Every finding on record at Caris Healthcare

Based on policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the hospice’s own policies and procedures by failing to ensure clinical notes were documented in a timely manner for 5 of 18 (Patient #2, #5, #9, #11, and #17) patients reviewed. --- The findings included: 1. Review of the agency policy "DOCUMENTATION REQUIREMENTS" last revised 3/26/2024, revealed, "…Members of the interdisciplinary team document the interventions provided to the patient…their response to care, services provided…Real time documentation is performed at the bedside and completed shortly after the visit using the hospice electronic charting system…” 2. Review of the medical record revealed Patient #2 was admitted to the agency on 6/3/2025, with diagnoses of Senile Degeneration of Brain, Alzheimer’s Disease, Dementia, Chronic Congestive Heart Failure and Anxiety. Review of the Client Coordination Note Report revealed a visit was made on 6/21/2025 at 4:30 PM. The documentation for the visit was completed on 6/23/2025 at 9:19 AM.  3. Review of the medical record revealed Patient #5 was admitted to the agency on 1/29/2025, with diagnoses of Malignant Neoplasm of the Kidney, Atrial Fibrillation, Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease. Review of the Client Coordination Note Report revealed a visit was made on 5/6/2025 at 1:26 PM. The documentation for the visit was completed on 5/9/2025 at 12:51 PM. Review of the Client Coordination Note Report revealed a visit was made on 5/8/2025 at 4:54 PM. The documentation for the visit was completed on 5/12/2025 at 9:29 AM. Review of the Client Coordination Note Report revealed a visit was made on 5/16/2025 at 2:13 PM. The documentation for the visit was completed on 5/24/2025 at 9:49 AM. Review of the Client Coordination Note Report revealed a visit was made on 5/20/2025 at 3:35 PM. The documentation for the visit was completed on 5/25/2025 at 9:31 PM. Review of the Client Coordination Note Report revealed a visit was made on 5/22/2025 at 10:06 AM. The documentation for the visit was completed on 5/25/2025 at 10:05 PM. Review of the Client Coordination Note Report revealed a visit was made on 5/27/2025 at 12:47 PM. The documentation for the visit was completed on 5/30/2025 at 9:03 PM. Review of the Client Coordination Note Report revealed a visit was made on 6/3/2025 at 2:05 PM. The documentation for the visit was completed on 6/5/2025 at 10:24 AM. Review of the Client Coordination Note Report revealed a visit was made on 6/5/2025 at 1:12 PM. The documentation for the visit was completed on 6/7/2025 at 7:04 AM. Review of the Client Coordination Note Report revealed a visit was made on 6/10/2025 at 2:55 PM. The documentation for the visit was completed on 6/12/2025 at 6:36 AM. Review of the Client Coordination Note Report revealed a visit was made on 6/13/2025 at 10:12 AM. The documentation for the visit was completed on 6/16/2025 at 10:05 PM. Review of the Client Coordination Note Report revealed a visit was made on 6/17/2025 at 1:27 PM. The documentation for the visit was completed on 6/22/2025 at 6:33 PM. Review of the Client Coordination Note Report revealed a visit was made on 6/19/2025 at 1:05 PM. The documentation for the visit was completed on 6/22/2025 at 7:15 PM. Review of the Client Coordination Note Report revealed a visit was made on 6/24/2025 at 12:27 PM. The documentation for the visit was completed on 6/26/2025 at 12:58 AM. Review of the Client Coordination Note Report revealed a visit was made on 6/26/2025 at 3:48 PM. The documentation for the visit was completed on 6/30/2025 at 7:38 AM. Review of the Client Coordination Note Report revealed a visit was made on 7/1/2025 at 2:05 PM. The documentation for the visit was completed on 7/8/2025 at 10:46PM. Review of the Client Coordination Note Report revealed a visit was made on 7/4/2025 at 3:12 PM. The documentation for the