Every finding on record at Arkansas Home Hospice, LLC

Based on clinical record, agency's record review and staff interview, it was determined the agency failed to ensure there was a medication review of all medications for interactions for 1 (#14) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all patients on census that have orders for over-the-counter and alternative medications. Findings follow: --- Clinical Record #14 with a start of care date of 3/7/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).The Plan of Care included a medication list which included Prebiotic Lactobacillus and Premium CBD-FYH 50/10 which was not checked against all other medications for interactions. The computer system utilized by the agency does not include all medications and there is a highlighted blue listing on the medication list.The Policy and Procedure titled, "Medication Management" provided by the Executive Director documented, "... ...The clinician will check all medications the patient is taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, contraindicated medication(s), and known drug to drug interactions and shall report any problems to the physician..." On 3/27/25 the Executive Director and management staff were asked to provide any further details on this matter and none were provided.

Based on clinical record review and agency staff interview, it was determined the agency failed to ensure the pain care plan was individualized for 13 (#1 -#4 and #6-#14) of 13 (#1-#14) active clinical records reviewed. This failed practice had the potential to affect all patients on census in that the direct care staff would not be aware of the most updated and individualized interventions that would inhibit pain for the patients in their care. Findings follow: --- Clinical records #1- #4 and #6- #14 had a care plan that was not individualized for pain management. The interventions on the care plans documented to provide education on the pain scale and when to call the hospice agency. There were no specific interventions in the care plan for each patient that helped alleviate or inhibit pain. A Policy and Procedure provided by the Executive Director documented, "Purpose: To ensure each patient has an individualized plan of care that includes the specific needs, goals and desires of the patient...The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: a. Interventions to manage pain and symptoms..." On 03/27/25, the agency management staff were asked to provide any further information on the pain care plans and nothing more was provided.

Based on clinical record review and staff interview, it was determined the agency failed to ensure there was a specific order for an indwelling catheter for 1 (#10) of 3 (#10, #12, and #15) clinical records reviewed that had an indwelling catheter. This failed practice had the potential to affect all patients on census that have an indwelling catheter in that the direct care staff would not have the most updated information and aware of the patient's specific needs. Findings follow: --- Clinical Record #10 with a start of care date of 2/17/25 revealed a patient with a diagnosis of Heart Disease. The Admission Nursing Assessment dated 2/17/25 documented a size 16 indwelling catheter was inserted 2/28/25. The Hospice Certification and Plan of Care with a certification period of 2/17/25 - 5/17/25 documented, "... Provide education to caregiver regarding indwelling catheter care..." There was not a specific size in the order for the indwelling catheter. On 3/26/25 the Executive Director was asked to provide an order for the catheter and nothing further was provided.

Based on clinical and agency record review and staff interview, it was determined the agency failed to ensure there was documented progress and status of wounds for 2 (#4 and #10) of 3 (#3, #4, and #10) clinical records reviewed that had wounds being treated. This failed practice had the potential to affect all patients on census that have various types of wounds in that the physician would not be aware of any changes or stalled healing of the wounds. Findings follow: --- Clinical Record #4 with a start of care date of 8/27/24 revealed a patient with a diagnosis of Atherosclerotic Heart Disease. The patient had two active Deep Tissue Injuries (DTI's). One of the DTI's was on the heel, and one was on the plantar of the left foot. The wounds were initiated 2/22/25 for the left heel and 2/25/25 for the left plantar. There were measurements and assessment on 2/24/25 and 2/28/25 respectively. There was no evidence of further assessments or measurements to demonstrate progress toward expected outcomes. Clinical Record # 10 with a start of care date of 2/17/25 revealed a patient with a diagnosis of Heart Disease. The patient had a coccyx wound. The wound was identified and assessed on 2/17/25 but not measured. It was documented as "refusal" for measuring on 2/17/25. The next assessment and the first measurement were dated 2/27/25. There was no further assessment or measurements until 3/20/25. On 03/25/25 the Registered Nurse Case Manager stated wounds are measured weekly. On 3/26/25 the Executive Director stated wounds are measured weekly. The Policy and Procedure titled, "Care, Treatment & Services" documented, "... Wound measurements (weekly) including the length, depth, and width of the wound in centimeters... Stage the wound weekly..." On 3/27/25 the Executive Director and management staff were asked to provide any further information and none was provided.

