Every finding on record at Affinity Hospice Arkansas LLC

Based on clinical record review and staff interviews, it was determined that the agency did not individualize the plan of care for 18 (#1 - #17, #19) of 20 client records reviewed. This failed practice could result in potential harm for all patients on census in that the agency did not provide a detailed and specific plan which guides caregivers in direct care for the patient. Findings follow: --- 1. A form titled, "Hospice POC [Plans of Care] Report" was reviewed and revealed that 18 (#1 - #17, #19) of 20 records reviewed had the same care plan for pain and was not individualized for each patient. The document noted, "... Need for assessment of effectiveness of pain control/comfort measure...G [Goal] Pain is currently managed at a level acceptable to patient..." These plans of care did not explain what the acceptable level of pain was for each patient individually and specifically. 2. Review of clinical record #3 with a start of care date of 11/29/23 and a diagnosis of Malignant Neoplasm of Prostate with metastasis to the bone, revealed a document titled, ";Hospice POC [Plan of Care] Report" and dated 11/29/23 noted, ";...Need for skilled nurse to insert/maintain indwelling catheter..." There was no instruction for the foley catheter to include the size of the catheter to be inserted or balloon size. 3. Review of clinical record #4 with a start of care date of 12/6/23 and a diagnosis of Atherosclerotic Heart Disease, revealed the following: A. A document titled, ";Visit Note Report" dated 12/8/2023 identified the patient as a full code as evidenced by, ";...MSW [Medical Social Worker] Hospice Add-on evaluation...NARRATIVE...PT [patient] is a Full Code...MSW frequency will be 2x[times]monthly and PRN [as needed] to address code status..." B. A document titled, ";Hospice POC [Plan of Care] Report" revealed there were no interventions to include planned full code discussions with the patient and family by the MSW. 4. Review of clinical record #6 with a start date of 9/2/2023 and a diagnosis of Congestive Heart Failure (CHF) revealed a document titled, ";Hospice POC Report" revealed there was no Advance Directive decision ( Advance directives are legal documents that provide instructions for medical care for end of life) included in the Plan of Care. A document titled, ";Hospice POC Report" revealed there was no documentation regarding interventions by the MSW for Advance Directive decisions. 5. Review of clinical record #7 with a start of care date of 10/9/2023 and a diagnosis of Congestive Heart Failure (CHF) revealed the following: A. A document titled, ";Visit Note Report" dated 10/11/2023 revealed, ";...MSW Hospice Add-On Evaluation...NARRATIVE... [Patient's Name] is full code... MSW visits 2 x[times] monthly and prn [as needed] due to patient being a full code..." B. A document titled, ";Hospice POC Report" revealed there was no notation of full code status and what interventions were to be implemented. 6. Review of clinical record #10 with a start of care date of 11/3/2023 and a diagnosis of Cerebral Infarction, revealed the following: A. A document titled, ";Hospice POC Report" revealed wound care orders dated 11/3/2023, ";... Need for wound care-hospice.... Provided wound care per orders...". In addition, the document revealed, ";Need for skilled teaching related to feeding tube (NG [nasogastric]/Gastrostomy)-hospice...". B. There were no specific instructions in the plan of care regarding what wound care products to use and when to provide dressing changes, nor were there instructions for specific enteral nutrition to provide and how often. 7. On 1/9/24 at 10:00 a.m., the agency Office Manager and Executive Director were asked to provide any further information regarding the plans of care that would demonstrate an individualized plan of care was developed for each patient and none was provided.

