Every finding on record at Hospice of Central Arkansas, LLC

Based on clinical record review, observation during a home visit, and personnel interview it was determined the agency failed to ensure there was a detailed and individualized plan of care to address pain management for 8 (#3, #5, #6, #7, #9, #15, #16, and #17 of 19 (#1-#19) clinical records reviewed. The prevalence noted for a lack of a pain management plan for these 8 patients by the agency revealed a systemic failure of the Interdisciplinary Group (IDG) to address a significant element of hospice care and services. The IDG did not have the problem of Pain (or its potential), goal(s), nor individualized interventions listed in the Plans of Care for these 8 patients to demonstrate pain management as a key role of the hospice agency itself which had the potential to lead to pain being unnoticed and untreated effectively and timely. --- Specific evidence and findings documented in L546.

Based on clinical record review and personnel interview, it was determined the agency failed to ensure there were individualized plans of care for 1 (#5) of 19 (#1-#19) clinical records reviewed. This failed practice had the potential to affect all patients on census in that the direct care personnel would have limited knowledge of how and when to provide specific care for the patients. Findings follow: --- A. Clinical Record #5 with a start of care date of 02/04/26 revealed a patient with a diagnosis of Amyotrophic Lateral Sclerosis (ALS), Respiratory Failure, and Pneumonia. The skilled nurse visits documented the patient had a Percutaneous Endoscopic Gastrostomy (PEG) tube for nutrition, a condom catheter, and a trilogy (a portable non-invasive or invasive ventilator that assists with intermittent or continuous breathing). The Hospice Certification and Plan of Care with a certification period of 02/04/26 to 05/04/26 did not include the care and maintenance of these medical devices to prevent an infection or medical complication. B. The agency's Policy and Procedure titled "Interdisciplinary Group (IDG) membership and responsibilities documented, ".... A revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care..." C. On 03/10/26 the Executive Administrator was asked to provide an individualized care plan for this patient including PEG tube, condom catheter, and trilogy care, and she confirmed there was no further information.

Based on clinical record review, observation during a home visit, and personnel interview it was determined that the agency failed to ensure there was a plan of care to address pain for 8 (#3, #5, #6, #7, #9, #15, #16, and #17) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to affect all patients on census for those patients with orders for scheduled pain medication, have signs of pain, or have a diagnosis that have a high potential for pain would not have pain addressed timely and effectively. Findings follow: --- A. Clinical Record #3 with a start of care date of 01/21/26 revealed a patient with a diagnosis of Alzheimer's disease and Stage 3 pressure ulcer to sacrum. During a home visit on 03/04/26, the patient was observed lying on an air mattress, required total care for all activities of daily living (ADL's), received wound dressing change, and recovering from a recent skin lesion with swelling to the bridge of the patient's nose. There was no plan of care for pain or the potential of pain for this nonverbal patient.  B. Clinical Record #5 with a start of care date of 02/04/26 revealed a patient with a diagnosis of Amyotrophic Lateral Sclerosis (ALS), Respiratory Failure, Pneumonia, and Malignant Neoplasm of Prostate. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 02/23/26 noted a patient with a tracheostomy, enteral gastrostomy tube feedings, and a skin alteration to both great toes and there was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. C. Clinical Record #6 with a start of care date of 01/27/26 revealed a patient with a diagnosis of Acute Kidney Failure, Acute on Chronic Respiratory Failure. This patient had a stage 3 pressure ulcer on coccyx and stasis ulcers on the left lower extremity. The clinical record revealed the wound had an infection on 02/09/26 and the medication list included Gabapentin 100 mg (milligrams) twice daily for nerve pain. There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. D. Clinical Record #7 with a start of care date of 02/02/26 revealed a patient with a diagnosis of Congestive Heart Failure and Chronic Pulmonary Edema. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 03/04/26 documented new orders for Acetaminophen 325 mg (milligrams) suppository every 4 hours as needed for fever or mild pain and Skilled nurse visits daily related to patient decline. Additionally, the plan of care was updated 03/03/26 which documented, "Actively Dying". There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. E. Clinical Record #9 with a start of care date of 02/25/26 revealed a patient with a diagnosis of Malignant Neoplasm of Colon. There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. F. Clinical Record #15 with a start of care date of 02/04/26 revealed a patient with a diagnosis of Atherosclerotic Heart Disease (ASHD) and Cerebral Infarction. The Hospice Certification and Plan of Care with a certification period of 02/04/26 to 05/04/26 documented a right heel wound that required daily dressing changes with Santyl (chemical debridement) and Tramadol (pain medication) 50 mg 3 times daily was listed on the medication list. A client coordination note report dated 02/09/26 documented, "...PT [Patient] has pain with any movement. [Dr Name] gave orders to schedule comfort meds Q [every] 4 hrs [hours]..." There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. G. Clinical Record #16 with a start of care date of 01/02/26 revealed a patient with a diagnosis of Malignant Neoplasm of Pancreas. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 02/23/26 documented a medication change of Morphine increased to 0.5ml (milliliters) every 2 hours and skilled nurse visits increased to daily visits. The Care Plan was updated 02/05/26 which documented the patient was "actively dying". There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. H. Clinical Record #17 with a start of care date of 08/29/25 revealed a patient with a diagnosis of ASHD and Emphysema. The Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 02/18/26 documented a physician's order for Fentanyl 50 mcg (micrograms) / hour patch every 72 hours and Hydrocodone 10mg-Acetaminophen 325mg every 4 hours as needed. The clinical record noted the patient took the Hydrocodone regularly. There was no plan of care for pain or the potential of pain to include goal(s) and other interventions for pain control. I. The agency's Policy and Procedure titled "Plan of Care" documented, ".... The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms..." J. On 03/10/26 the Executive Administrator was asked about the lack of a specific care plan for those patients on a pain medication or high risk for pain. She confirmed the findings in Clinical Record #3, #5, #6, #7, #9, #15, #16, and #17 and there was no additional information to provide.

