Every finding on record at Heart of Hospice, LLC

Based on observation, review of documentation and staff interview, the Hospice Inpatient Unit (IPU) failed to consistently monitor and document the temperatures of refrigerated medications and biological products provided to patients. Review of the temperature logs identified incomplete daily entries and a lack of documented verification that refrigerator temperatures remained within the required range. Failure to consistently monitor and document refrigerator temperatures places temperature-sensitive medications at risk of improper storage, potentially compromising their potency, stability, and overall effectiveness, and posing a risk to patient safety. This deficient practice has the potential to affect the health and safety of all patients receiving care within the unit. --- Review of the document titled “Med Room Fridge Temperature Log 2026” revealed incomplete temperature entries on 12 of 31 days in January and 3 of 9 days in February.During an interview conducted on February 9, 2026, at 2:30 PM, Agency Personnel #1 stated that refrigerator temperatures are required to be checked daily.In a subsequent interview on February 9, 2026, at 3:30 PM, Agency Personnel #2 confirmed that refrigerator temperatures are required to be checked daily and acknowledged that the agency failed to ensure temperatures were consistently monitored and documented each day.

Based on observation, review of medication cart, and staff interview, the Hospice Inpatient Unit (IPU) failed to ensure an effective system for the proper labeling, storage, and disposal of medications maintained in the patient medication cart. Failure to appropriately label, store, and remove medications increases the risk of administering expired, mislabeled, or otherwise unusable drugs and biological products. This practice may result in decreased medication effectiveness, potential patient harm, and an increased risk of medication errors. This deficient practice has the potential to affect the health and safety of all patients receiving care within the unit. --- A medication cart audit identified expired medications and medications with altered labels. Label alterations included marking out the patient’s name with black marker or removing the patient’s name entirely from the label.Medications with altered or improper labeling:Lacosamide – Exp. 04/30/26ClearLax powder – Exp. 03/19/26ClearLax powder – Exp. 06/28/26Nix crème rinse – Exp. 02/24/26Guaifenesin liquid – Exp. 09/25/26Fleet laxative enema – Exp. 04/12/26ClearLax powder – Exp. 07/10/26Lactulose – Exp. 08/16/26Expired medications:Acetaminophen 325 mg – Exp. 11/2025Glutose 15 oral glucose gel – Exp. 09/30/2025 During an interview conducted on February 10, 2026, at 2:30 PM, Agency Personnel #2 inquired about the location where the medications were found and acknowledged that they appeared to belong to patients who had been discharged from the IPU.In a subsequent interview on February 10, 2026, at 3:30 PM, Agency Personnel #2 confirmed that the agency failed to properly dispose of medications belonging to discharged patients, as well as expired medications.

Based on observation, review of the storage supply room, and staff interviews, it was determined that the Hospice Inpatient Unit (IPU) did not have an effective process in place to identify and monitor expired medical supplies used for patient care.The presence of expired supplies available for use may compromise sterility, effectiveness, and overall quality of care, increasing the risk of infection, delayed healing, and other adverse patient outcomes. This deficient practice has the potential to affect the health and safety of all patients receiving care within the unit. --- On February 10, 2026, at 12:00 PM, an inventory of the patient supply storage room revealed the following expired items that should not have been available for patient use:Vascular Access and Syringe Supplies:1 BD Vacutainer blood collection set – Exp. 04/30/251 Surshield safety winged infusion set – Exp. 04/30/2543 – 1 mL Luer Lock syringes – Exp. 01/19/26Tracheostomy Supplies:7 Tracheostomy tubes – Exp. 07/31/243 Tracheostomy tube holders – Exp. 01/31/2510 Inner cannulas – Exp. 03/25/2510 Inner cannulas – Exp. 11/26/2510 Inner cannulas – Exp. 04/22/251 Tracheostomy care tray – Exp. 04/16/241 Tracheostomy care tray – Exp. 05/25/24Urological and Ostomy Supplies:13 Male incontinence catheters – Exp. 11/01/2410 Colostomy pouches – Exp. 06/01/2510 Colostomy pouches – Exp. 05/01/25Wound Care and Topical Products:8 McKesson bottle iodoform packing strips – Exp. 09/20251 Curad bottle iodoform packing strip – Exp. 12/22/242 Sivasorb gel – Exp. 03/22/251 Box povidone-iodine prep pads – Exp. 07/20253 Iodoflex cadexomer iodine pads – Exp. 08/01/241 Aspercreme pain relief patch – Exp. 12/20241 Mepilex foam dressing – Exp. 12/28/252 Mepilex foam dressings – Exp. 01/28/2620 DermaFoam wound dressings – Exp. 02/20/243 DermaFoam foam wound dressings – Exp. 09/04/252 ComfortFoam border wound dressings – Exp. 02/09/25During an interview conducted on February 10, 2026, at 2:00 PM, Agency Personnel #2 stated she was responsible for ordering supplies but had not been monitoring expiration dates. She indicated that she believed a former employee had previously overseen expiration date checks and confirmed there was no current process in place to routinely review or rotate stock.In a subsequent interview on February 10, 2026, at 3:30 PM, Agency Personnel #2 acknowledged that the agency failed to maintain adequate oversight to ensure expired supplies were identified and removed from inventory in a timely manner.