Based on clinical record review and staff interview, it was determined the agency failed to ensure the Medical Social Worker (MSW) made visits according to the care plan for 1 (#4) of 4 (#4, #17 -#19) clinical records reviewed who had a decline in status and had orders for increased visits. This failed practice had the potential to affect all patients on census that have a significant decline in condition, termed as transitioning per the agency staff. Findings follow: --- Clinical Record #4 with a start of care date of 8/27/24 revealed a patient with a diagnosis of Atherosclerotic Heart Disease. A physician's order dated 3/13/25 and entered by the MSW documented to add MSW visits due to transitioning. The visits changed from 1 time a month to 3 times a month for the month of March. A physician's order dated 3/14/25 and entered by the MSW documented to update the patient calendar and remove the MSW visit from 3/20/25. The MSW visits were 2 times a month for the month of March after this order on 3/14/25. A physician's order dated 3/21/25 and entered by the MSW documented to remove the MSW visit from 3/24/25. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 3/26/25 revealed the chaplain/spiritual counselor and the nursing staff had increased visits order and participation in the month of March due to the patient's decline in condition/ transitioning. Specifically, the Plan of Care update report dated 3/26/25 documented the chaplain/spiritual counselor visits were increased to 2 times a month ordered 3/3/25. On 3/13/25 the chaplain/spiritual counselor visits were ordered to be changed to weekly. The skilled nursing visits were increased to 3 times for the week on 3/8/25 due to the patient's decline in condition and continued the week of 3/16/25 and 3/21/25. On 3/27/25, the Executive Director and management staff stated as a patient has a decline in condition, and they are transitioning then the agency staff increase visits to the patient and family. They were asked to provide any further information on this matter and none was provided.

Based on clinical record review and staff interview, it was determined the agency failed to ensure there was collaboration between the agency's spiritual counselor and the patient's local clergy for 3 of 3 (#9, #11, #13) clinical records reviewed which had documentation of a local church membership. This failed practice had the potential to affect allclients on census in that a lack of coordination could result in the patient's church members and clergy would not be involved at their usual level with the continued spiritual guidance and comfort needed for the patient during their end of life. Findings follow: --- Clinical Record #9 with a start of care date of 3/15/25 revealed a patient with a diagnosis of Malignant Neoplasm of breast, brain and spine. The 3/18/25 spiritual counselor assessment documentation revealed the patient and family are members of their local church. There was no documentation that the local clergy was contacted to facilitate visits from them and/or others in the church community. Clinical Record #11 with a start of care date of 1/28/25 revealed a patient with a diagnosis of Alzheimer's disease. The 1/31/25 spiritual counselor assessment documentation revealed the patient and family are members of their local church. The narrative note documented, "...Patient does not have adequate spiritual support and [Name] will be the patient's main source of spiritual support...." There was no documentation that the local clergy was contacted to facilitate visits from them and/or others in the church community. Clinical Record #13 with a start of care date of 1/21/25 revealed a patient with a diagnosis of Malignant Neoplasm of the lunch. The 1/23/25 spiritual counselor assessment documentation revealed the patient and family have a community of faith and named the local church. There was no documentation that the local clergy was contacted to facilitate visits from them and/or others in the church community. On 3/27/25 the Executive Director provided a Policy and Procedure which documented, "... Spiritual care is provided either directly or through coordination with the patient/representative's designated religious professional, as appropriate...The Chaplain or qualified spiritual counselor will coordinate resources and services to meet the patient/representative's needs. This will include coordination of services with the patient/representative's designated local clergy, pastoral counselor or other individual as appropriate..." On 03/27/25, the Executive Director and management staff were asked to provide any further information and none was provided.

