Every finding on record at Caris Healthcare

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure that the comprehensive assessment included an initial bereavement assessment. CLINICAL RECORD 7: The patient elected the hospice benefit 06/11/2025 with a terminal diagnosis of Huntington's Disease. The start of care comprehensive assessment did not include documentation of the initial bereavement assessment. There was no documentation in the record of an initial bereavement assessment that focused on the patient's family and other individuals, needs related to social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care agreed there was no documentation in the clinical record of an initial bereavement assessment.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed, the agency did not ensure the individualized written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit 06/18/2025 with the terminal diagnosis of hypertensive heart without heart failure. The Registered Nurse (RN) documented on the initial assessment dated 06/18/2025 that the patient was unable to respond to the question "Are you uncomfortable because of pain?" The RN assessed the patient's pain with a standardized pain tool and documented the FACE was 2-"hurts a bit." The RN documented the physician was notified and orders were received for Hydrocodone 5mg-Acetaminophen 325 mg tablet one tablet every six hours PRN [as needed] and Morphine concentrate 20mg/ml 0.5 ml hourly as needed for generalized pain. The plan of care included the pain goal, "pain is managed at a level acceptable to patient." The goal on the plan of care was not measurable when it did not include the patient’s acceptable level for pain. CLINICAL RECORD 2: The patient elected the hospice benefit on 12/19/2024 with diagnoses of hypertensive heart disease, diabetic neuropathy, and arthritis. The RN documented on the comprehensive that pain was an active problem for the patient which occurred less than daily and had an effect on quality of life. The plan of care included the pain goal, "pain is managed at a level acceptable to patient." The goal on the plan of care was not measurable when it did not include the patient’s acceptable level for pain. During a joint review of records and interview on 06/25/2025, the Patient Care Manager stated that the goals for pain were not individualized and measurable.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by document review, clinical record review, and interview. In 1 of 3 (33%) clinical records reviewed for patients with a wound, the agency did not ensure the Registered Nurse documented skin integrity/wound assessment as required by agency policy. Agency policy titled Wound Care Treatment, required in part: "The nurse will perform a complete head-to-toe assessment of the patient's skin integrity on a weekly basis and document findings in the EMR." CLINICAL RECORD 4: The patient elected the hospice benefit on 03/28/2025 with a terminal diagnosis of senile degeneration of the brain. The Registered Nurse (RN) documented on the initial comprehensive assessment that the patient was admitted with a stage IV coccyx wound. The RN documented skin integrity/ wound assessments on the nursing visit notes dated 06/04/2025 and 06/16/2025. However, there was no documented evidence that the nurse assessed the patient’s skin integrity/wound the week of 06/08/2025 to 06/14/2025 as required by agency policy. During an interview and joint review of records on 06/26/2025, the Patient Care Manager stated that the RN did not assess the skin integrity/wound the week of 06/08/2025 and there was no documentation as to why the assessment was not completed in the clinical record.