Based on clinical record review and personnel interview it was determined the agency failed to ensure there were clear visit frequencies documented for each of the disciplines in the Interdisciplinary Group (IDG) meeting notes for 11 (#1, #2, #3, #5, #6, #7, #8, #10, #11, #13, and #14) of 19 (#1-#19) clinical records reviewed. This failed practice had the potential to affect all patients on census in that the failure to have a documented plan of visit frequency could result in ineffective patient and care staff collaboration and patient/family unaware of expectations. Findings follow: --- A. On 3/3/26- 3/10/26, during clinical record review, it was noted the Interdisciplinary Group (IDG) meeting notes did not have documentation of how often the team members would make their scheduled visits within the 2 weeks going forward. B. There was no documentation of the scheduled Chaplain visits in the last IDG meeting notes for #1, #2, #6, #7, #8, #11, and #13 at 03/04/26 IDG meeting, #3 and #5 at the 02/23/26 IDG meeting.C. There was no documentation of the scheduled Nursing visits in the last IDG meeting notes for #1, #2, #6, #8, #10, #11, #13 at the 03/04/26 meeting, #5 at the 2/23/26 IDG meeting, and #14 at the 02/09/26 IDG meeting.D. There was no documentation of the scheduled Medical Social Worker visits in the last IDG meeting notes for #3 and #5 at 02/23/26 IDG meeting, and #13 at the 03/04/26 IDG meeting. E. On 03/10/26, Executive Administrator was asked to provide any further documentation. The Administrator confirmed the findings and there was no further documentation.

Based on clinical record review and personnel interview it was determined the agency failed to ensure the non-licensed employee (Certified Nursing Assistant) made notification to a licensed nurse so that medical assessment and intervention could take place for 1 (#7) of 19 (#! - #19) clinical records reviewed. Additionally, the Skilled Nurse (RN) failed to notify the physician of changes of condition and obtain orders to prevent further complications for 1 (#7) of 19 (#1 - #19) clinical records reviewed. This failed practice had the potential to adversely affect all patients on census in that there could be an acute change of condition not addressed and could lead to pain or hasten death. Findings follow: --- A. Clinical Record #7 with a start of care date of 02/02/26 revealed a patient with a diagnosis of Acute on Chronic Systolic (Congestive) Heart Failure, Chronic Pulmonary Edema.B. A Hospice Aide Visit Note dated 02/24/26 and 02/26/26 documented the patient's last bowel movement was 02/19/26. There was no documentation that the nurse was notified. C. A Skilled Nursing Visit completed by a Registered Nurse (RN) on 02/26/26 documented the patient's last bowel movement was 02/20/26. There was no documentation the physician was notified.D. A Client Coordination Note Report dated 02/28/26 document a call from the patient's family member to the triage nurse and stated that the "...patient has not had a BM for 9 days..." and "...is having severe stomach pain..." A visit note report dated 02/28/26 documented the patient's caregiver was instructed to increase Senna to twice daily and give a suppository. There was no physician's order change for the Senna or the suppository. E. A Hospice Aide Visit dated 03/03/26 documented the patient had not had a bowel movement since 02/24/26 and the skilled nurse was not notified.F. A RN Skilled visit note dated 03/03/26 documented the patient had no bowel movement in 7 days. There was no documentation the physician was notified. G. The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 03/04/26 did not include new physician's orders for constipation, nor a specific care plan for constipation. H. On 03/10/26 the Executive Administrator was asked to provide any further information regarding the lack of timely assessment, interventions, and documentation of outcome. The Administrator confirmed the findings, and no further information was provided.

