Every finding on record at Area Agency on Aging of Western Arkansas, Inc.

Based on record review and interview it was determined the agency did not have initial bereavement assessments completed for 12 (#1-#10, #12 and #13) of 14 (#1 - #14) clinical records reviewed. This failed practice had the potential to affect all 18 patients on the census in that there was no individualized plan for those that accepted and needed bereavement care. Findings follow: --- On 04/16/24, the Director of the hospice agency stated the chaplain completes the initial bereavement assessment and would be in the individual charts. On 04/17/24, during record review it was revealed that Patients #1-#10, #12 and #13 did not have initial bereavement assessments completed. On 04/18/24, during an interview with the Director and the Director of Nursing, it was explained that since the new computer system almost a year ago, the chaplain had not been selecting the correct assessment option in the system and he had not completed a separate initial bereavement assessment. The Director stated, "We didn't know this until you asked about it [assistance in finding these assessments]."

Based on record review and interview it was determined the agency failed to ensure there was involvement by all members of the Interdisciplinary Group (IDG) and to accurately reflect the current status and plans of care for 13 (#1-#9, #11-#14) of 14 (#1 - #14) clinical records reviewed. This failed practice had the potential to affect 18 patients on the current census in that the IDG may not identify lack of progress toward goals and revise plans of care accordingly. Findings follow: --- Review of clinical record #1 with a start of care date of 05/09/23 and certification period of 03/04/24 - 05/02/24 revealed a patient with a diagnosis of Hypertensive Heart Disease and other kidney disease. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse does not include information on the physical and medical needs of the patient and family, progress towards goals, and status of the current plan of care. Review of clinical record #2 with a start of care date of 06/13/23 and certification period of 04/03/24 - 06/01/24 revealed a patient with a diagnosis of COPD. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse had limited information on the physical and medical needs of the patient and family, and no notation regarding progress towards goals, and status of the current plan of care. Review of clinical record #3 with a start of care date of 11/07/23 and certification period of 03/06/24 - 05/04/24 revealed a patient with a diagnosis of Huntington's disease. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse does not include information on the physical and medical needs of the patient and family, progress towards goals, and status of the current plan of care. In addition, the sections for DNR (Do Not Resuscitate) Status and Funeral Home were blank. Review of clinical record #4 with a start of care date of 02/23/24 and certification period of 02/23/24 - 04/22/24 revealed a patient with a diagnosis of Dysphagia following CVA. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse does not include information on the physical and medical needs of the patient and family, progress towards goals, and status of the current plan of care. Review of clinical record #5 with a start of care date of 01/11/24 and certification period of 04/10/24 - 07/08/24 revealed a patient with a diagnosis of Huntington's disease. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse had limited information on the physical and medical needs of the patient and family, and no notation regarding progress towards goals, and status of the current plan of care. In addition, the DNR status section was blank. Review of clinical record #6 with a start of care date of 03/29/24 and certification period of 03/29/24 - 06/26/24 revealed a patient with a diagnosis of Alzheimer's disease with late onset. The IDG meeting notes dated 04/10/24 did not include a notation from the skilled nurse. In addition, the section to document Funeral Home was blank. Review of clinical record #7 with a start of care date of 11/30/23 and certification period of 02/28/24 - 05/27/24 revealed a patient with a diagnosis of Alzheimer's disease. The IDG meeting notes dated 03/27/24 did not include a notation from the chaplain. The notation from the skilled nurse does not include information on the physical and medical needs of the patient and family, progress towards goals, and status of the current plan of care. In addition, the DNR status and Funeral Home sections were blank. Review of clinical record #8 with a start of care date of 11/01/23 and certification period of 01/30/24 - 04/28/24 revealed a patient with a diagnosis of Alzheimer's. The IDG meeting notes dated 04/10/24 did not include a notation from the skilled nurse, nor the chaplain. In addition, the Funeral Home section was blank. Review of clinical record #9 with a start of care date of 03/25/22 and certification period of 02/20/24 - 04/19/24 revealed a patient with a diagnosis of Hypertensive Heart Disease with heart failure. The IDG meeting notes dated 04/10/24 did not include a notation from the chaplain. The notation from the skilled nurse had limited information on the physical and medical needs of the patient and family, and no notation regarding progress towards goals, and status of the current plan of care. Review of clinical record #11 with a start of care date of 04/24/22, certification period of 12/15/23 - 02/12/24, and expired at home on 01/06/24. The patient had a diagnosis of Hypertensive Chronic Kidney Disease. The IDG meeting notes dated 01/03/24 did not have notations from the chaplain, nor the nurse. The notes dated 12/19/23 and 01/02/24 from the social worker were identical. In addition, the funeral home section was blank. Review of clinical record #12 with a start of care date of 11/30/23, certification period of 11/30/23 - 02/27/24, and expired at a medical facility on 12/22/23. The patient had a diagnosis of Malignant Neoplasm of Prostate. The IDG meeting notes dated 12/20/23 did not have notations from the chaplain, nor the nurse. In addition, the funeral home section was blank. Review of clinical record #13 with a start of care date of 04/20/23, certification period of 12/16/23 - 02/13/24, and discharged on 02/05/24 after a hospital admission on 01/13/24. The patient had a diagnosis of Amyotrophic lateral stenosis. The IDG meeting notes dated 01/31/24 documented there was no change since last IDG meeting, however, patient remained in the hospital since 01/13/24 with COVID, an abdominal abscess and received IV antibiotics. The infection section of the IDG notes documented, "No active Infections". The DNR status and Funeral Home sections were blank. Review of clinical record #14 with a start of care date of 01/20/21, certification period of 07/09/23 - 09/06/23, and discharged on 09/06/23. The patient had a diagnosis of Senile Degeneration of the Brain. The IDG meeting notes dated 08/30/23 did not have notations from the chaplain. In addition, the funeral home section was blank. During an interview on 04/18/24 the Director and Director of Nursing stated the IDG participants sign-in or log in on their laptops when the meeting is held. It was determined the computer system had a sign-in sheet during the IDG meetings held. The sign-in sheet was provided for the 04/10/24 IDG meeting which documented, "...IDG Meeting Time 8:00 AM - 9:00 AM (CST).." It was noted the chaplain had a sign-in time of 7:13 PM, the Director of Nursing had a sign-in time of 2:12 PM, the Social Worker had a sign-in time of 10:18 AM, the physician's sign-in time was on 04/11/24 at 9:30 AM. All other sign-in times were varied through the morning of 04/10/24.The time frames for logging-in was 7:25 AM at the earliest and 04/11/24 at 9:30 AM at the latest.