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the written certification included current subjective and objective medical findings. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023 with a diagnosis of senile degeneration of the brain. The physician written certification dated 04/21/2025 did not include current subjective and objective medical findings. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care agreed that the certification statement did not include current subjective and objective medical findings and stated that the hospice Medical Director had been counseled in the past related to including the required documentation in the written certifications.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the agency did not ensure the discharge summary was sent to the patient's attending physician. CLINICAL RECORD 19: The patient elected the hospice benefit on 04/21/2025 with a terminal diagnosis of chronic obstructive pulmonary disease and revoked the hospice benefit on 05/04/2025. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 20: The patient elected the hospice benefit on 02/21/2025 with a terminal diagnosis of hypertensive heart disease without heart failure and was administratively discharged on 06/17/2025. There was no documented evidence in the clinical record review that the discharge summary was forwarded to the patient's attending physician. During an interview and review of findings with the Regional Vice President of Clinical Care (RVPCC) on 06/26/2025, there was an extensive search for documentation that the discharge summaries were sent to the receiving provider. The RVPCC explained the agency’s policy was to provide the discharge summary to the attending physician, but there was no evidence present in the clinical record, or the fax reports that the summaries had been sent to the providers.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment [DME] and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG [interdisciplinary group]. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the patient and/or caregiver(s) were instructed on the proper handling, storage, and safe utilization of durable medical equipment. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/24/2025 with a terminal diagnosis of chronic obstructive pulmonary disease. Clinical record review revealed physician orders for a wheelchair and an oxygen concentrator on 04/24/2025, an over the bed table and nebulizer on 04/25/2025, and an alternating air mattress and Hoyer lift on 04/28/2025. There was no documented evidence in the clinical record that the patient and/or caregiver were instructed on the proper handling, storage, and safe utilization of the durable medical equipment ordered for the patient. During an interview and joint review of records on 06/26/2025, the Regional Vice President of Clinical Care stated there was no documentation in the clinical record of DME education provided to the patient. She explained that the EMR [electronic medical record] did not have a designated section in the comprehensive assessment or plan of care to document this education, so the nurses were not prompted to document the training in the clinical record and sometimes forget to document the DME education.

Based on agency policy review, medical record review, agency investigation review, and interview, the agency failed to prevent sexual abuse for 1 patient (Patient #1) of 4 patients reviewed for abuse. The findings include: Review of the agency policy titled, "Abuse, Neglect, Mistreatment, And Exploitation," reviewed 2/25/2020, showed "...[agency name] follows all Federal and State requirements regarding alleged violation involving mistreatment, neglect, or verbal, mental, sexual and physical abuse..." Medical record review showed Patient #1 was admitted to the agency on 11/4/2021 with diagnoses including Malignant Neoplasm of Sigmoid Colon, Vitamin D Deficiency, Melena, Traumatic Brain Injury, Renal Infarction, Post-Traumatic Stress Disorder, Panic Disorder, Depression, Low Back Pain, and Osteoarthritis. Review of Patient #1's Hospice Plan of Care dated 11/4/2021- 2/1/2021, showed the patient was alert and he was to have skilled nurse visits 1 time per week for 12 weeks. Review of Patient #1's visit note dated 11/4/2021, showed the Patient was alert and oriented to person, place, and time. Review of the visit schedule showed the patient was seen by Registered Nurse (RN) #1 on 11/4/2021, 11/10/2021, 11/15/2021, 11/22/2021, and on 11/30/2021. The patient was seen by Licensed Practical Nurse (LPN) #1 on 12/2/2021, 12/8/2021, and 12/10/2021 (phone call). Review of the agency investigation showed a Fact Finding Report dated 12/7/2021, "...[Patent #1] called the corporate office and was transferred to our office at approx. 9:44 AM 12/7/21. [Patient #1] stated to the Office manager...that he had been sexually assaulted by our nurse [RN #1]. He [Patient #1] told her [Office Manager] that he had video and photographic proof..." Review of the agency's Fact Finding Report dated 12/8/2021 showed "...I [The Administrator] received a call from...SW [Social Worker] at approx. 