Good Heart Hospice and Palliative Care

“Upon patient record review, 4 of 5 (Patients #1,#2,#4,#5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The medical record contains spiritual care provider documentation identifying spiritual care to continue. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. Corrected on site. Patient 2: The medical record contains spiritual care provider documentation identifying spiritual care to continue. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. The record also contained nursing documentation upon admission identifying patient was on services for senile degeneration of the brain and was assessed as high risk for skin impairment, falls, and issues with anxiety. There was no evidence of problems, goals, and interventions related to neurological dysfunction, fall safety, skin, and anxiety included in the plan of care. Corrected on site. Patient 4: The medical record contains spiritual care provider documentation identifying spiritual care to continue. There was no evidence of problems, goals, and interventions related to spiritual care included in the plan of care. The record contained nursing documentation upon admission identifying patient is on services for heart failure, has issues with dyspnea requiring oxygen, is insulin dependent and a high risk for falls. There was no evidence of problems, goals, and interventions related to cardiac dysfunction, respiratory, fall safety, and endocrine included in the plan of care. Corrected on site. Patient 5: The medication profile identified the patient was on Eliquis twice daily. There was no evidence of problems, goals, and interventions related to risk of bleeding included in the plan of care.”

“Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1: The medical record contained social worker and spiritual care provider documentation upon initial evaluations, identifying patient was to receive ongoing psychosocial and spiritual support. There was no evidence of orders for the anticipated frequencies. Corrected on site. Patient 2: The medical record contained spiritual care provider documentation upon initial evaluation identifying patient was to receive ongoing spiritual support. There was no evidence of an order for the anticipated frequency. Corrected on site. Patient 3: The medical record contained spiritual care provider documentation upon initial evaluation identifying patient was to receive ongoing spiritual support. There was no evidence of an order for the anticipated frequency. Corrected on site. Patient 4: The medical record contained social worker and spiritual care provider documentation upon initial evaluations, identifying patient was to receive ongoing psychosocial and spiritual support. There was no evidence of orders for the anticipated frequencies. Corrected on site.”

“Upon patient record review, 1 of 5 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The medical record contained an order in error for atorvastatin PRN in addition to a scheduled dose. The record also contained an order for a lidocaine topical patch without an area defined for administration, and orders for differing gabapentin doses without instructions whether able to take together or needs spacing in frequency. Corrected on site.”

“Upon patient record review 2 of 5 (Patients #1,#3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 1: There was no evidence of an aide supervisory visit. Patient’s first aide visit was completed on 5/13/25. Corrected on site with late data entry. Patient 3: There was no evidence of an aide supervisory visit. Patient’s first aide visit was completed on 5/14/25. Corrected on site with late data entry.”

“Upon patient record review, 1 of 14 (Patient #11) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #11: This patient was on service for ALS. On 05/10/24, the caregiver called to report that the patient was experiencing increased agitation and was uncomfortable “moaning and restless” The caregiver stated that they had given ABHR gel “with minimal relief”. They stated they were completely out of oral Ativan. Hospice nurse documents that the Ativan could not be filled until 05/18/24. The order was changed to allow for the Ativan to be given more frequently, however, there is no documentation of the order being called to the pharmacy or a visit being made to the patient to evaluate symptoms. On 05/11/24, there is a documented call from Lori, reportedly the patient’s daughter. The nurse documents that this call came in “after the other caregivers had been calling all throughout the night. Lori stated they had no Ativan and were frustrated that the patient has been in symptom crisis with nothing to help her. The nurse reminded her of ABHR gel but no visit made. The next entry was on 05/13/24, at 0830AM when a call was received by the daughter stating her mom had a change. She was concerned that she did not know if it was due to medications or an actual neurological change in her condition. No visit made. At 1140 am on 05/13/24, a call was received from patient’s sister, upset regarding patients symptoms and again concerned about change in status, that she was less responsive, not using G tube and asking questions about how long the patient may have. The nurse told her if she is not eating it could be 1-2 weeks. There was no visit documented or offered. There continued to be calls over the next 2 days and there was one medication change, however on 05/15/24 the family requested to revoke from Canyon Lake hospice.”