visit was completed on 7/9/2025 at 12:25 PM. Review of the Client Coordination Note Report revealed a visit was made on 7/8/2025 at 1:48 PM. The documentation for the visit was completed on 7/13/2025 at 1:59 PM. Review of the Client Coordination Note Report revealed a visit was made on 7/10/2025 at 1:28 PM. The documentation for the visit was completed on 7/20/2025 at 10:36 AM. Review of the Client Coordination Note Report revealed a visit was made on 7/15/2025 at 9:40 PM. The documentation for the visit was completed on 7/22/2025 at 10:54 AM. Review of the Client Coordination Note Report revealed a visit was made on 7/17/2025 at 1:25 PM. The documentation for the visit was completed on 7/27/2025 at 10:46 AM. Review of the Client Coordination Note Report revealed a visit was made on 7/22/2025 at 4:12 PM. The documentation for the visit was completed on 7/28/2025 at 7:10 PM. Review of the Client Coordination Note Report revealed a visit was made on 7/24/2025 at 1:14 PM. The documentation for the visit was completed on 7/30/2025 at 9:04 PM. 4. Review of the medical record revealed Patient #9 was admitted to the agency on 11/7/2024 with diagnoses that included Malignant Neoplasm of Colon, Alzheimer's Disease, and Hypertension. Review of the Client Coordination Note Report revealed a visit was made on 7/29/2025 at 3:40 PM. The documentation for the visit was completed on 7/31/2025 at 9:42 PM. Review of the Client Coordination Note Report revealed a visit was made on 8/1/2025 at 5:11 PM. The documentation for the visit was completed on 8/5/2025 at 5:48 PM. 5. Review of the medical record revealed Patient #11 was admitted to the agency on 7/18/2025 with diagnoses that included Senile Degeneration of Brain, Adult Failure to Thrive, Depression, Diabetes, and Chronic Pain. Review of the Client Coordination Note Report revealed a visit was made on 7/25/2025 at 4:58 PM. The documentation for the visit was completed on 7/27/2025 at 10:20 PM. 6. Review of the medical record revealed Patient #17 was admitted to the agency on 1/14/2025 with diagnoses that included Heart Failure, Aortic Stenosis, and Failure to Thrive. Review of the Client Coordination Note Report revealed a visit was made on 5/2/2025 at 11:34 AM. The documentation for the visit was completed on 5/7/2025 at 8:03 PM. 7. During an interview on 8/13/2025 beginning at 12:45 PM, the Regional Vice President of Clinical Care confirmed the time frame for documentation of visits notes for Patient #2, #5, #9, #11, and #17 were not completed timely.

Based on policy review, medical record review, and interview, the facility failed to ensure assessments were performed on 1 of 2 (Patient #2) patients reviewed for wound care.The findings included:Review of the agency policy "Wound Care Treatment" dated 4/7/2020, revealed, "...If a patient already has wound or develops a wound/pressure injury, the nurse will provide care in accordance with the hospice's infection control protocol and physician orders...If a wound/pressure injury is present, the documented findings include location, appearance, measurements, drainage, odor, and treatment orders..."Review of the medical record revealed Patient #2 was admitted to the agency on 6/3/2025 with diagnoses of Senile Degeneration of Brain, Alzheimer's Disease, Dementia, Chronic Congestive Heart Failure, and Anxiety.Review of the physician order's dated 6/3/2025, revealed, "...Skilled nurse to educate patient/caregiver in monitoring for signs and symptoms of infection including: increased drainage, foul odor, excessive bleeding, change in color/size of wound, fever..."Review of the Wound Record Report failed to reveal wound measurements on 7/15/2025, 7/17/2025, 7/18/2025, 7/21/2025, 7/22/2025, 7/23/2025, and 7/31/2025.During an interview on 8/14/2025 at 12:54 PM, the Regional Director of Clinical Care stated "...They should measure every week even if the caregiver completes the care..."

