Every finding on record at Eh Home Health of East Texas

Based on a review of clinical records and staff interviews, it was determined the agency failed to include essential Foley catheter management details in the individualized plan of care for one (#6) of two (#6 and #10) clinical records reviewed with catheter orders. Specifically, the plan of care did not specify the catheter size, balloon volume, irrigation solution, or catheter replacement frequency. This deficient practice failed to ensure safe and appropriate catheter management and had the potential to affect all patients on census with catheter orders, increasing the risk of preventable harm such as trauma or infection. Findings follow: --- A review of Clinical Record #19, with a start of care date of January 12, 2024, revealed the patient was diagnosed with Chronic Obstructive Pulmonary Disease. Review of the “Hospice Recertification Plan of Care Update,” with a certification period of 11/02/2025 to 12/31/2025, showed an order reading: “HOSPICE NURSE TO PLACE CATHETER, FR (French), WITH CC (cubic centimeter) BALLOON INFLATED WITH CC OF (SPECIFY NORMAL SALINE OR STERILE WATER). MAY IRRIGATE WITH CC OF Q (every) CHANGE CATHETER Q AND 1-3 VISITS PRN (as needed) FOR CATHTER DISLODGMENT, LEAKAGE, OCCLUSION, OR DISCOMFORT.” The catheter order was incomplete and did not specify the catheter size (French), balloon volume, irrigation solution/type, irrigation volume, or catheter replacement frequency.During an interview on November 20, 2025, at 3:30 PM, Agency Personnel #1 confirmed the plan of care did not include specific, complete, or individualized Foley catheter orders.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to follow the written plan of care in one  (#10) of fourteen (#1-#14) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in missed or delayed symptom management, ineffective care delivery, and unmet physical, psychosocial, or emotional needs. Findings follow: --- A review of clinical record #10, with a start of care date of October 27, 2025, revealed a patient diagnosed with Stage 5 Chronic Kidney Disease. Review of a form titled  “Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report” and dated November 5, 2025, revealed orders for Hospice Health Aide (HHA) visits three times per week for one week, followed by five times per week for twelve weeks, effective October 27, 2025. HHA visits were documented on October 30 and October 31, 2025. One HHA visit was missed during the period of October 27 through November 1, 2025.During an interview conducted on November 20, 2025, at 4:00 PM, Agency Personnel #2 confirmed that the HHA visit had been missed.