed early or whether it was changed by the LTCF nurse or the hospice nurse; and; - On 01/03/2025 at 3:35 PM, a SOAP note (an acronym for subjective, objective, assessment, and plan; a type of structured clinical documentation), RN-F documented he/she responded to a call from the LTCF requesting assistance with a catheter change (one day after the previous change). The note failed to show the reason the catheter was changed one day after the previous change. Observation on 01/14/2025 at 1:30 PM, during the patients home visit, showed the coordinated task plan of care with the LTCF included the Foley catheter change with a 16 Fr. five ml bulb (the hospice order was for a 10 ml bulb) and the party responsible for changing the catheter was marked as both the hospice and the LTCF. The plan of care failed to give instruction as to when the LTCF should change the catheter versus when the hospice nurses were to change the catheter. Per an interview conducted during the observation, RN-F stated that the LTCF usually did the catheter changes, but they would call him/her if they had trouble inserting it. During an interview on 01/16/2025 at 11:30 AM, the administrator stated that the hospice nurse and the LTCF nurses usually do a verbal report of information, and he/she would expect the RN to document why the catheter was being changed and who had performed the changes.”