Hospice of the Heartland

“Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness provided to all current staff at time of hire. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: According to the hospice policy titled Emergency Operations Plan, dated 6/2025, the current staff will be trained on the Emergency Operations Plan initially and annually. All new staff will be trained on the plan within 30 days of start date. Volunteers must have emergency preparedness training initially and then yearly. a. Review of Staff G, Chaplain employee record revealed a start dated of 11/13/24. b. Review of the agency’s emergency preparedness plan lacked documentation of initial training completed for Staff G. During an interview on 6/25/25 at 2:35 PM, the Administrator stated no training completed for the emergency preparedness plan for Staff G. The above findings were reviewed with the Agency Administrator and the Clinical Manager.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care that specified scope and frequency for all services required by and provided to patients for 3 of 3 sampled patients (Patient #6, #12 and #14) who received general inpatient and/or respite services. Failure to identify scope and frequency for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: 2. Patient #6 had a hospice admission date of 12/30/24, a discharge date of 1/8/25, received hospice services while residing in a private residence from 12/30/24 to 12/31/24, received hospice services while residing at the hospital for general inpatient care from 12/31/24 to 1/3/25, and received hospice services while residing at the hospital in respite care from 1/3/25 to 1/8/25. Clinical record review revealed: a. The POC, dated 12/30/24 to 3/29/25, included physician orders to admit patient to hospice services with skilled nursing, social worker and massage therapy services. b. Patient admission setting documentation, dated 12/30/24, identified the patient received routine home care services at home; dated 12/30/24; identified the patient received general inpatient services at the hospital; dated 12/31/24; identified the patient received inpatient respite services at the hospital; dated 1/3/25; and identified the patient revoked hospice care at the hospital on 1/8/25. The hospice clinical record failed to identify interim physician orders to change level of care from routine to general inpatient to respite. 3. Patient #14 had a hospice admission date of 7/18/24, a death date of 7/24/24, received hospice services while residing in a private residence from 7/18/24 to 7/20/24 and received hospice services while residing at the hospital for respite care from 7/20/24 to 7/24/24. Clinical record review revealed: a. The POC, dated 7/18/24 to 10/15/24, included physician orders to admit patient to hospice services with skilled nursing and social work services. b. Patient admission setting documentation, dated 7/18/24, identified the patient received routine home care services at home; dated 7/18/24; identified the patient received inpatient respite services at the hospital; dated 7/20/24; and identified the patient expired at the hospital on 7/24/24. The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite. The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Plan of Care, dated 5/2025, the written plan of care will include all services necessary for the palliation and management of the related condition. Review of the plan of care will be done by the interdiscipliary team, in collaboration with the patient’s attending physician. During an interview on 6/25/25 at 2:12 PM, the Clinical Manager stated hospice staff did not always write orders for the change in service to respite services. The written order identified did not flow over to IDG as it should have and will look into the reason it did not. 1.Patient #12 had a hospice admission date of 12/16/24, a death date of 12/30/24, received hospice services while residing in a private residence from 12/16/24 to 12/18/24 and 12/23/24 to 12/29/24. The patient received hospice services while residing at the hospital in respite care from 12/18/24 to 12/23/24 and 12/29/24 to 12/30/24. Clinical record review revealed: a. The Plan of Care (POC), dated 12/16/24 to 3/15/25, included physician orders to admit the patient to hospice services with skilled nursing, social worker and hospice aide services. b. The physicians order, dated 12/18/24, included an order to transfer the patient to the hospital for inpatient hospice respite care. c. IDG meeting note, dated 12/31/24, included documentation nursing services were provided during respite care and the patient returned to the private residence to receive services in the home. The note failed to include the order to transfer to the hospital for inpatient respite services or an order to transfer back to the private residence to receive services in the home. The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite and to return from respite to routine level of care.”