Based on observation, a tour of unoccupied patient rooms, and staff interviews, it was determined that the Hospice Inpatient Unit (IPU) failed to maintain a safe and sanitary patient care environment in two of two patient rooms observed.Failure to ensure that patient care equipment was properly cleaned, disinfected, and stored has the potential to compromise infection prevention and control standards, create environmental safety hazards, and interfere with the safe delivery of care. This deficient practice has the potential to affect all patients receiving services within the unit. --- During a tour of the IPU on February 9, 2026, at 3:00 PM, accompanied by Personnel #1, a shower chair was observed left unattended in the shower area of two of two unoccupied patient rooms toured. Additionally, multiple pieces of patient care equipment—including shower chairs, bedside commodes, and walkers—were observed piled together and stored in a patient room annex rather than in a designated clean equipment storage area.In an interview conducted on February 9, 2026, at 3:00 PM, Agency Personnel #1 stated she was unsure why the shower chairs had been left in the patient rooms or why equipment was being stored in the annex. She further indicated that most patients admitted to the IPU do not use the showers, nor do their family members.In a subsequent interview on February 9, 2026, at 4:00 PM, Agency Personnel #2 stated she did not know why the unit maintained that quantity of equipment and confirmed that the agency failed to ensure patient care equipment was consistently cleaned and properly stored after use.

Based on observation, review of Center for Disease Control (CDC) guidelines, a tour of unoccupied patient rooms, and staff interviews, it was determined that the Hospice Inpatient Unit (IPU) failed to ensure the proper storage and control of clean linens in two of two patient rooms observed.Failure to appropriately secure and store clean linens increases the risk of environmental contamination and does not support compliance with established infection prevention and control standards. This deficient practice has the potential to affect the health and safety of all patients receiving care within the unit. --- According to the CDC guidelines for Environmental Infection Control in Health Care Facilities (2003), linens should be stored on clean shelves, in closed cabinets, or on covered carts.During a tour of the IPU on February 9, 2026, at 3:00 PM, accompanied by Agency Personnel #1, linens were observed stored in two unoccupied patient rooms rather than in a designated clean linen storage area.In an interview conducted on February 9, 2026, at 3:00 PM, Agency Personnel #1 stated that she was unsure why linens were being stored in patient rooms, suggesting that aides may have placed them there in preparation for the next patient admission.In a subsequent interview on February 9, 2026, at 4:00 PM, Agency Personnel #2 confirmed that the agency did not ensure proper storage and control of clean linens in accordance with infection control standards.

Based on clinical record review and staff interview, it was determined the Agency failed to ensure the medications were accurate in the home for 2 (#12 and #13) of 4 (#11-#14) patients observed on home visits. This failed practice had the potential to affect all patients on the current census as the medication inaccuracy had the potential to cause harm for patients. Findings follow: --- Review of Clinical Record #12 with a start of care date 09/04/23 revealed a patient with a diagnosis of Hypertensive Heart and Chronic Kidney Disease. On 10/23/24, during a home visit, the medication list was reviewed with the family member, and it was noted there were discrepancies. The medications were not in the home as the family member stated the patient will throw them away. She stated, "I don't give her the depakote but twice a day. I can't get her to take them three times a day." She stated she sets up her medication in planners. When asked, the planners were presented but they were empty. The Registered Nurse (RN), after the visit and in private, stated she comes on Fridays and calls ahead of time so when she gets to the house, the planners were set up and they appear correct. She was unsure why the planners were now empty on today's visit. She stated, "We keep the depakote on the list as 3 times a day because that is what is ordered even though the family doesn't give it to her that way." Review of Clinical Record #13 with a start of care date 02/06/23 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. On 10/23/24, during a home visit, the medication was reviewed with the family member. There were bottles of Ativan 0.5 mg with a refill date of 09/19/24 and a bottle of Haldol. These were as needed (PRN) medications. The family member stated she gives these to him when he needs it but since he has a new order for Seroquel 50 mg (milligrams) at bedtime that maybe she won't have to give those as much. These were not on the medication list but there was an order for Xanax 1 mg 3 times a day, Trazodone 100 mg at bedtime. On 10/24/24 at 2:30 p.m., the Executive Director and Director of Clinical Operations were made aware of the discrepancy of the medication lists as compared to what was in the home and how the family members were giving these medications. There was no further information provided.