Based on clinical record review and staff interview, it was determined the agency failed to ensure visits were documented when completed after the patient requested additional visits for 1 (#6) of 19 (#19) clinical records reviewed. This failed practice had the potential to affect all patients on census in that the lack of documented information could affect upcoming assessments by the agency staff and additional visits with the patient. Findings follow: --- Clinical Record #6 with a start of care date of 2/19/25 revealed a patient with a diagnosis of Atherosclerotic Heart Disease. According to the clinical record #6 there were 3 (three) triage (after hours) phone calls placed on 2/22/25 and 1 (one) call on 2/23/25 by the patient requesting to be seen. Clinical Record #6 revealed 2 (two) visits completed on the Monday morning of 2/24/25. The record noted the patient had some relief from the issue that was he was referring to over the weekend. On 2/26/25, there were two missed visit notifications for 2/22/25 and 2/23/25 and documented as the patient had refused these visits. On 3/26/25, the Executive Director was asked to provide more information regarding these additional visits and the documentation noted. She stated the patient did receive visits over the weekend of 2/22/25 and 2/23/25 but there was not documentation for these visits.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) did not complete a comprehensive assessment for 2 (#1 and #2) of 3 (#1, #2 and #4) patients with a documented wound. The absence of a wound assessment had the likelihood to affect all patients needing wound care in that, the RN could not establish the patient's wound care progress. Findings follow: 1. Review of Clinical Record #1 showed the RN did not assess the wound on the comprehensive assessment for the patient's start of care and showed the following: A. The patient had a Start of Care (SOC) date of 03/04/22 with diagnosis of Lung Cancer. B. A form titled, "Visit Note Report" dated 03/04/22 showed the patient had two wounds noted. A skin tear on the patient's mid forearm and stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister) on the patient's coccyx. The RN documented the wounds were not assessed due to the caregiver completed care, "Wound care not provided; caregiver completed care." C. A form titled, "Visit Note Report" dated 04/18/22 showed the RN had assessed the wound for the first time and documented, "Has a worsening stage 2 pressure ulcer to coccyx and new wound care orders received." 2. Review of Clinical Record #2 showed the following: A. The Patient had a SOC date of 04/27/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. B. A form titled, "Visit Note Report" on the SOC dated 04/27/22 showed the RN noted a stage 3 wound (full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling) to the coccyx. The RN documented the wound was not assessed and, "Wound care not provided; caregiver completed care." C. From 04/27/22, the patient's SOC, through 06/06/22, there was no evidence the RN documented wound assessments. 3. On 06/10/22 at 01:55 PM, Agency Personnel #1 confirmed the RN had not assessed the wound on Patient #1's SOC and had not assessed the wound on Patient #2. .

Based on Clinical Record review and staff interview, the Interdisciplinary Group (IDG) failed to document in the Plan of Care (POC) the Social Worker's (SW) frequency of visits in 4 (#1, #6, #8, and #10) of 13 (#1 - #13) Clinical Records reviewed. This failed practice by the IDG resulted in a POC which failed to reflect the patient's individualized needs and services to include scope and frequency of visit required by SW and had the likelihood to affect all patient's on census. The findings follow: 1. Review of Clinical Record #1 revealed the following: A. A Patient with a start of care of 03/04/22 and a primary diagnosis of lung cancer. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. On the IDG's dated on 04/19/22, 05/03/22 and 06/01/22, there were no frequencies listed for the SW visits. 2. Review of Clinical Record #6 revealed the following: A. A Patient with a start of care of 05/24/22 and a primary diagnosis of liver cancer. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. On the IDG dated on 05/26/22, there was no frequency listed for the SW visits. 3. Review of Clinical Record #8 revealed the following: A. A Patient with a start of care of 04/27/22 and a primary diagnosis of chronic obstructive pulmonary disease. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. On the IDG's dated on 05/03/22, 05/18/22 and 06/01/22, there were no frequencies listed for the SW visits. 4. Review of Clinical Record #10 revealed the following: A. A Patient with a start of care of 04/20/22 and a primary diagnosis of Cerebral Vascular Accident. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. On the IDG's dated on 05/03/22, 05/18/22 and 06/01/22, there were no frequencies listed for the SW visits. 5. On 06/09/22 at 2:00 PM, Agency Personnel #1 confirmed the missed frequencies on the patient's POC. .