Based on medical record review and interview, the agency failed to follow the frequency of services necessary to meet the specific patient and family needs listed in the plan of care for 1 patient (#7) of 16 patients reviewed. The findings include: Medical record review showed Patient #7 was admitted to the agency on 10/3/2021 with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Dominant Side. Medical record review of the plan of care (POC) for recertification period 10/3/2021 to 10/29/2021 showed, "...Aide [Home Health Aide] 2WK [week] 3...TO ASSIST WITH PERSONAL CARE..." Medical record review of Patient #7's visit calendar revealed there had been no Aide visit for the week of 10/3/2021-10/8/2021. Interview on 11/3/2021 at 8:49 AM, the Regional Director of Clinical Care confirmed the Home Health Aide had missed 2 scheduled visits for the week of 10/3/2021-10/8/2021.

Based on agency policy review, medical record review, and interview, the agency failed to complete a weekly assessment of the skin integrity and document the findings for 3 patients (#3, #6, and #9) of 16 medical records reviewed. The findings include: Review of the agency's policy titled, "Wound Care Treatment," revised 6/29/2021, showed "...The nurse will perform a complete...assessment of the patient's skin integrity on a weekly basis and document findings...If a wound/pressure injury is present, the documented findings include location, appearance, measurements, drainage..." Medical record review showed Patient #3 was admitted to the agency on 1/30/2020 with diagnoses to include Chronic Diastolic Congestive Heart Failure, Delusional Disorder, Anemia, and Hypertensive Heart Disease. Medical record review of a Registered Nurse (RN) visit note dated 10/5/2021, showed Resident #3 had arterial wounds to the left ankle and heel, the left side of foot, the left bottom of foot at the 1st metatarsal head (long bone in the foot), and the left 3rd toe with documented location, appearance, measurements, and drainage. Medical record review of an RN Routine Home Health Aide (HHA) supervisory visit note dated 10/13/2021, showed the wounds had not been assessed or documented in the medical record. Medical record review of a Licensed Practical Nurse (LPN) visit note dated 10/20/2021, showed the wounds had not been assessed or documented in the medical record. Medical record review showed Resident #3's wounds were stable. During an interview on 11/3/2021 at 9:50 AM, the Regional Vice President of Operations confirmed Patient #3's wounds had not been assessed or documented in the medical record on 10/13 and 10/20/2021. Medical record review showed Patient #6 was admitted to the agency on 10/1/2021 with diagnoses to include Type 2 Diabetes, Chronic Kidney Disease, and Anemia. Medical record review of an RN routine visit note dated 10/2/2021, showed Patient #6 had a left heel pressure ulcer with documented location, appearance, measurements, and drainage. Medical record review of an RN routine visit note dated 10/4, 10/7 and 10/19/2021, showed the wound had not been assessed or documented in the medical record. Medical record review of a RN Routine LPN/HHA supervisory visit note dated 10/15 and 10/28/2021, showed the wound had not been assessed or documented in the medical record. Medical record review showed Resident #6's wound was stable. During an interview on 11/3/2021 at 10:05 AM, the Regional Vice President of Operations confirmed Patient #6's wound had not been assessed or documented in the medical record on 10/4, 10/7, 10/15, 10/19 and 10/28/2021. Medical record review showed Patient #9 was admitted to the agency on 10/8/2021 with diagnoses to include Senile Degeneration of The Brain, Dementia, and Heart Failure. Medical record review of an RN admit visit note dated 10/8/2021, showed Resident #9 had a left shoulder and a right leg wound with documented location, appearance, measurements, and drainage. Medical record review of an RN routine visit note dated 10/9, 10/19, and 10/25/2021, showed the wounds had not been assessed or documented in the medical record. Medical record review of a RN routine LPN/HHA supervisory visit note dated 10/13, 10/21, and 10/23/2021, showed the wounds had not been assessed or documented in the medical record. Medical record review showed Resident #9's wounds were stable. During an interview on 11/3/2021 at 9:15 AM, the Regional Director of Clinical Care, confirmed Patient #9's wounds had not been measured weekly or documented in the medical record on 10/9, 10/13, 10/19, 10/21, 10/23, and 10/25/2021.