Based on agency record review and personnel interview it was determined the agency failed to ensure the volunteer hours equaled 5% or more of the total patient care hours from all paid hospice employees and contract staff for the year 2025. The failed practice had the potential to affect all patients on census and their families in that if needed assistance would have been requested by the patient or family the agency would not have the volunteer staff available to provide this assistance. Findings follow: --- A. The 2025 Agency data collection documented for the number of volunteer hours totaled 358 hours or 2.12%. B. The agency's Policy and Procedure titled "Volunteer Recruiting, Selection, and Retention" documented, "....Recruitment activities are ongoing and include various media, such as advertisements in newspapers, church bulletins, and community bulletins..."  C. On 03/10/26 the Executive Administrator was asked to provide any further documentation. The Administrator confirmed the findings.

Based on clinical record review and agency staff interview it was determined the Medical Social Worker (MSW) failed to conduct a comprehensive assessment no later than 5 days from the start of care in 3 (#13, #14 and #16) of 19 (#1- #19) clinical records reviewed. This failed practice by the MSW delayed identification of patient and family psychosocial needs and placed patients and families at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. Findings as follows: --- Review of clinical record #13 with a start of care (SOC) of 02/10/23 revealed a patient with an admitting diagnosis of Metabolic Encephalopathy. A document titled "Visit Note Report" revealed the Medical Social Worker (MSW) completed the initial assessment on 02/17/23, which was 7 days after SOC (2 days past the required 5 day time frame). Review of clinical record #14 with a SOC of 02/14/23 revealed a patient with an admitting diagnosis of Pancreatic Cancer. There was no evidence to indicate the MSW completed a visit or assessed the patient's psychosocial needs as of current survey date 02/23/23, which was 9 days after SOC (4 days past the required 5 day time frame). Review of clinical record #16 with a SOC of 09/08/22 revealed a patient with an admitting diagnosis of Malignant Neoplasm of Cerebellum. There was no evidence to indicate the MSW completed a visit or assessed the patient's psychosocial needs prior to discharge on 09/20/22, which was 12 days after SOC (7 days past the required 5 day time frame). On 02/24/23 at 1:26 PM Agency Personnel #1 confirmed the Agency's failure to conduct the MSW assessment visit no later than 5 days after SOC.

Based on clinical record review and agency staff interview it was determined the Agency failed to complete an Initial Bereavement Assessment in 2 (#14 and #16) of 19 (#1-#19) clinical records reviewed. This failed practice had the potential to negatively impact the grieving process for the patient and the family in that social, spiritual and cultural factors which could interfere with coping mechanisms might not be discovered or addressed. Findings as follows: --- On 02/23/23 at 9:30 AM Agency Personnel #1 reported the Medical Social Worker (MSW) completes the initial Bereavement Assessment. Review of clinical record #14 with a SOC of 02/14/23 revealed a patient with an admitting diagnosis of Pancreatic Cancer. No Initial Bereavement Assessment had been accomplished as of survey date 02/23/23 Review of clinical record #16 with a SOC of 09/08/22 revealed a patient with an admitting diagnosis of Malignant Neoplasm of Cerebellum. No Initial Bereavement Assessment accomplished prior to discharge on 09/20/22. On 02/24/23 at 1:26 PM Agency Personnel #1 confirmed the lack of Initial Bereavement Assessments.