Heartlite Hospice

“Based on review of medical records (MR), agency policies and procedures, and interviews it was determined the agency failed to ensure staff:1. Performed pulse oximetry and documented results per physician’s orders and plan of care (POC).2. Changed a Foley catheter monthly per physician’s orders.This affected Home Visit (HV) # 2, in one of one MRs reviewed with pulse oximetry ordered, and MR # 9, in one of four MRs reviewed with Foley catheters, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Plan of CarePolicy Number: 3.003Revised Date: 10/1/2024 Policy: A written plan of care (POC) is developed for each patient/family by the attending physician, if any, the Medical Director, or hospice physician designee and the IDG. Procedure: ...2. The POC must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: …d. Drugs, biologicals, and treatments necessary to meet the needs of the patient. …j. Coordination of care.Agency Policy: Physician OrdersPolicy Number: 3.009Revised Date: 10/1/2024 Purpose: To outline a process of receiving and documenting physician orders. Procedure: …10. Services are provided according to the most recent orders updating the patient’s POC. 2. MR # 9 was admitted to the agency on 3/6/25 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage Five Chronic Kidney Disease, and Hemiplegia Following Cerebral Infarction.Review of the Hospice Certification and Plan of Care (HCPOC) revealed SN visit frequency once a week for the first week, then two times a week for twelve weeks.Review of HCPOC and physician’s order dated 6/4/25 revealed SN to insert 22 french suprapubic catheter with 10 milliliter bulb connected to drainage bag via sterile technique monthly or as needed for dislodgement, leaking, or obstruction. SN/CG to irrigate catheter with 10 cubic centimeter normal saline as needed for malfunction. Next catheter change week of 6/29/25.Review of the MR revealed there was no documentation the catheter had been changed as of 7/10/2025.An interview was conducted on 7/10/25 at 3:05 PM with EI # 1, who confirmed the catheter had not been changed monthly per physician’s orders. 1. HV # 2 was admitted to the agency on 12/20/2024 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure.Review of the IDG Comprehensive Assessment and POC Update Report dated 6/25/25 revealed an order for the Skilled Nurse (SN) to assess patient’s pulse oximetry. Review of five of five SN Visit Note Reports dated 6/18/25 to 7/7/25 revealed SN respiratory assessment documentation of abnormal breath sounds, dyspnea with minimal exertion, and diminished breath sounds. Further review of five of five SN Visit Reports dated 6/18/25 to 7/7/25 revealed no documentation the SN assessed the patient’s pulse oximetry.An interview was conducted on 7/10/25 at 2:45 PM with Employee Identifier (EI) # 1, Executive Director, who verified the staff failed to perform and document pulse oximetry per physician’s order and POC.”

“Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to ensure the Hospice Aide (HA) was supervised at least every fourteen days.This did affect one of twelve MRs reviewed of patients receiving HA services including MR # 1, and had the potential to negatively affect all patients receiving HA services.Findings Include:Agency Policy: Hospice Aide SupervisionPolicy Number: 8.007Revision Date: 11/1/22Policy:The Registered Nurse (RN) will supervise the Hospice aides according to specific State guidelines and Federal Conditions of Participation to ensure quality and appropriateness of the hospice aide service.Procedure:1. The RN must perform the Aide supervisory visits...These visits are made according to specific...guidelines below:Hospice Aide Supervisory Requirement:At least every fourteen days with or without aide present for all patients... 1. MR # 1 was admitted to the agency on 6/10/25 with diagnoses including Amyotrophic Lateral Sclerosis and Other Frontotemporal Neurocognitive Disorder.Review of the Hospice Certification and Plan of Care (HCPOC) revealed orders for HA one time a week for one week and three times a week for twelve weeks for personal care and bathing. Skilled Nurse (SN) one time a week for one week and two times a week for twelve weeks.Review of the HA Visit Notes Reports (VNR) from 6/13/25 to 7/2/25 revealed nine HA visits were completed.Review of the SN VNR from 6/16/25 to 7/5/25 revealed an aide supervisory visit was completed on 7/5/25.The SN failed to document HA supervision for 22 days of HA service. An interview was conducted on 7/10/25 at 2:53 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to ensure the HA supervision was conducted at least every 14 days.”