Based on clinical record review and staff interview, it was determined the agency did not include complete orders to meet the needs of the patient in 3 (#3, #10 and #11) of 20 (#1 - #20) clinical records reviewed. who had a foley catheter during clinical record review. 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 patients specific needs. Findings follow: --- 1. Review of clinical record #3 with a start of care date of 11/29/23 and a diagnosis of Malignant Neoplasm of Prostate with metastasis to the bone, revealed a document titled, ";Hospice POC [Plan of Care] Report" and dated 11/29/23 noted, ";...Need for skilled nurse to insert/maintain indwelling catheter..." There was no instruction for the foley catheter to include the size of the catheter to be inserted or balloon size. 2. Review of clinical record #10 with a start of care date of 11/3/2023 and a diagnosis of Cerebral Infarction, revealed the following: A. A document titled, ";Hospice POC Report" revealed wound care orders dated 11/3/2023, ";... Need for wound care-hospice.... Provided wound care per orders...". In addition, the document revealed, ";Need for skilled teaching related to feeding tube (NG [nasogastric]/Gastrostomy)-hospice...". B. There were no specific instructions in the plan of care regarding what wound care products to use and when to provide dressing changes, nor were there instructions for specific enteral nutrition to provide and how often. 3. Review of clinical record #11 with a start of care date of 07/29/2022 and a diagnosis of Senile Dementia of the Brain revealed the follow: A. A document titled, ";Hospice POC Report" revealed orders with a certification period of 11/21/2023 through 01/19/2024 for services to be provided. There were no orders for Social Worker visits or assessments. B. Review of the Clinical Record showed no evidence of social worker visits or assessments being made during the certification period reviewed. C. During a home visit made on 01/02/24 at 09;10 AM, an interview with the patient's husband/caregiver reported multiple stressors. These stressors including the husband not being able to leave the house, time to himself, or to enjoy his hobbies. D. There was no evidence in the clinical record to show where the social worker attempted to make visits to assess the patient's husband's stress and subsequent needs. 4. On 01/09/24 at 10:05 AM, the Agency Manager and Agency Executive Director confirmed the findings.

Based on clinical record review and staff interview, it was determined that the agency failed to note progress toward outcomes using measurable goals for 18 (#1 - #17, #19) of 20 (#1 - #20) patients' clinical records reviewed. This failed practice had the potential to affect all patients on census in that the patient's progress toward goals could not be monitored by the agency. Findings follow: --- 1. A form titled, "Hospice POC [Plans of Care] Report" was reviewed and revealed that 18 (#1 - #17, #19) of 20 records reviewed had the same care plan for pain and was not individualized for each patient. The document noted, "... Need for assessment of effectiveness of pain control/comfort measure...G [Goal] Pain is currently managed at a level acceptable to patient..." These plans of care did not explain what the acceptable level of pain was for each patient individually and specifically. 2. On 1/9/24 at 10:00 a.m., the agency Office Manager and Executive Director confirmed the findings.

Based on observation, clinical record review and staff interview, it was determined that the agency failed to ensure acceptable standards of practice to prevent the transmission of infection were followed for 1 of 1 (# 13) hospice patients observed with a pressure ulcer. This failed practice had the potential to affect all patients with pressure ulcers in that, the agency did not ensure standard practice for infection control and prevention were followed. Findings follow: --- Review of clinical record #13 with a start of care date 12/28/2023 and a diagnosis of Atherosclerotic Heart Disease, revealed the following: A. A document titled, ";Hospice Certification and Plan of Care" with a certification period of 12/28/2023 – 3/26/2024 revealed, ";...Orders of Discipline and Treatments: ... Hospice nurse to perform wound care to stage IV pressure ulcer on sacrum. Utilizing clean technique-Cleanse with dermal spray apply wet to dry with NS [normal saline] cover with ABD pad and change every day and prn [as needed] ..." B. On 1/4/2024, during a home visit, a wound dressing change observation was completed. Employee # 13 placed gauze in the normal saline solution and placed directly into the wound then covered with ABD pad. Employee # 13 did not clean the pressure ulcer with dermal spray as ordered. C. On 1/9/2024 at 10:30 AM, the agency Office Manager and Executive Director confirmed the findings.

