Novel Hospice Care

“Based on record review and interview, the agency failed to include in the plan of care required elements, such as medications and treatments, applicable to the scope of services provided by the agency in 3 (Patient #1, Patient #2, and Patient #3) of 3 patient records reviewed. This failure could cause the patients to not receive appropriate medications and treatments. Findings:Record review of Patient #1’s medical record revealed Patient #1 was admitted to hospice services on 5/1/2026 with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), a disease that affects the lungs and causes increased shortness of breath. On admission, Patient #1 had a 16fr foley catheter (a tube placed in the bladder to drain the urine) in place. The initial plan of care (POC) dated 5/4/2026 documented to “Change urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered.” IDG Meeting documentation dated 5/12/2026, 5/26/2026, and 6/9/2026 documented to “Change urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered.” Plans of care documented on 5/25/2026 and 6/9/2026 documented to “Change urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered.” No other orders outlining the care or changing of the catheter were found in Patient #1’s medical record. Record review of Patient #2’s medical record revealed Patient #2 was admitted to hospice services on 3/14/2026 with a diagnosis of left hemiplegia (paralysis) after a Cerebrovascular Accident (CVA also referred to as a stroke). On admission, Patient #2 had a 16Fr foley catheter (a tube placed in the bladder to drain the urine) in place. The initial plan of care (POC) dated 3/15/2026 and IDG Meeting dated 3/17/2026 failed to mention the catheter. A physician order written 4/7/2026 ordered “Foley Catheter Protocol: 1) Foley Catheter 16Fr 10 cc Balloon-when there is blockage, leakage, or infections and as needed…” A physician order written 5/27/2026 ordered “Macrobid Oral Capsule 100mg twice a day for 5 days for a urinary tract infection.” A physician order written 7/9/2026 ordered “Sacral (base of spine) wound—cleanse with wound cleanser, pat dry, apply Calcium alginate and cover with a dry dressing 3 times a week and as needed.” Plans of care documented on 6/22/2026, 7/5/2026, 7/9/2026, and 7/21/2026 documented to “Change urinary drainage device (e.g. foley, suprapubic catheters, urostomy) as ordered,” Macrobid was not found on the attached medication profile, and there were no orders for the wound care on these plans of care. No other orders outlining the care or changing of the catheter were found in Patient #2’s medical record. Record review of Patient #3’s medical record revealed Patient #3 was admitted to hospice services on 7/23/2025 with a diagnosis of Alzheimer’s disease, a disease that causes progressive forgetfulness and confusion. On admission, Patient #3 had a pressure ulcer on the coccyx (tailbone). IDG Meeting documentation dated 8/5/2025 included admission nursing notes dated 7/23/2025 documented “Keflex 500mg four times a day for wound infection. [Patient #3] has a stage 2 decubitus ulcer to the coccyx approximately 3.5cm x 2.5cm with scant sanguinous drainage.” IDG Meeting documentation dated 9/3/2025, 9/30/2025, and 10/14/2025 failed to mention the wound or wound treatment ordered. Plan of care orders documented on 7/23/2025 and 8/5/2025 documented “Altered Skin Integrity” as a problem but failed to outline the actual wound or wound care treatment ordered. These Plans of care also failed to include Keflex with the medication profile. No other orders outlining the wound and wound treatment were found in Patient 3’s medical record. In an interview on 7/30/2026 at 2:28 p.m. the surveyor asked how often the foley catheter was changed for Patient #2. RN B stated, “We usually change it about every 60 days. The order is to leave it alone if it’s not bothering [Patient #2] or leaking. I’d have to check with CMS guidelines.” In an interview on 7/31/2026 at 1:30 p.m. the surveyor asked why the plans of care did not include wound care orders and only stated “as ordered” for catheter care and changes. The Administrator (ADM) stated, “If the nurse wrote the order, then she knows what is going on with the [client]. I understand what you’re saying about it being on the plan of care but there is an order.” The surveyor asked about medications such as Keflex and Macrobid not being on the plan of care. ADM stated, “I’m not sure why the antibiotics didn’t get added to the plan of care.” The surveyor asked who was responsible for updating the plan of care. ADM stated, “The nurse case manager.” The surveyor asked about the statement on the plans of care about catheters, “change as ordered.” The surveyor asked what the order was for catheters. ADM stated, “[Nurses] change it as needed.” The surveyor asked why the plans of care did not reflect “as needed” or specify when or what was “as needed.” ADM stated, “If [catheter] gets blocked or [catheter] is leaking, etc.” The surveyor asked why it wasn’t specified on the plan of care. ADM stated, “I’m not sure.” When asked how clients may be affected if medications, orders, and wound care are not included on the plans of care ADM stated, “It could cause [patients] not to receive proper care.” In an interview on 7/31/2026 at 4:00 p.m. the surveyor asked who was responsible for updating the plan of care. RN A stated, “[Nurses] are supposed to update it.” The surveyor asked if supplies, medical equipment, medications, orders and wound treatments were supposed to be on the plans of care. RN A stated, “[Nurses] have to put wound care, orders, and medications on the plans of care.” When asked what the policy said RN A stated, “I’m not sure what the policy says.” The agency had a policy [TX.9] titled, “Plan of Care and Process” dated 10/12/15. The policy read in parts: “…Procedure: A. A registered nurse coordinates the implementation of the plan of care for each patient and is responsible for insuring the following: …6. Ongoing evaluation and assessment, with recommendations to the IDG on modifications to the POC. …C. Updated Interdisciplinary Group Plan of Care: …3. Content of the IDG Plan of Care will include: …e. Medications and treatments to meet needs of patient…””

“Upon patient record review, 3 of 14 (Patient #4,8,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank. Patient #8: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank. Patient #14: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank.”

“Upon patient record review, 3 of 14 (Patient #7,#8,#12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient#7:The patient declined chaplain at admission, but Chaplain 1 x month was documented on the care plan beginning 12-26-25. Patient #8: The patient declined an aide, but the care plan dated 3-17-26 and 3-31-26 documented aide visits 3 x week. Patient #12: The patient was diagnosed with Diastolic Heart Failure, CAD, HTN and A-Fib, but there was no evidence of a care plan for cardiac.”

“Upon client record review, 3 of 14 (Patient #9,12, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#9:The Chaplain was visiting once a month, but the plans of care dated 3-17-26, 3-31-26 and 4-14-26 had no frequency documented for the chaplain. Patient#12: The nurse, chaplain and social work were accepted by the patient and family, but the plan of care dated 2-17-26 had no frequencies documented for the Nurse, Aide or Social Work. Patient #13: The plan of care dated 3-17-26, 3-31-26 and 4-17-26 indicate the chaplain is visiting 2 x month, but there is evidence of only 1 visit in March.”

“Upon patient record review 3 of 14 (Patient #5,#7,#12) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #5:An aide supervisory visit was completed on 3-2-26 and not again until 4-1-26 indicating greater than 14 days. Patient #7: An aide supervisory visit was completed on 3-4-26 and not again until 4-9-26 indicating greater than 14 days. Patient #12: An aide supervisory visit was conducted on 3-2-26 and not again until 3-19-26 indicating greater than 14 days.”

“Upon patient client record review, 4 of 14 (Patient #4,#6,#8,#14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #4: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank. Patient #6: There was no evidence the patient was informed of the right to receive the election statement addendum as the declined or chosen statement was left blank. Patient #8: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank. Patient #14: There was no evidence the patient chose or declined an attending physician on the Informed Consent and Election of Benefits form due to that portion being blank.”