“Based on staff interview, clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 3 of 3 hospice aides (Staff D, Staff E and Staff H) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient’s bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 5 of 10 sampled patients (Patient #4, #5, #7, #8 and #12) who required an extra skill be performed. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. According to the agency’s policy titled Hospice Aide Services, dated 6/2025, the hospice aide’s supervising clinical manager will be responsible to maintain documentation regarding any specific skills taught to the hospice aide as assigned to provide cares. During an interview on 6/25/25 at 8:30 AM, the Administrator identified Staff I, Registered Nurse (RN), is responsible for training and competency testing hospice aides in the skills beyond basic skills. 1.Patient #4 had a hospice admission date of 4/16/24, a discharge date of 6/24/24, and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to perform nail care; trim nails. b. Review of the clinical record showed Staff D, Hospice Aide, Staff E, Hospice Aide and Staff H, Hospice Aide, provided aide services independently for Patient #4. c. Staff D, Hospice Aide, had a hire date of 8/2/16. Staff D’s personnel file lacked documentation an RN had observed Staff D competently perform the task trim nails. d. Staff E, Hospice Aide, had a hire date of 10/4/04. Staff E’s personnel file lacked documentation an RN had observed Staff E competently perform the task trim nails. e. Staff H, Hospice Aide, had a hire date of 9/16/14. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails. 2.Patient #5 had a hospice admission date of 4/15/24, a discharge date of 9/30/24, and received hospice services while residing in a private residence. a. The aide care plan included RN instructions to the aide to apply ace wrap to left knee for comfort. b. Review of the clinical record showed Staff D, Hospice Aide, provided aide services independently for Patient #5. c. Staff D, Hospice Aide, had a hire date of 8/2/16. Staff D’s personnel file lacked documentation an RN had observed Staff D competently perform the task apply ace wrap. 3. Patient #7 had a hospice admission date of 9/4/26, a discharge date of 9/26/24 and received hospice services in a nursing home. a. The aide care plan included RN instructions to the aide to assist with transfers using an EZ stand (a device that provides assistance for individuals with difficulty standing from chairs etc.). b. Review of the clinical record showed Staff D, Hospice Aide, provided aide services independently for Patient #7. c. Staff D, Hospice Aide, had a hire date of 8/2/16. Staff D’s personnel file lacked documentation an RN had observed Staff D competently perform the task assist with transfers using an EZ stand. 4.Patient #8 had a hospice admission date of 7/8/24, a discharge date of 8/2/24, and received hospice services while residing in a private residence. a. The aide care plan included RN instructions to the aide to perform nail care; trim nails. b. Review of the clinical record showed Staff E, Hospice Aide and Staff H, Hospice Aide, provided aide services independently for Patient #8. c. Staff E, Hospice Aide, had a hire date of 10/4/04. Staff E’s personnel file lacked documentation an RN had observed Staff E competently perform the task trim nails. d. Staff H, Hospice Aide, had a hire date of 9/16/14. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails. 5.Patient #12 had a hospice admission date of 12/16/24, a discharge date of 12/30/24, and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to perform nail care; trim nails. b. Review of the clinical record showed Staff H, Hospice Aide, provided aide services independently for Patient #12. c. Staff H, Hospice Aide, had a hire date of 9/16/14. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 9 of 11 sampled patients receiving hospice aide services (Patients #1, #2, #3, #4, #7, #8, #10, #12 and #13). The hospice reported a current census of 3 patients, including 3 who received hospice aide services at the time of the survey. Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. 