Based on Clinical Record review and staff interview, it was determined the Agency failed to include interventions and goals into the plan of care necessary to meet the patient's needs that were identified through clinician assessments in 1 (#2) of 13 (#1 - #13) Clinical Records reviewed. This lack of including patient's individualized and specific interventions and goals inhibited the Interdiscplinary Team and Physician's ability to make informed decisions regarding the patients care and to evaluate the patient's progress. This deficient practice had the likelihood to affect all patients on census. Findings follow: Review of Clinical Record #2 revealed the following: 1. A patient with a Start of Care (SOC) date of 04/27/22 and a primary diagnosis of Chronic Obstructive Pulmonary Disease. 2. On a form titled, "Visit Note Report" dated 04/27/22 (Start of Care), the Registered Nurse (RN) noted a Stage 3 wound [Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling] to the patient's coccyx [tail bone area]. 3. On a form titled, "Hospice POC [Plan of Care] Report dated 04/27/22, there were no interventions or goals relating to the Patient's wound care. 4. On form titled "Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report" dated 5/3/22; 5/18/22; 6/1/22 there were no interventions or goals related to the patient's wound care and wound progress. 5. On a form titled "Visit Note Report" dated 4/28/22, the RN documented, "...Going as long as months without bathing. Sound as if patient may have undiagnosed, underlying mental illness. Relayed info to MSW (Master of Social work)..." 6. On a form titled "Visit Note Report" dated 5/2/22 the RN documented, "...Patient seems very depressed. She continues to be unkept (unkempt) and refusing help with ADLs (Activities of Daily Living) and hygiene. Per family she has been playing in her own feces and throwing it at them. Relayed info to MSW...." 7. On a form titled "Visit Note Report" and dated 5/4/22, the RN documented, "...APS [Adult Protective Services] involved in case and plans to make home visit soon..." 8. On a form titled "Visit Note Report" and dated 5/9/22, the RN documented, "...APS involved in case..." 9. On a form titled "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 5/3/22; 5/18/22; 6/1/22 there were no interventions or goals related to the patient's behavioral issues or APS involvement identified in the comprehensive assessments by the RN. On 06/09/22 at 2:15 PM, Agency Personnel #1 confirmed the lack of interventions and goals in the Patient's Plan of Care. .

Based on Clinical Record review and staff interview, it was determined the Agency failed to ensure the Interdisciplinary Group (IDG) reviewed, revised and documented updates to the patients Plan of Care (POC) at least every 15 days in 2 (#1 and #4) of 16 (#1 - #16) Clinical Records reviewed. The late update to the POC by the Agency, had the likelihood to place patients and their families at risk for adverse outcomes and delay patient and family attainment of defined goals. Findings follows: 1. Review of Clinical Record #1 showed the following: A. A Patient with a start of care (SOC) of 03/04/22 and a primary diagnosis of lung cancer. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. The Agency documented IDG's on 04/19/22, 05/03/22 and 06/01/22 (14 days late). D. On 06/09/22 at 3:15 PM, Agency Personnel #1 reported the Agency had conducted an IDG on 05/18/22 but it was not documented in the Patient's Clinical Record. 2. Review of Clinical Record #4 showed the following: A. A Patient with a SOC of 04/29/22 and a primary diagnosis of heart failure. B. The Agency documented IDG's (Plan of Care Updates) on a form titled, "Hospice IDG Comprehensive Assessment and Plan of Care Update Report." C. The Agency documented the first IDG on 05/18/22 (19 days after SOC and 4 days late). D. On 06/09/22 at 2:10 PM, Agency Personnel #1 confirmed the late IDG.