“Upon patient record review, 3 of 14 (Patient #1, 2, 3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During home visit, it was noted in the family handbook that patient had a signed prescription for medications in the comfort kit that were in the home. These medications were not included on the hospice medication list. Patient #2: During a home visit to the B & C, it was noted that the patient medication list at home included orders for Odansetron and Immodium. These medications were not present on the hospice medication list. The Hospice medication list included orders for Azithromycin, Miralax, and Pantoprazole which were not on the medication list in the B&C medication list. Patient #3: The medication list in the patient residence included orders for Alendronate, Diclofenac gel and Ibuprofen. These medications were not included in the Hospice medication record.”

“Upon patient record review, 1 of 14 (Patient #4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4: Patient was admitted 01/31/25, however, initial bereavement assessment was not completed until 03/26/25.”

“Upon patient record review, 3 of 14 (Patient #6, 8, 10) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient’s attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patients 6, 8, and 10: There is no evidence that the plan of care was developed in consultation with the patient’s attending physician. All patients had requested their local physician to be a part of their plan of care and there was no communication/collaboration with the attending physician in the medical record.”

“Upon patient record review, 4 of 14 (Patients #2, 3, 6, 9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2: On 03/27/25, the hospice aide called the office to report patient had new bruising on her left arm. It is documented that the RN called the home and the caregiver said that the patient had been restless and was scooting down in the bed to get out of bed, states she hit her arm on side rails. No visit done by nurse for report of injury/bruising. No follow up phone call or visit to patient for 8 days. Patient #3: On 03/27/25, the agency received a call from the caregiver with concerns that the patient was experiencing combativeness with care as well as not sleeping. A verbal order was give by physician for Lorazepam and Seroquel. The nurse did not make a visit at time of call and no follow up phone call or visit was made to address new meds including a controlled medication for 6 days. Patient #6: On 03/12/25, RN did visit and patient was noted to be experiencing “moderate pain” Verbal orders received for Tramadol. No follow up visit or phone call on new pain medication for 7 days. Patient #9: Patient was admitted on 02/22/25. The pain assessment read that patient had a 2/10 pain and that 3 was the patients self identified threshold. The nurse documented “patient is moaning and showing through her facial expressions that she is suffering with pain.” No call to physician, no change in orders, and no follow up phone call or visit for 4 days.”

“Upon patient record review, 6 of 14 (Patients #4,5,6,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4: The Respiratory care plan does not include interventions or goals for CPAP, nebulizer, or suction machine. The Nutrition plan of care does not include interventions or goals for Glucerna. The patient is on service with breast Cancer - there are no interventions or goals for cancer on the plan of care. Patient #5: The plan of care has a problem for Cardiac related to low blood pressure, however the interventions are to contact nurse if systolic pressure is above 150 or the diastolic is above 90 which is high blood pressure. There is a problem for environmental safety. The interventions include the following: “keep both side rails up when unattended”, and “PCG to make sure patient is positioned in the center of her bed as there are no side rails.” The patient is alert and oriented times 3 and has half rails. Patient #6: The patient is admitted with biliary cirrhosis. The GI POC has no interventions related to biliary cirrhosis. The respiratory plan of care does not include interventions or goals for nebulizer or suction machine. Patient #8: The patient is on service with lung cancer. There are no interventions or goals related to cancer on the plan of care. There are no interventions or goals for pain, despite patient being on oxycodone for severe pain. Megace is ordered but there are no interventions or goals for nutrition on the plan of care. Patient #9: There are no interventions or goals for ensure on nutritional plan of care. There are no interventions or goals for the nebulizer or suction machine on the plan of care. Pain was identified but there is not a pain plan of care. Patient #10: The patient is on Xarelto. There is no interventions of goals on the plan of care for anti coagulant use or bleeding precautions. The patient is on a mechanical soft diet and requiring thickened liquids. There are no interventions or goals for use of modified diet and thickener.”