Based on review agency documentation and staff interview, the agency did not utilize volunteers to supplement administrative duties and patient care assistance for the year 2023. This lack of volunteer support had the potential to affect all patients on census in that the agency did not have volunteers to provide the needed service. Findings follow: --- 1. Review of an agency form titled "Volunteer Coordinator's Cost Saving Monthly Report" revealed no volunteer service hours were provided for the year 2023. 2. On 01/09/24 at 10:15 AM, the Agency Office Manager confirmed the agency did not have volunteers to provide service hours administratively or in direct patient care.

Based on review of Agency documentation and staff interview, the agency did not meet the 5% requirement for volunteer hours for the year 2023. This lack of volunteer hours had the potential to affect all patients on census in that the agency could not compliment and support patient care. Findings follow: --- Review of the form titled, "Volunteer Coordinator's Cost Saving Monthly Report revealed the Agency had no volunteer hours for the year 2023 therefore not meeting the 5% requirement. On 01/09/2024 at 10:15 AM, the Agency Office Manager confirmed the Agency dd not meet the 5% requirement.

Based on clinical record review and staff interviews, it was determined that the agency did not include an accurate advance directive after it had been revised in the clinical record for 1 (#6) of 20 (#1- #20) records reviewed. This failed practice could result in potential harm for all patients on census in that, the agency did not include the revised advance directive as selected by the patient and could have resulted in a patient receiving resuscitation. Findings follow: --- Review of clinical record #6 with a start date of 9/2/2023 and a diagnosis of Congestive Heart Failure (CHF) revealed the following: A. A document titled, ";Hospice POC Report" revealed there was no Advance Directive decision included in the Plan of Care. B. A document titled, ";Visit Note Report" dated 11/30/2023 revealed, ";MSW Hospice subsequent visit...NARRATIVE... He wishes to remain a full code at this time..." C. A document titled, ";IDG Summary Report" dated 12/1/2023 revealed, ";.... Advanced Directives Directive Full Code.... Registered Nurse... CODE STATUS: FULL CODE.... Mottling present...Social Worker...[Name] wants to remain a FULL CODE. MSW [Medical Social Worker] to continue discussing code status with patient..." D. A document titled, ";Visit Note Report" dated 12/7/2023 revealed, ";...RN hospice subsequent ...visit.... NARRATIVE...Code Status: DNR [Do Not Resuscitate] ...PT [patient] educated on CPR [Cardiopulmonary Resuscitation] and wishes to change code status to DNR. E. A document titled, ";Visit Note Report" dated 12/26/2023 revealed, ";...MSW hospice subsequent visit... NARRATIVE...Pt is a DNR..." F. During clinical record review, there was no updated Advanced Directive to reflect the change from Full Code status to DNR. G. During an interview on 1/9/2024 at 1:00 p.m., the Agency Director stated, ";We have looked for the form and we cant find it. The nurse that made that note is no longer working here so we cant ask her about it."

Based on agency personnel review and staff interviews, it was determined that the agency did not complete the criminal background checks to include an Arkansas Department of Health determination letter as required by the State of Arkansas. This failed practice could result in potential harm for all patients on census in that, the agency did not include a complete background check for those hired to provide hands-on care within the agency. Findings follow: --- 1. The manual titled, ";Rules and Regulations for Conducting Criminal History Records Checks for Home Health, Hospice and Private Care Agencies in Arkansas" documented, ";... Definitions ... Determination means the determination made by the licensing or certifying agency that a service provider, operator, applicant for employment with, or employee of a service provider is or is not disqualified from licensure, exemption from licensure, certification, any other operating authority, or employment based on the criminal history of the service provider, operator, applicant, or employee...Section 7... F. If the licensing or certifying agency issues a determination that an applicant or employee is not disqualified from employment or if there is no criminal history on an applicant or employee, the service provider may employ the applicant or continue the employment of the employee..." 2. During personnel record review, it was noted that 4 of 4 (#1 - #4) unlicensed personnel records did not have an Arkansas Department of Health (ADH) (licensing and certifying agency) determination letter in their personnel files. 3. During an interview on 1/9/2024 at 12:15 p.m., the Office Manager and Executive Director were unaware of the AR state requirement to include a determination letter from the ADH in the personnel files.