Heart ‘n Home Hospice

“Based on observation, medical record review, and staff interview, it was determined medications were not properly reconciled for 1 of 3 patients (Patient #11) whose record was reviewed and an observational visit was conducted. This had the potential to affect the care of Patient #11. Findings include: Patient #11 was a 96-year-old male on hospice services with a terminal diagnosis of coronary artery disease and atherosclerosis of CABG. He had a start of care of 12/30/25 and was in his third benefit period. Surveyor observed the RN for this routine home visit on 07/07/26 at 3:00 PM. During this home visit, the RN reviewed patient medications with the patient and his wife. Patient #11’s daily medications included: aspirin 81 mg daily and Advil 200 mg daily. This was not consistent with Patient #11’s medication list in his medical record. The medical record stated: “Acetaminophen 80 mg chewable tablet, 1 tablet daily; and Advil 200 mg tablet, 1 tablet 2 times daily.” The RN was interviewed outside after the visit. Patient #11’s medication list was reviewed with her. She confirmed there was a discrepancy in the record for these 2 medications. Medications in the home were not consistent with the medication list in the medical record. K”

“Based on medical record review, observation, and staff interview, it was determined the agency failed to provide all services on the plan of care for 1 of 14 Patients (Patient #12) whose medical records were reviewed. This had the potential to miss concerns addressed at the initial assessment and not provide the comprehensive services offered by hospice. Findings include: Patient #12 was an 84 year old female on hospice services for a terminal diagnosis of senile degeneration of the brain and comorbidity of atrial fibrillation. The plan of care included chaplain services. The medical record included a note by the RN in November, 2025, which stated the family requested a chaplain visit after the Thanksgiving holiday. There was no further documentation or visit documented by the chaplain or RN which addressed chaplain services. In an interview with the Clinical Director on 07/09/26, beginning at 11:00 AM, the medical record for Patient #12 was reviewed in her presence. She confirmed the family requested chaplain services after Thanksgiving and there was no subsequent note or visit documented by the chaplain. Chaplain services remained on the plan of care. The plan of care was not followed. K”

“Based on medical record review, QAPI data, and staff interviews, it was determined the agency failed to capture in an incident, all antibiotics prescribed to patients for 1 of 2 Patients (Patient #8) whose records were reviewed and had documented antibiotics prescribed. This led to inaccurate QAPI data for infections and had the potential for trends to be missed. Findings included: Patient #8 was a 78-year-old female admitted to hospice services on 03/01/23 with a terminal diagnosis of emphysema. The medical record contained an RN note for 06/25/26 which stated, “Start azithromax for respiratory symptoms.” The order was signed by the hospice physician but it was not captured as an incident for an infection. In an interview with the Clinical Director on 07/08/26, beginning at 2:10 PM, she stated antibiotics were not automatically captured by HCHB (electronic medical record). Antibiotics had to be entered by the RN as an incident for that data to be captured and included in quality data for infections. She confirmed the RN did not capture the antibiotic for Patient #8. QAPI data was not accurately captured. K”

“Based on observation, CDC guidelines, and staff interviews, it was determined the agency failed to ensure proper hand hygiene was performed for 1 of 3 Patients (Patient #11) observed by surveyors. This had the potential to affect all patients at the agency. Findings include: CDC guidelines for hand hygiene, accessed 07/10/26 at cdc.gov states: “Hand hygiene is indicated after contact with a patient’s intact skin...and after removing gloves.” This guideline was not followed. An example included: Patient #11 was a 96-year-old male on hospice services with a terminal diagnosis of coronary artery disease and atherosclerosis of CABG. He had a start of care of 12/30/25 and was in his third benefit period. Surveyor observed the RN for this routine home visit on 07/07/26 at 3:00 PM. During this home visit, the RN was observed to don gloves, perform vital signs, remove gloves, and proceeded to enter data on the laptop. No hand sanitizer was used prior to laptop use. The RN then donned a new pair of gloves and auscultated lungs, cleaned stethoscope, removed gloves, and proceeded to enter data on the laptop. No hand sanitizer was used prior to laptop use. The RN was interviewed outside after the visit. Hand hygiene was reviewed and she confirmed she forgot to use hand sanitizer after glove removal and prior to use of laptop. Ther Clinical Director was interviewed on 07/08/26 at 2:10 PM. She confirmed the agency followed CDC guidelines and these guidelines were not followed. Proper hand hygiene was not performed. K”

“Based on clinical record review, policy review, and interview, the hospice failed to ensure patients were discharged appropriately for 2 of 3 sampled patients (Patient #4 and #6) whose records were reviewed for live discharge. This had the potential to compromise the patients’ Medicare benefit rights and mischaracterize patient/caregiver compliance within the medical record. Medicare Benefit Policy Manual, Chapter 9, Section 20.2.3 (Hospice Discharge) included: “Discharge for cause: There may be extraordinary circumstances in which a hospice would be unable to continue to provide hospice care to a patient. These situations would include issues where patient safety or hospice staff safety is compromised. “ An agency policy titled “Live Discharge/transfer of the Hospice Patient “ (Last Revised: 05/01/26) was reviewed. The policy stated, “The hospice agency discharges the patient for cause. There may be extraordinary circumstances in which the hospice agency may be unable to continue to provide hospice care to the patient. These situations would include issues where patient safety or hospice staff safety is compromised.” This policy was not followed. Examples include: Patient #4 was 89-year-old female on hospice services with a start of care of 02/10/26 and primary diagnosis of dementia. The 02/10/26 – 03/10/26 episode of care was reviewed. Record Review: Review of Patient #4’s record documented reason for discharge on 03/10/26 as, “discharge for cause.” However, in the coordination note the record documented on 03/03/26, “Husband upset today and request that wife be taken off services and allow the tribe to take care [of] her. He wishes all cares [from] the tribe. This RN will complete a discharge and will notify the tribal nurse.” Interview with Executive Director: The ED was interviewed on 07/08/2026 beginning at 12:30 PM, the agency executive director confirmed discharge for cause was not an appropriate reason for Patient #4’s discharge. The hospice failed to appropriately discharge Patient #4. Patient #6 was a 76-year-old male on hospice services with a start of care date of 4/10/23 with a primary diagnosis of hypertensive chronic kidney disease. Record Review: Review of Patient #2’s clinical record documented a nursing note on 12/04/25 which recorded, “patient is in respite care at Clearwater Hospital.” 12/04/25 nursing note documented, “this RN attempting to work with hospital for respite care … no PO intake and is non responsive.” RN visit on 12/08/25 documented medication orders were changed from IV to PO and that two doctors discussed changed and agreed. RN visit on 12/9/25 documented “Discharge for cause ..patient discharge due to [hospital] not wanting to follow plan of care.” Patient #6’s medical record included a client coordination note report dated 12/09/26 documented, “[Provider] notified of facility not wanting to follow his current medication and plan of care. This RN spoke with the DNS yesterday related to not follow plan of care and medication. … Today notified by POA that the stopped all [provider] orders and restarted their own with IV meds. ED gives order to discharge for cause due to not follow care plan.” The ED was interviewed on 07/08/26 beginning at 12:30 PM, the agency executive director confirmed discharge for cause was not an appropriate reason for Patient #6’s discharge. The hospice failed to properly discharge Patient #6.”