“Upon patient record review, 4 of 14 (Patient #2, 3, 5, 6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. No evidence of a routine frequency Patient #2, 5: The frequencies for MSW and SC both stated, “initial and prn” . No evidence of a routine frequency. Patient #3: The frequencies for MSW and SC both stated, “initial and prn”. No evidence of a routine frequency. This patient was in the second benefit period with no changes to orders to remove “initial” from the frequency order. Patient #6: The MSW documented on initial visit, “MSW will follow up monthly.” There was no further visits and IDG was entered as Initial and recert. No evidence of a routine frequency”

“Upon patient record review, 4 of 14 (Patient #1,2,3,4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: During home visit, it was noted in the family handbook that patient had a signed prescription for medications in the comfort kit that were in the home. These medications were not included on the plan of care orders. Patient #2: During a home visit to the B & C, it was noted that the patient medication list at home included orders for Odansetron and Immodium, these medications were not present on the plan of care orders. Patient #3: The medication list in the patient residence included orders for Alendronate, Diclofenac gel and Ibuprofen. These medications were not included on the plan of care orders. Patient #4: The plan of care states, “if after 3 doses of breakthrough medication and pain not relieved in one hour call RN.” It also states, “Administer pain medications as ordered”. This patient has no orders for pain medication on her record.”

“Upon patient record review, 1 of 14 (Patient#4) did not show evidence that the hospice had offered and/or provided spiritual counseling in accordance with the patient/family’s desires which include: •Providing an assessment of the patient’s and family’s spiritual needs (individual comprehensive assessments missing the spiritual assessment is cited under L524) •Providing spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service and in a manner consistent with their beliefs and desires •Making all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the patient’s spiritual needs to the best of their ability •Advising the patient and family of this service Patient #4: The SC did an initial visit with patient, they discussed her desire for spiritual support and SC documented “SC promised to continue spiritual support” this was on 02/03/25. The orders were written as follows: “SC initial visit and prn for spiritual support.””

“Upon patient record review, 4 of 14 (Patient #2, 3, 5, 10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient #2: The hospice aide assignment states that patient has partial rails however through observation during home visit the patient has full padded rails. The patient has oxygen, however, oxygen precautions are not noted on the hospice aide POC. The assignment states to encourage fluids and diet as tolerated. the patient is on a mechanical soft diet. The POC calls for the aide to apply lotion every visit but does not specify where to apply it. Patient #3: The hospice aide assignment states that patient ambulation is ad lib. The patient is bedbound. The POC states patient has partial rails, however, through observation during home visit, patient has full rails. The hospice aide assignment states, “Assist with oral medication administration per RN instructions.” This is outside the scope of a hospice aide. The POC states to assist with feeding and diet is as tolerated, however, patient is on a mechanical soft diet. The aide is to perform denture care each visit, however, the POC does not specify if the patient has upper, lower, full or partial dentures. Patient #5: The hospice aide assignment states patient to ambulate ad lib. Patient is bedbound. The aide assignment states “nails every visit” but it does not state what to do with nails. The hospice aide POC is missing seizure precautions as well as fall precautions. The added instructions state, “Special care as specified by RN” however it does not specify what task that is. Patient #10: The hospice aide assignment does not include bleeding precautions for this patient on anticoagulant therapy.”

“Upon patient record review 4 of 14 (Patients #2, 3, 5, 6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #2: The patient has orders for a hospice aide. The first visit was 02/05/25, the first supervision was completed after 21 days on 02/26/25. The next supervision was done timely on 03/12/25, however, there was a 30 day gap before the next supervision on 04/09/25. Patient #3: The patient has aide services. There has not been an RN supervised visit since 02/13/25, despite continuing with hospice aide orders of visits twice weekly. Patient #5: The patient receives aide services. She was admitted 01/14/25, no RN supervision completed until 03/10/25. Patient #6: The patient receives aid services. The last RN supervision visit was 03/25/25 (19 days)”