7. Patient #2 had a hospice admission date of 3/4/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC’s, dated 3/4/25 to 6/1/25 and 6/2/25 to 8/30/25, identified the patient had a diagnosis of cancer of the lung and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: assist the patient with oral care, shower with use of shower chair and whirlpool. c. Hospice aide visit note, dated 5/7/25, included documentation the hospice aide provided both a whirlpool bath and shower. d. Hospice aide visit notes, dated 4/21/25 and 4/28/25, identified oral care not completed and documented “not applicable this visit”. The notes failed to document the reason the oral care not completed. The hospice aide failed to provide services as instructed by the RN assignment. 8. Patient #7 had a hospice admission date of 9/4/24 and revoked services on 9/26/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 9/4/24 to 12/2/24, identified the patient had a diagnosis of end stage renal disease and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: provide Foley catheter care and empty the Foley catheter bag. c. Hospice aide visit note, dated 9/11/24, failed to included documentation the hospice aide provided Foley catheter care or empty the Foley catheter bag. d. Hospice aide visit notes, dated 9/18/24, failed to include the patients weight. The documentation included “unable to obtain” but failed to identify the reason the aide unable to obtain the patient’s weight. The hospice aide failed to provide services as instructed by the RN assignment. 9. Patient #12 had a hospice admission date of 12/16/24 and date of death of 12/30/24 and received hospice services while residing in a private residnence. Clinical record review revealed: a. The POC, dated 12/16/24 to 3/1/25, identified the patient had a diagnosis of degeneration of the automatic nervous system and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: assist the patient with a shower, assist the patient with a sponge bath if unable to shower, assist with shaving and empty the Foley catheter bag. c. Hospice aide visit notes, dated 12/17/24 and 12/24/24, identified oral care and empty the Foley catheter bag not completed and documented “not applicable this visit”. The notes failed to document the reason the oral care and empty the Foley catheter bag not completed. d. Hospice aide visit note, dated 12/27/24, identified staff provided both a shower and sponge bath for the patient. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with the Administrator and Clinical Manager. 4. Patient #1 had a hospice admission date of 4/17/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 4/17/25 to 7/15/25, identified the patient had a diagnosis of Cirrhosis of the liver and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: i. weight (every other week), with a start date of 4/17/25; and ii. change patient linen once per week, with a start date of 4/17/25 and a resolved date of 6/9/25. c. Hospice aide visit notes, dated 4/25/25, 5/2/25, 5/6/25, 5/16/25, 5/20/25, 5/23/25, 5/27/25, 5/30/25, 6/6/25, 6/10/25, 6/17/25 and 6/20/25, included documentation of patient’s weight obtained. d. Hospice aide visit note, dated 5/6/25, identified patient linen not changed. e. Hospice aide visit note, dated 5/9/25, included documentation the task change patient linen once a week, not applicable this visit but lacked a reason why this task was not completed as assigned. The hospice aide failed to provide services as instructed by the RN assignment. 5. Patient #4 had a hospice admission date of 4/16/24, a discharge date of 6/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/16/24 to 7/14/24, identified the patient had a diagnosis of Chronic respiratory failure and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task; weight (every other week), with a start date of 4/16/24 and a resolved date of 6/24/24. c. Hospice aide visit note, dated 4/24/24, included documentation of patient’s weight. d. Hospice aide visit notes, dated 5/8/24, 5/22/24 and 6/5/24 failed to include documentation of patient’s weight. The hospice aide failed to provide services as instructed by the RN assignment. 6. Patient #8 had a hospice admission date of 7/8/24, a discharge date of 8/2/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 7/8/24 to 10/5/24, identified the patient had a diagnosis of Breast cancer and included physician orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: i. nail care (file, trim, clean), with a start date of 7/8/24 and a resolved date of 8/2/24; and ii. change patient linen once per week, with a start date of 7/8/24 and a resolved date of 8/2/24. c. Hospice aide visit notes, dated 7/15/24, 7/22/24, 7/24/24, 7/29/24, 7/31/24 and 8/2/24, included documentation the task nail care, not applicable this visit but lacked a reason why the task was not completed as assigned. d. Hospice aide visit notes, dated 7/24/24, 7/26/24, 7/29/24, 7/31/24 and 8/2/24, included documentation the task change patient linen once per week not applicable this visit but lacked a reason why the task was not completed as assigned. The hospice aide failed to provide services as instructed by the RN assignment. Findings include: According to the hospice Policy, titled Hospice Aide Services, dated 6/2025, the hospice aide received patient care assignments from a Registered Nurse (RN) utilizing the individual patient electronic medical record. 