Based on record review and interview it was determined the agency failed to ensure visits from the healthcare team were completed as planned and documented in the plan of care for 6 (#1, #2, #3, #4, #7, and #9) of 10 (#1 - #10) clinical records reviewed. This failed practice had the potential to affect 18 patients on the current census in that care and services would not be provided as planned, as well as potential new health issues would not be identified. Findings follow: --- Review of clinical record #1 with a start of care of 05/09/23 revealed a patient with a diagnosis of Hypertensive Heart disease and other kidney disease. A document titled, "Hospice Plan of Care" with a certification period of 03/04/24 - 05/02/24 revealed Aide visits planned for 3 times a week for 8 weeks then 2 times a week for 1 week and Chaplain visits planned for 2 times a month for 3 months. During record review on 04/17/24, it was noted there were two (2) aide visits missing 03/29/24 and 04/08/24 and one (1) chaplain visit missing in March 2024. Review of clinical record #2 with a start of care of 06/13/23 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A document titled, "Hospice Plan of Care" with a certification period of 04/03/24 - 06/01/24 revealed Aide visits planned for 2 times a week for 1 week then 3 times a week for 8 weeks. During record review on 04/17/24, it was noted there was a missing visit 04/10/24. Review of clinical record #3 with a start of care of 11/07/23 revealed a patient with a diagnosis of Huntington's Disease. A document titled, "Hospice Current Plan of Care" with a certification period of 03/06/24 - 05/04/24 revealed Aide visits planned for 2 times a week for 1 week then 3 times a week for 8 weeks. Aide visits updated 03/18/24 changed to Aide visits 2 times a week for 7 weeks. During record review on 04/17/24, it was noted there were aide visits missing 03/06/24, 03/08/24, 03/15/24, 03/18/24 and 03/20/24. Review of clinical record #4 with a start of care of 02/23/24 revealed a patient with a diagnosis of Dysphagia following CVA (Cerebrovascular Accident). A document titled, "Hospice Plan of Care" with a certification period of 02/23/24 - 04/22/24 revealed Aide visits planned for 2 times a week for 8 weeks and Skilled Nursing 1 time a week for 8 weeks. During record review on 04/17/24, it was noted there were missing aide visits on 02/26/24, 02/28/24, 03/18/24, 03/20/24, and 03/26/24. It was also noted there was a missing skilled nurse visit the week of 03/11/24. Review of clinical record #7 with a start of care of 11/30/23 revealed a patient with a diagnosis of Alzheimer's disease. A document titled, "Hospice Plan of Care" with a certification period of 02/28/24 - 05/27/24 revealed Aide visits planned for 2 times a week for 1 week then 3 times a week for 11 weeks. During a record review on 04/17/24, it was noted there were missing aide visits on 03/06/24 and 04/08/24. Review of clinical record #9 with a start of care of 03/25/22 revealed a patient with a diagnosis of Hypertensive Heart Disease with heart failure. A document titled, "Hospice Plan of Care" with a certification period of 02/20/24 - 04/19/24 revealed Aide visits planned for 2 times a week for 1 week then 3 times a week for 8 weeks. During a record review on 04/17/24, it was noted there were missing aide visits on 02/21/24, 02/28/24, 03/01/24, 03/20/24, 03/22/24, and 04/08/24. On 04/18/24, the agency Director and Director of Nursing were given the above missed visits notification and there was no additional information provided.

