Every finding on record at Mena Medical Center Hospice, LLC

Based on a review of clinical records and staff interviews, it was determined that the agency failed to complete a Spiritual Needs Assessment as part of the Initial Comprehensive Assessment within five (5) days following the election of hospice services for two (#6 and #9) of nineteen (#1-#19) clinical records reviewed. This failed practice had the potential to affect all hospice admissions, as it may delay the identification of patient and family spiritual and psychosocial needs. Such delays could place patients and/or families at increased risk for inadequate coping with end-of-life issues, lack of appropriate spiritual resources, and insufficient emotional or familial support. --- A review of clinical record #6, with a start of care (SOC) date of 04/23/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of the document titled “Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report,” dated 04/28/2026, showed the chaplain documented, “SPIRITUAL CAREGIVER WILL CALL TO SET UP VISIT WITH PATIENT/CAREGIVER.” Further review revealed the chaplain completed the initial spiritual assessment on 04/29/26, one day beyond the required timeframe.A review of clinical record #9, with a SOC date of 04/30/26, revealed a patient diagnosed with Malignant Neoplasm of Lower Lobe Right Bronchus or Lung. Review of the document titled “Client Coordination Note Report,” dated 05/07/26, showed the chaplain documented, “chaplain was out on medical emergency.” Further review revealed the chaplain was scheduled to complete the initial spiritual assessment on 05/08/26, three days beyond the required timeframe.During an interview conducted on 05/08/26 at 10:10 AM, Agency Personnel #1and #2 confirmed that the Spiritual Assessment had not been completed within the required five (5) calendar days from the SOC, as required by the Medicare Hospice Conditions of Participation as part of the comprehensive assessment.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to include all medications utilized by the patient on the medication list for one (#8) of nineteen (#1-#19) clinical records reviewed. This failure had the potential to impact all patients currently on census and may result in inadequate medication management, potential drug interactions, and prevent a thorough medication regimen review to ensure patient safety and effective symptom management. Findings follow: --- A review of clinical record #8, with a start of care (SOC) date of 03/19/26, revealed a patient diagnosed with Other Cirrhosis of Liver. Review of the “Visit Note Report" dated 03/19/26 showed the Skilled Nurse (SN) documented that oxygen was to be delivered to the patient’s home. On a subsequent visit dated 04/22/26, the SN documented oxygen administration via nasal cannula at 2 LPM (liters per minute). Review of a form titled "Medicine List" did not reflect oxygen as an active medication. Additionally, there was no documentation in the clinical record indicating that oxygen had been reviewed for actual or potential medication side effects or interactionsDuring an interview conducted on 05/08/26 at 09:30 AM, Agency Personnel #1 and #2 confirmed that not all medications had been reviewed for actual or potential drug side effects or interactions.

Based on a review of clinical records and staff interviews, it was determined that the agency failed to ensure the development and implementation of individualized plans of care for two (#6 and #10) of nineteen (#1-#19) clinical records reviewed. This deficient practice had the potential to affect all patients currently receiving services and could result in inconsistent, non-individualized care, increased risk for treatment errors, unmet patient needs, inadequate symptom management, and adverse patient outcomes. --- A review of clinical record #6, with a start of care (SOC) date of 04/23/26, revealed a patient diagnosed with Severe Protein Calorie Malnutrition. Review of the skilled nurse visit note dated 04/23/26 revealed the nurse documented the patient “has a Foley catheter in place.” Review of the visit note dated 04/29/26 revealed the patient contacted the agency reporting “abdominal pain and clogged catheter.” The nurse subsequently made a visit and replaced the catheter with a 16 FR (French) coude catheter with a 30 cc (cubic centimeter) balloon; however, the balloon was inflated with only 10 cc of saline. Further review of the clinical record revealed no documented physician orders specifying catheter management, including catheter size, balloon volume, frequency of catheter changes, or indications for catheter replacement.A review of clinical record #10, with a SOC date of 04/27/26, revealed a patient diagnosed with Gastroparesis. Review of a document titled “Hospice Certification and Plan of Care” for the certification period 04/27/2026 through 07/25/2026 revealed an order to “Instruct caregiver on administration of tube feeding.” Review of the skilled nursing visit note dated 04/27/2026 revealed the nurse documented the patient’s “nutrition comes from feedings through J-tube (jejunostomy tube) due to malabsorption.” Further review of the clinical record revealed no specific physician orders for the tube feeding regimen, including the name and strength of the formula, administration method (bolus or continuous), rate of infusion for continuous feedings, and water flushes to be administered before, after of between feedings and/or medications administered via the tube.During an interview conducted on 05/08/26 at 10:10 AM, Agency Personnel #1and #2 confirmed that not all plans of care were specific, complete, and individualized to meet the patients’ identified needs.