1.Patient #3 had a hospice admission date of 12/27/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed the following: a. Interdisciplinary group (IDG) meeting notes, dated, 4/8/25, 4/22/25, 5/6/25, 5/20/25, 6/3/25 and 6/17/25, included IDG orders for hospice aide services. b. Undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: i. weight (every other week), with a start date of 12/27/24 and a resolved date of 6/11/25; and ii. nail care (file, trim, clean), with a start date of 12/27/24. c. Hospice aide visit notes, dated 4/21/25, 4/24/25, 4/28/25, 5/1/25, 5/5/25, 5/8/25, 5/12/25, 5/15/25, 5/19/25, 5/22/25, 5/27/25, 5/30/25, 6/2/25, 6/5/25 and 6/9/25, included documentation of patient weights obtained. d. Hospice aide visit notes, dated 4/21/25, 4/23/25, 4/24/25, 4/30/25, 5/1/25, 5/5/25, 5/7/25, 5/8/25, 5/12/25, 5/14/25, 5/15/25, 5/19/25, 5/21/25, 5/22/25, 5/27/25, 5/28/25, 5/30/25, 6/2/25, 6/4/25, 6/5/25, 6/9/25, 6/11/25, 6/12/25, 6/16/25 and 6/18/25, included documentation the task nail care, not applicable this visit but lacked a reason why this task was not completed as assigned. The hospice aide failed to provide services as instructed by the RN assignment. 2. Patient #10 had a hospice admission date of 2/11/25, a death date of 2/26/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a. Plan of Care, dated 2/11/25 to 4/11/25, included physician orders for hospice aide services. b. IDG meeting note, dated, 2/25/25, included IDG orders for hospice aide services. c. Undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks assist with transfers, empty foley catheter, assist patient with dressing, shower, shampoo, oral care and report patient pain to nurse; with start dates of 2/11/25 and resolved date of 2/26/25. d. Hospice aide visit notes, dated 2/12/25, 2/17/25 and 2/21/25, included documentation the tasks oral care and report patient pain to nurse, not applicable this visit but lacked a reason why these tasks were not completed as assigned. e. Hospice aide visit note, dated 2/26/25, included documentation the tasks assist with transfers, empty foley catheter, assist patient with dressing, shower and shampoo, not applicable this visit but lacked a reason why these tasks were not completed as assigned. The hospice aide failed to provide services as instructed by the RN assignment. 3. Patient #13 had a hospice admission date of 12/23/24, a death date of 1/7/25 and received hospice services while residing in a private home from 12/23/24 to 12/29/24 and a nursing home from 12/30/24 to 1/7/25. Clinical record review revealed the following: a. Plan of Care, dated 12/23/24 to 3/22/25, included physician orders for hospice aide services. b. IDG meeting note, dated, 12/31/24, included IDG orders for hospice aide services. c. Undated hospice aide care plan included RN instructions to the hospice aide to perform the task nail care (clean, file, trim), with start date of 12/23/24 and resolved date of 1/7/25. d. Hospice aide visit notes, dated 12/24/24, 12/27/24 and 1/2/25, included documentation the task nail care, not applicable this visit but lacked a reason why this task was not completed as assigned. The hospice aide failed to provide services as instructed by the RN assignment.”

“Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 2 sampled services (Medical equipment/supply provider). Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: Review of the contract between the hospice and sampled medical equipment/supply provider, dated 4/1/2016, identified the contract lacked the following required components: a. The hospice retains administrative and financial management and b. All services are authorized by hospice and delivered in accordance with the patient’s plan of care. The hospice failed to ensure the contractual agreement with the medical equipment/supply provider contained all required components for safe and effective patient care. The above findings were reviewed with the Administrator and Clinical Manager.”