Precise Personalized Care Hospice LLC

“Based on record review and interview, the agency failed to maintain a system of communication to ensure that the interdisciplinary group-maintained responsibility for directing, coordinating, and supervising the care and services to be provided for 1 (Patient #6) of 6 inactive patient records reviewed.This failure caused the client to develop an infection due to not receiving necessary care and treatment. Findings:Record review of Patient #6’s medical record revealed Patient #6 admitted to hospice services on 12/9/2023 with a diagnosis of Senile Degeneration of the Brain [age related brain disorder that slowly destroys memory and thinking skills]. Patient #6 resided in an assisted living facility.The initial plan of care dated 12/9/2023 listed Benign prostatic hyperplasia [enlarged prostate gland] with lower urinary tract symptoms as an unrelated diagnosis. The initial plan of care contained no orders for catheter (thin, flexible tube inserted into the bladder) care and changes.The nursing assessment dated 12/19/2023 stated Patient #6 had a perineal urethrostomy [urethral opening in the perineum] using a foley catheter with a leg bag. The assessment stated Patient #6 had multiple emergency room and in-patient hospitalizations for catheterization over 6 months prior to admission with the most recent requiring a urologist [physician that focuses on the urinary system] for catheter insertion. The plans of care for benefit periods 9, 10, 11, and 12 for dates 2/7/2024-4/6/2024, 4/7/2024-6/5/2024, 6/6/2024-8/4/2024, and 8/5/2024-10/3/2024 did not outline orders for the catheter care or responsibility for the catheter changes.A nursing note dated 2/14/24, 2/21/24, 2/28/24, 3/13/24, 3/20/24, 8/6/24, 8/7/24, 8/9/24, and 8/27/2024 documented, “[Catheter] inserted 12/08/2023.” There is no date next to “date changed.”A nursing note dated 9/3/2024 documented, “[Catheter] inserted 3/22/2024.” There is no date next to “date changed.” “Patient [catheter] patent, draining to gravity with a leg bag in place. Patient is having blood tinges output over the last 2-3 days, today, no bloody output. [Urine] is now amber cloudy urine draining into foley catheter with a foul smell. UA test strip revealed a urinary tract infection.” An order was obtained for Keflex 500mg by mouth twice a day for 7 days.Nurse Note 9/4/2024 documented, “[Foley catheter] inserted: 12/08/2023.” There is no date next to “date changed.”A nursing note dated 9/6/2024 stated, “Patient seen to check on new Foley [catheter] placed by urologist today.”A nursing note dated 9/7/24, documented the patient was seen for follow-up Foley replacement “yesterday.” “Maintain patent foley catheter. Patient/ Caregiver/ family will verbalize understanding of and correctly perform catheter care and emptying of drainage bag. Patient/ Caregiver will verbalize signs/ symptoms of infection and obstruction of foley catheter. SN [skilled Nurse] to irrigate (flush) foley catheter prn (as needed) for occlusion using 60 cc (cubic centimeter = 1 milliliter) sterile water.”Record review of agency personnel records revealed RN B was oriented to indwelling urinary catheter insertion on 9/30/22.In an interview on 7/1/2026 at 12:43 pm, the surveyor spoke with FM A. FM A stated, “The hospice was responsible for changing the catheter every 30 days. [Patient #6] developed an infection. I realized that [Patient #6] hadn’t had a catheter change in months. [RN B] told me she didn’t know how to change the catheter, but she should have found someone that did. I’m not saying [Patient #6] age didn’t factor on but he went straight downhill after this [infection].”In an interview on 7/1/2026 at 1:10 pm, the surveyor spoke with RN B. When the surveyor asked what the agency policy was for catheter care and changes RN B stated, “I work for different agencies, so it depends on the policy and procedure of the company. I can’t remember what the policy is for the agency. Patient #6 was the only patient I ever had with a catheter, and [catheter] was difficult to change.” The surveyor asked if the catheter was ever changed. RN B stated, “Yes, it was. [Patient #6] went to the ER and the doctor and they had difficulty changing [catheter]. [Catheter placement] was weird. [Catheter] wasn’t anything I had ever seen before. If I remember correctly [catheter] was inserted in the side of the penis.” The surveyor asked who was responsible for catheter care. RN B stated, “I worked with a LVN and they [LVN] did some things and I did some things.” The surveyor asked where the orders for catheter care would be documented. RN B stated, “[Orders] should be in the sections on the plan of care and at recertification.”In an interview on 7/1/2026 at 1:45 pm, the surveyor spoke with the Administrator/ Director of Nurses (ADM A) and the Alternate Administrator (ADM B). The surveyor asked who would be responsible for coordinating the care for the catheter. ADM A stated, “The nurse would be.” The surveyor asked where the coordination should be documented. ADM A and ADM B both agreed it should be on the care plan. The surveyor asked how it could affect the patient if the catheter care is not coordinated. ADM A stated, “Like this happened it could cause infections or other issues.”In an interview on 7/2/2026 at 1:00 pm, the surveyor spoke with MD B and MA A. The surveyor asked who was responsible for catheter care. MD B stated, “I was only seeing Patient #6 every 8 weeks. I thought the hospice was providing catheter care. I saw the catheter hadn’t been changed so I called a urologist friend, and he agreed to see Patient #6 the next day. We [MD B and MA A] took it upon ourselves to schedule the appointment.”The agency had a policy (PC.30) titled “Plan of Care Process” dated 3/16/2026. The policy read in parts: “…Purpose: To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s and family’s specific needs. Policy: I. All hospice care and services furnished to patients and their families will follow an individualized written POC …and in accordance with the patient’s needs. II. The Hospice will develop an individualized written POC for each patient. The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The POC will include all services necessary for the palliation and management of the terminal illness and related conditions. …VI. The POC includes, but is not limited to: …D. Drugs and treatments necessary to meet the needs of the patient…”The agency had a policy (PC.35-TX) titled, “Implementing Care and Treatment-Addendum” dated 4/14/2023. The policy read in parts: “…A. the principles of the care to be provided, including but not limited to dressing changes, foley catheter changes, and wound irrigation…”The agency had a policy (PC.40) titled, “Interdisciplinary Group Roles and Responsibilities” dated 9/1/2024. The policy read in parts: “…Policy: …IV. The IDG/ IDT responsibilities will include but not be limited to: …B. Provision and supervision of hospice care and continuity of services; …Procedure: …VI. The IDG/ IDT will maintain responsibility for directing, coordinating, and supervising care and services provided. …XI. Formal communication regarding the patient’s POC is documented at the IDG/ IDT meeting ensuring care and services are provided in accordance with the POC. A. Informal verbal and written communication demonstrating coordination of care among all staff members and others providing care is documented in the medical record. B. The hospice will develop a system to communicate among all persons involved in the patient’s care, …XII. …D. Document coordination with community resources, as well as other care providers …F. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions…”The agency had a policy (PC.110) titled, “Coordination of Care” dated 9/1/2024. The policy read in parts: “…Purpose: To ensure coordination of all care provided for patients receiving hospice services and/ or services from other providers. Policy: …I. The Hospice will develop and maintain a system of communication and integration, in accordance with the Hospice’s own policies and procedures to: A. Ensure that the Interdisciplinary Group/ Team (IDG/ IDT) maintains responsibility for directing, coordinating, and supervising care and services provided. …D. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. E. Provide for and ongoing sharing of information with other non-hospice healthcare providers furnishing services… Procedure: I. The designated registered nurse (RN) will coordinate care with the IDG/ IDT …III. IDG/ IDT will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical facilities …VI. All communications and coordination of care is documented in the clinical record…””