Based on clinical record review and staff interview, it was determined the Agency failed to ensure a detailed statement of scope and frequency of services was included on the plan of care for 2 (#12 and #14) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all patients on the current census as care and services could be missed if the plan of care is not clear for the direct caregivers. Findings follow: --- Review of clinical record #12 with a start of care date of 09/04/23 and certification period of 08/29/24 - 10/27/24 revealed a patient with a diagnosis of Hypertensive Heart and Chronic Kidney Disease. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 09/05/24 did not include the scope and frequency of visits by the skilled nurse. Review of clinical record #14 with a start of care date of 07/09/24 and certification period of 09/07/24- 11/05/24 revealed a patient with a diagnosis of Alzheimer's disease. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 10/17/24 did not include the frequency of visits by the skilled nurse, hospice aide, and the social worker. On 10/24/24 at 2:30 p.m., the Executive Director and the Regional Quality Assurance Nurse were informed the frequency of visits scheduled/ordered were not included on the Plan of Care. They concurred the IDG and Plan of Care Update Report is the most current and working Plan of Care and used as a reference by the direct caregivers in the Agency.

Based on Clinical Record review and staff interviews, it was determined the urinary catheter order was not complete in that the order did not include the size or type of catheter to be used and how often to change the catheter in 4 (#2, #5, #17, and #19) of 5 (#1, #2, #5, #17, and #19) Clinical Records reviewed with urinary catheter orders. The failed practice did not ensure the appropriate type or sized catheter was used to prevent harm to the patient. The deficient practice could result in potential harm for all patients on census with orders for a urinary catheter. Findings follow: --- A review of Visit Note Reports, Coordination Notes, and Interdisciplinary Group (IDG) meeting notes for patient #2, #5, #17, and #19 revealed patient assessments by the Registered Nurse which included the patient having an indwelling urinary catheter. There was no evidence in Clinical Records #2, #5, #17, and #19 the Agency obtained a complete order for urinary catheters to include the specific type, size including the bulb size, and how often to change the catheter. On 10/24/24 at 2:30 p.m., the Executive Director (ED) and Director of Clinical Operations were interviewed and the ED stated, "We've gone back and forth on that. If we should have a detailed order on the catheters or not."

Based on clinical record review and staff interview, it was determined the Agency did not directly provide wound measurements and Registered Nurse (RN) wound assessments for 2 of 2 (#7 and #19) clinical records reviewed who had a pressure ulcer. The failed practice had the potential to affect all patients on the current census who have a pressure ulcer and live in a Skilled Nursing Facility (SNF). Findings follow: --- 1. Review of Clinical Record #7 with a start of care date of 10/09/24 revealed a patient with a diagnosis of Huntington's Disease. Additionally, the patient has a stage IV to the right ankle, surgical wound to left elbow and sacrum, as well as multiple other wounds. She lives in a Skilled Nursing Facility (SNF) a. The RN made visits on 10/09/24, 10/10/24, 10/14/24, and 10/21/24. There were no measurements or assessment of any wounds documented during these visits. 2. Review of Clinical Record #19 with a start of care date of 08/22/24 and expired on 08/29/24 revealed a patient with a diagnosis of Osteomyelitis left ankle and foot, wounds to bilateral heels and Stage III to coccyx. He lived in a SNF. a. The RN made visits on 8/22/24, 8/24/24, 8/25/24, 8/26/24, 8/27/24, and 8/28/24. Although, the 8/24/24 visit documentation noted wound care was not due, the RN documented the right and left heels were not assessed on any of the other visit dates by the Agency nurse but rather, the caregiver (SNF nurse) had completed the wound care. 3. On 10/24/24 at 2:50 p.m., the Executive Director and Director of Clinical Operation was interviewed. They had no other information to provide regarding this matter.