4:10 PM and said that there was an issue. She stated when she and the LPN [LPN #1] went to see patient [Patient #1] he asked them if they knew what was going on. They said they knew something was going on but had no idea what. He then proceeded to tell them that he had been a victim of sexual assault from our nurse [RN #1]. He then proceeded to show them several nude pictures of [RN #1] that he had on his phone...Employee suspended pending investigation..." Further review of the Administrators witness statement dated 12/8/2021, showed RN #1 reported to the Administrator that she had sent Patient #1 (2) nude photos of herself. Review of a Case Conference Summary dated 12/15/2021, showed "...Sw [Social Worker] completed initial visit with pt [patient] in his room on 12/8/2021...RN also present for visit. During SW's initial visit with pt on 12/8/2021, he reported that a prior nurse case manager [RN #1] had "sexually taken advantage " of him. The pt showed this SW pictures from his phone of the prior nurse case manager in compromising positions. SW reported this information to...Admin [Administrator]...Assessments have been completed for danger or harm to the patient and Investigations have been completed. The patient was offered the opportunity to move to another agency but was declined. SW will continue to monitor pt for distress..." Review of the agency's Request For Termination dated 12/10/2021, showed "...Involuntary Termination of [RN #1]...Chronology of Events Leading to Decision to Terminate: Accusation of sexual assault against patient and employee admitted to sending nude pictures to patient via phone..." During an interview on 5/9/2022 at 10:25 AM, the Administrator stated RN #1 had been Patient #1's nurse. The patient had only wanted nursing services at the time of his admission, he was seen weekly by the nurse, and had been on service for about 1 month when he reported the allegation of abuse. RN #1 had taken another position in the agency and was no longer going to be seeing patients. At that time, she was training another nurse to take her patients. The Administrator stated RN #1 had expressed to her that she was uncomfortable caring for Patient #1 and the Administrator had told RN #1 to tell Patient #1 that a new nurse would be seeing him because she had taken another role in the agency and would no longer be making patient visits. The Administrator stated on 12/7/2021, Patient #1 had called the agency's office and told the Office Manager he had been sexually assaulted by RN #1 and he had photo and video proof. The Administrator stated she then spoke to RN #1 about the patient's allegation and RN #1 had stated that she knew he was going to do that because she wasn't going to be his nurse any longer. The next day, on 12/8/2021, the Administrator had sent another nurse (LPN #1) and the SW to the patient's home. She stated she got a call from them saying he had shown them photos of RN #1 performing sexual acts with Patient #1 and it had been clear in the photos that the person was RN #1. The Administrator confirmed sexual relationships between employees and patients were not tolerated within the company and RN #1 was terminated on 12/10/2021. During a telephone interview on 5/9/2022 12:06 PM, SW #1, stated she went to see Patient #1 after he had made comments about a nurse "...doing something to him..." She stated she went to the patient's home with another nurse (LPN #1). SW #1 stated "...he flashed his cell phone in front of us and it was pictures of [RN #1] nude...one was of her clothed snuggling with him, her laying on his chest. He said that they had sexual intercourse, oral intercourse..." The SW confirmed the phots were of RN #1 and the patient had stated the photos were a mixture of ones he had taken of RN #1 and some she had sent to his phone. During a telephone interview on 5/9/2022 at 12:37 PM, LPN #1 stated she had went with SW #1 to Patient #1's home and he had shown her "...pictures of him having sex with [RN #1]..." and stated RN #1's face was visible in the photos. LPN #1 stated "...she was having sex with him [Patient #1]...oral sex with him... he also had video..." LPN #1 stated she did not watch the video and the patient had stated RN #1 had sent some of the pictures to his phone. LPN #1 confirmed the nurse in the photos was RN #1 "...it was [RN #1]...she took advantage of my patient..." During a telephone interview on 5/9/2022 at 3:24 PM, RN #1 stated she did have a relationship with Patient #1 "...We basically started dating and ended up having a relationship...initially it started by I called him using my cell phone and he started texting me constantly first about random things and then started talking more in depth...we started dating very briefly, then I told him if we were going to date that I couldn't be his nurse..." RN #1 confirmed she did have an intimate relationship with Patient #1 and they did have sexual intercourse. RN #1 stated "...honestly he initiated the intimate relationship, but It is my fault, I knew better..." RN #1 stated she tried to switch his care to a different nurse "...but he got mad about that and that's when the relationship ended, he told me that if you're not gonna be my nurse I don't need you...everybody knows there is an ethical boundary..." During a telephone interview 10:50 AM 5/10/2022, Patient #1 stated "...it's a plain up sure case of she drugged me up and raped me..." Patient #1 stated he did not have a consensual relationship with RN #1.