Based on clinical record review and staff interview, it was determined the Agency failed to complete a Spiritual Needs Assessment and/or Psychosocial Assessment as part of the Initial Comprehensive Assessment within 5 days after the election of Hospice services in 5 (#1, #2, #5, #6 and #11) of 20 (#1 - #20) clinical records reviewed. This failed practice by the Chaplain and Social Worker had the potential to affect all admissions to the Agency in that, there could be a delay in identification of patient and family spiritual and psychosocial needs and could place patient and/or family at risk of inadequate coping mechanisms with end-of-life issues, lack of resources and ineffective family support. --- Review of clinical record #1 with a start of care of 05/02/23 revealed a patient with a diagnosis of Heart Disease Unspecified. A document titled "Visit Note Report" with a visit type of "HOSPICE MSW (Medical Social Worker) INITIAL ASSESSMENT VIRTUAL VISIT" and dated 05/09/23 revealed the psychosocial assessment was completed 7 days after SOC (2 days past 5-day requirement). Review of clinical record #2 with a start of care of 04/26/23 revealed a patient with a diagnosis of Cirrhosis of the Liver. A document titled "Visit Note Report" with a visit type of "HOSPICE MSW (Medical Social Worker) INITIAL ASSESSMENT VIRTUAL VISIT" and dated 05/08/23 revealed the psychosocial assessment was completed 12 days after SOC (7 days past 5-day requirement). Review of clinical record #5 with a SOC (start of care) of 04/26/23 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. A document titled "Visit Note Report" with a visit type of "CHAPLAIN HOSPICE SPIRITUAL ASSESSMENT" and dated 05/02/23 revealed the spiritual assessment was completed 6 days after SOC (1 day past 5-day requirement). A document titled "Visit Note Report" with a visit type of "HOSPICE MSW (Medical Social Worker) INITIAL ASSESSMENT VIRTUAL VISIT" and dated 05/11/23 revealed the psychosocial assessment was completed 15 days after SOC (10 days past 5-day requirement). Review of clinical record #6 with a start of care of 05/01/23 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. A document titled "Visit Note Report" with a visit type of "HOSPICE MSW (Medical Social Worker) INITIAL ASSESSMENT VIRTUAL VISIT" and dated 05/11/23 revealed the psychosocial assessment was completed 10 days after SOC (5 days past 5-day requirement). Review of clinical record #11 with a start of care of 04/26/23 revealed a patient with a diagnosis of Malignant Neoplasm of Overlapping Sites of Esophagus. A document titled "Visit Note Report" with a visit type of "CHAPLAIN HOSPICE SPIRITUAL ASSESSMENT" and dated 05/02/23 revealed the spiritual assessment was completed 6 days after SOC (1 day past 5-day requirement). An interview on 05/18/23 at 9:30 am with Agency Personnel #1 confirmed the Spiritual Needs Assessment and/or Psychosocial Assessment was not completed within the required 5-day time frame as part of the Comprehensive Assessment.

Based on clinical record review and staff interview, it was determined the Agency failed to provide a Comprehensive Assessment which included the psychosocial assessment and/or spiritual needs assessment of the patient in 5 (#4, #7, #11, #14, and #15) of 20 (#1 - #20) clinical records reviewed. This failed practice had the potential to affect the patient and/or family in obtaining relief from spiritual and/or emotional conflict to promote the hospice patients well-being, comfort, and dignity throughout the dying process. Findings follow: --- Review of clinical record #4 with a start of care of 04/21/23 revealed a patient with a diagnosis of Lung Involvement in Systemic Lupus Erythematosus. No evidence to indicate the Chaplain had assessed the patient's spiritual needs or had any involvement in developing the Initial Comprehensive Assessment. Review of clinical record #7 with a start of care of 05/03/23 revealed a patient with a diagnosis of Hypertensive Chronic Kidney Disease. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment. Review of clinical record #11 with a start of care of 04/26/23 revealed a patient with a diagnosis of Malignant Neoplasm of Overlapping Sites of Esophagus. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment Review of clinical record #14 with a start of care of 05/02/23 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment Review of clinical record #15 with a start of care of 05/11/23 revealed a patient with a diagnosis of Malignant Neoplasm of Right Upper Lobe Lung with Metastasis to Bone. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment An interview on 05/18/23 at 9:30 am with Agency Personnel #1 confirmed the psychosocial assessment and spiritual needs assessment was not completed as part of the Initial Comprehensive Assessment.