Based on record review and interview it was determined the agency failed to ensure there were individualized care plans with specific goals and interventions for the problems identified by the Interdisciplinary team members for 14 of 14 (#1 - #14) clinical records reviewed. This failed practice had the potential to affect 18 patients on the current census in that the direct caregivers and others would lack the specific instructions on how to care for the patient, what and when to assess, and what the goals are for the patient. Findings follow: --- Review of clinical record #1- #14 revealed there were missing goals and interventions for problems identified from assessments by the Interdisciplinary Team members. Review of the Hospice Plan of Care for active clinical records #1- #10 revealed there were identical and nonspecific aide care plan interventions for bathing, "...transfers, ambulation, exercise program...", "...positioning, repositioning, alignment...", and "...meal preparation, set-up, feeding..." On 04/18/24, the Director and Director of Nursing were given the information and allowed to provide any further documentation. None were provided by the end of the survey.

Based on record review and interview, it was determined the agency failed to ensure there were complete orders for 2 of 2 (#2, #12) clinical records reviewed with urinary catheter orders, 2 of 2 (#2, #5) clinical records reviewed with wound dressing orders, 2 of 2 (#3, #5) clinical records reviewed with orders for enteral feeding, and 2 of 2 (#9, #10) clinical records reviewed with oxygen orders. The incomplete orders had the potential to cause harm to those patients with orders for urinary catheters, wound dressings, enteral feedings, and/or oxygen as the direct care staff did not have specifics to care for them correctly. Findings follow: --- Review of clinical record #2 with a start of care date of 06/13/23 revealed a patient with a diagnosis of COPD and orders for an indwelling catheter and pressure ulcer dressings. The Hospice Plan of Care did not include size of indwelling catheter, bulb size of catheter, and how often to change the catheter and by whom. The wound dressing plan did not include how often the dressing would be changed and by whom, as the patient resides in a skilled nursing facility. Review of clinical record #3 with a start of care date of 11/07/23 revealed a patient with a diagnosis of Huntington's disease and orders for continuous enteral feeding via gastrostomy tube. The Hospice Plan of Care did not include the care of the gastrostomy tube insertion site, who would oversee this, and who would take responsibility for reinsertion of the gastrostomy tube routinely or as needed as this patient resides in a skilled nursing facility. Review of clinical record #5 with a start of care date of 01/11/24 revealed a patient with a diagnosis of Huntington's disease. The Hospice Plan of Care documented, "...Nutrition: Tube Feeding..." There were no orders for the enteral feeding in the Plan of Care. The wound dressing plan did not include how often the dressing would be changed and by whom, as the patient resides in a skilled nursing facility. Review of clinical record #9 with a start of care date of 03/25/22 revealed a patient with a diagnosis of Hypertensive Heart Disease with heart failure. The medication list included, "...Oxygen via nasal cannula device; Administer 2-4 liter(s) inhaled Continuous for shortness of breath..." The Plan of Care was not specific in the rate of administration. On 04/18/24, the patient was observed at the facility not wearing oxygen. Review of clinical record #10 with a start of care date of 01/20/23 revealed a patient with a diagnosis of Nonrheumatic Aortic Valve Stenosis with insufficiency. The medication list included, "...Oxygen via nasal cannula device; Administer 2-4 liter(s) inhaled Continuous for shortness of breath..." The Plan of Care was not specific in the rate of administration. On 04/18/24, during an interview, the patient stated she has her oxygen rate at 2Liters. Review of clinical record #12 with a start of care date of 11/30/23 revealed a patient with a diagnosis of Malignant Neoplasm of Prostate. The Plan of care did not have any specifics on the size, bulb size of catheter, how often to change the catheter, and by whom. On 04/18/24, the Director and Director of Nursing were informed of the issues identified with the plans of care. No further documentation was provided by the end of the survey.

Based on record review and interview, the agency failed to ensure there was documentation regarding cost savings achieved through the use of volunteers. This failed practice had the potential to affect 18 patients as listed on the current census. --- On 04/16/24 and 04/18/24, the Director was asked to provide the cost savings report through the use of volunteers, as required. There was no documentation of cost savings achieved by the end of the survey.

Based on record review and interview, the agency failed to provide volunteer services of 5% or greater, which would include administrative and/or direct care duties as required. This failed practice had the potential to affect 18 patients as listed on the current census list. Findings follow: --- 1. On 04/16/24, the Director was asked to provide the volunteer hours percentage rate. The Director provided a report with the hours of 10.18 hours thus far for the 2024 calendar year. The Director provided on 04/18/24, a report for 2023 which documented there were 81.97 hours needed and 31.59 hours reported for the year of 2023. The Director stated, "We don't have the 5% rate. She [volunteer coordinator] has worked really hard to get more volunteers."