Based on personnel record review and management interview, it was determined the agency failed to ensure national criminal background checks were completed appropriately for 5 (#1, #2, #3, #5, and #6) of 6 (#1 - #6) non-licensed personnel records reviewed. This failed practice had the potential to affect all patients on the current census as there was a potential risk of an unvetted employee caring directly for vulnerable patients in their homes. Findings follow: --- The Arkansas Code 20-38-101 (Arkansas state law) Criminal Background Checks documented, in part, a Hospice Provider must verify that a potential employee (an applicant) has lived continuously in the state of Arkansas for the past five (5) years and if unable to do so, must Initiate a fingerprint-based criminal history records check performed by the Federal Bureau of Investigation on the applicant and conduct a registry records check on the applicant in addition to a state criminal background check with the Arkansas State Police. On 10/24/24, during the personnel record review, it was noted the 5 randomly chosen, non-licensed employees' files did not have an approved national criminal background check completed, nor a verification of Arkansas 5-year residency. The files contained either a report completed by a third-party vendor, an Office of Inspector General (OIG) statement, or no criminal background check other than a state check. On 10/24/24 at 11:05 a.m., the business office manager stated, "I just called [predecessor] and she stated that we run an OIG report for Medicare exclusions to make sure they are not blacklisted by Medicare." On 10/24/24 at 2:45 p.m., the Executive Director concurred that the OIG report had been used for the national background check and more recently, the third-party vendor, "Certiphi".

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) did not complete a comprehensive assessment for 1 of 1 (#13) patient with wound care orders in a Skilled Nursing Facility (SNF). The absence of a wound assessment had the potential to affect all patients needing wound care in a facility in that, the RN could not establish the patient's wound care progress. This failed practice did not ensure the RN had assessed for an improvement or decline in wound status and had the likelihood to affect any patient with wound care orders in a SNF. Findings follow: 1. Review of Clinical Record #13 showed the following: A. The patient had a Start of Care date of 12/09/2021 with a Primary Diagnosis of Malnutrition and was a resident of a SNF. B. A form titled, "Hospice Certification and Plan of Care" dated 12/09/2021 showed the patient's Plan of Care (POC) included orders for the SN (Skilled Nurse) to O/A [observe and assess] the integumentary [skin] for early identification of complications. C. The Start of Care note dated 12/09/2021 showed the Registered Nurse (RN) documented the patient had a stage two wound (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) to her left heel. D. The RN documented visits on 12/09/2021,12/10/2021, 12/14/2021, 12/21/2021, 12/30/2021, 01/05/2022 and 01/11/2022. There was no evidence the RN had assessed the patient's wound. 2. On 01/14/2022 at 11:34 AM, Agency Personnel #1 and #2 confirmed the RN did not perform a wound assessment. .

Based on clinical record review and staff interview, it was determined the Hospice did not directly provide nursing services for 1 of 1 (#13) patient with wound care orders in a Skilled Nursing Facility (SNF). The failed practice did not ensure the patient's wound or wound care was assessed by the Hospice. This failure by the Hospice had the likelihood to affect any patient with wound care orders in a SNF. Findings follow: 1. Review of Clinical Record #13 showed the following: A. The patient had a Start of Care date of 12/09/2021 with a Primary Diagnosis of Malnutrition and was a resident in a SNF. B. A form titled, "Hospice Certification and Plan of Care" dated 12/09/2021, showed the patient's Plan of Care (POC) included orders for [Hospice] skilled nursing services to include O/A [observe and assess] the integumentary [skin] for early identification of complications. C. On the Start of Care note dated 12/09/2021, the Hospice Skilled Nurse (SN) documented the patient had a stage two wound (Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed) to her left heel. The SN documented the SNF nurse was monitoring and treating the patient's wound. D. The Hospice SN documented visits on 12/09/2021,12/10/2021, 12/14/2021, 12/21/2021, 12/30/2021, 01/05/2022 and 01/11/2022. There was no evidence the Hospice SN assessed the wound or the wound care provided by the SNF. E. The Hospice had Interdiscplinary Group meetings (Patient Plan of Care updates) on 12/16/2021, 12/22/2021, and 01/06/2022. The Hospice SN documented on a form titled, "Hospice IDG [Interdiscplinary Group] Comprehensive Assessment and Plan of Care Update Report" (the form the Agency uses to document Patient Plan of Care updates), "Stage 2 wound to left heel being treated by facility nurse." 2. On 01/14/2022 at 11:34 AM, Agency Personnel #1 and #2 confirmed the Hospice SN did not assess the patient's wound or wound care provided by the SNF therefore, confirming the Hospice did not routinely directly provide all core services including nursing.