Based on clinical record review and staff interview, the Skilled Nurse (SN) failed to include Oxygen on the patient's "Medications" list (a section of the Agency's Care Plan containing the medication profile) in 1 (#3) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #10, #14, #15, #18, and #19) clinical records reviewed of patients utilizing oxygen. This deficient practice presented a potential risk to patients currently requiring Oxygen therapy by delaying pertinent information to the attending Physician regarding the patients individualized medication regimen. Findings follow: --- Review of clinical record #3 with a start of care of 04/24/23 revealed a patient with a diagnosis of Alzheimers. Review of a document titled "Vital Signs Report" revealed patient utilization of oxygen on 04/24/23 and 05/08/23. Review of a document titled "Client Medication Report" failed to include oxygen on the patient's list of current medication. An interview on 05/17/23 at 9:30 am with Agency Personnel #1 confirmed the failure to include oxygen on the patient's current list of medications.

Based on clinical record review and staff interview, it was determined the Agency failed to perform an Initial Bereavement Assessment in 2 (#7 and #11) of 20 (#1-#20) clinical records reviewed. This missed assessment had the potential to negatively impact the grieving process for the patient and family in that bereavement risk factors could interfere with coping mechanisms and might not be discovered and/or addressed. Findings follow: --- Review of clinical record #7 with a start of care of 05/03/23 revealed a patient with a diagnosis of Hypertensive Chronic Kidney Disease. There was no evidence an Initial Bereavement Assessment had been conducted. Review of clinical record #11 with a start of care of 04/26/23 revealed a patient with a diagnosis of Malignant Neoplasm of Overlapping Sites of Esophagus. There was no evidence an Initial Bereavement Assessment had been conducted. An interview on 05/18/23 at 9:30 am with Agency Personnel #1 confirmed the Initial Bereavement Assessment had not been conducted.

Based on clinical record review and staff interview, it was determined the Agency failed to conduct a psychosocial assessment in 4 (#7, #11, #14, and #15) of 20 (#1 - #20) clinical records reviewed. This failed practice had the potential to affect the patient and their family in that coping mechanisms of the patient and family may be inadequate, family dynamic needs may not be met, caregiver's function may be adversely affected, family support systems may be challenged which may limit the hospice staff from providing emotional support, social support, and ancillary resources for the patient and/or family. --- Review of clinical record #7 with a start of care of 05/03/23 revealed a patient with a diagnosis of Hypertensive Chronic Kidney Disease. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment. Review of clinical record #11 with a start of care of 04/26/23 revealed a patient with a diagnosis of Malignant Neoplasm of Overlapping Sites of Esophagus. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment Review of clinical record #14 with a start of care of 05/02/23 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment Review of clinical record #15 with a start of care of 05/11/23 revealed a patient with a diagnosis of Malignant Neoplasm of Right Upper Lobe Lung with Metastasis to Bone. There was no evidence to indicate the psychosocial assessment had been completed or included in the development of the Initial Comprehensive Assessment An interview on 05/18/23 at 9:30 am with Agency Personnel #1 confirmed the psychosocial assessment was not completed as part of the Initial Comprehensive Assessment.

Based on clinical record review and staff interview, it was determined the Agency failed to conduct a spiritual needs assessment of the patient and/or family, provide spiritual counseling with patients and/or families, and to facilitate visits by local clergy to support the patient's/family's spiritual needs in 1 (#4) of 20 (#1 - #20) clinical records reviewed. This failed practice had the potential to affect the patients and families in obtaining relief from spiritual and/or emotional conflict in order to improve the quality of life for the patient and/or family. Findings follow: --- Review of clinical record #4 with a start of care of 04/21/23 revealed a patient with a diagnosis of Lung Involvement in Systemic Lupus Erythematosus. No evidence to indicate the Chaplain had assessed the patient's spiritual needs or had any involvement in developing the Initial Comprehensive Assessment. 2. An interview on 05/17/23 at 9:30 am with Agency Personnel #1 confirmed the spiritual needs assessment was not completed as part of the Initial Comprehensive Assessment.

Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services through on-site supervisory aide visits (SAV) every 14 days in 1 (#13) of 17 (#1, #2, #3, #4, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #19 and #20) current patients records reviewed with Hospice Aide (HA) services. This lack of supervision by the RN had the potential to place all patients receiving HA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the Plan of Care by the HA or possible changes in the needs of the patient and family. Findings follow: --- Review of clinical record #13 with a start of care of 10/21/21 and a diagnosis of Malignant Neoplasm Right Kidney revealed orders for HA services. The Hospice RN documented on a form titled "Visit Note Report" supervisory aide visits conducted on 04/13/23 and 04/28/23 (1 day past the 14-day time frame). An interview on 05/19/23 at 10:30 am with Agency Personnel #1 confirmed the late supervisory aide visit.