Heart N Home Hospice & Palliative Care

“Based on policy review, record review, and staff interview, it was determined the agency failed to ensure POCs were individualized for each specific patient for 2 of 19 patients (Patients #2 & #6) whose records were reviewed. This resulted in no interventions or goals related to the terminal illness addressed on patient’s POC and had the potential to affect all patients receiving services from the agency. Findings include: 3. Patient #8 was a 70-year-old female admitted to hospice on 8/16/24 with a primary diagnosis of moderate protein calorie malnutrition. She received SN, HHA, Chaplain and SW services. Her medical record, including the POC, was reviewed. A surveyor observational visit was conducted on 8/19/24 with the SW and this patient in the ALF. Patient #8s POC, dated 8/16/24, included the primary diagnosis of moderate protein calorie malnutrition but did not include a nutrition-based intervention or goal. The Regional Vice President (RVP)of the Hospice was interviewed on 8/22/24 at 10:00 AM, and Patient #8s medical record was reviewed in her presence. The RVP confirmed there were no interventions or goals created to address the primary diagnosis in the Patient #8s POC. The Agency failed to ensure that Patient #8s POC was comprehensive and addressed patients primary diagnosis. An agency policy titled, “;INITIAL & COMPREHENSIVE ADMISSION ASSESSMENT & PLAN OF CARE,” revised 4/01/22 stated, “;The purpose of the initial assessment visit will be to evaluate the patient’s physica4 psychosocia4 and emotional states related to the terminal illness and related conditions and to determine the patient’s immediate care and support needs. The information gathered in the initial assessment will be developed immediately into an initial plan of care.” This policy was not followed. Examples include: 1. Patient #2 was a 73 year old female admitted to the agency on 7/05/24 with a terminal diagnosis of “;nonspecific abnormal finding of lung field.” She had a mass in her left lung. She received SN, MSW, HHA, Chaplain, and volunteer services. Her record for the certification period 7/05/24 to 10/02/24 was reviewed. Patient #2s record included a POC that was completed on the SOC on 7/05/24. Orders for discipline and goals included generic hospice items including but not limited to pain reduction, education on pain scale, instructions on how to use medications, understanding of hospice services, and education on the hospice philosophy. There were no interventions or goals on the POC that were individualized to Patient #2s terminal diagnosis. Additionally, there were no respiratory interventions or goals related to Patient #2s terminal diagnosis of lung mass. The ED was interviewed on 8/21/24 beginning at 1:50 PM and Patient #2s POC was reviewed with her. She confirmed there were no respiratory interventions related to Patient #2s lung mass. She confirmed the POC was not individualized to Patient #2. 2. Patient #6 was a 58 year old female admitted to the agency on 7/05/24 with a primary diagnosis of dysphagia. Additional diagnoses included type 2 diabetes and alcohol abuse. She received SN, MSW, HHA, and chaplain services. Her record for the certification period 7/05/24 to 10/02/24 was reviewed. Patient #6s record included a POC that was completed on the SOC on 7/05/24. Orders for discipline and goals included generic hospice items including but not limited to pain scale, shortness of breath, vital sign assessment, and medication understanding. There were no interventions or goals on the POC that were individualized to Patient #6s terminal diagnosis. Additionally, there were no interventions or goals related to Patient #6s terminal diagnosis of dysphagia. The ED was interviewed on 8/21/24 beginning at 1:00 PM and Patient #6s POC was reviewed with her. She confirmed there was no interventions or goals related to Patient #6s terminal diagnosis of dysphagia. She confirmed Patient #6s POC was not individualized to Patient #6. The agency failed to ensure POCs were individualized for each specific patient.”

“Based on record review, and staff interview, it was determined the agency failed to ensure POCs included all interventions or goals necessary to manage symptoms for each specific patient for 1 of 19 patients (Patient #8) whose records was reviewed. This resulted in Patient #8’s POC not containing interventions or goals related to the identified symptoms. This had the potential to affect all patients receiving services from the agency. Findings include: . Patient #8 was a 70-year-old female admitted to hospice on 8/16/24 with a primary diagnosis of moderate protein calorie malnutrition. She received SN, HHA, Chaplain and SW services. Her medical record, including the POC, was reviewed. A surveyor observational visit was conducted on 8/19/24 with the SW and this patient in the ALF. Patient #8s medical record RN visits from 8/17/24 and 8/20/24. The visits documented a specific visual hallucination of a young boy in the Patient #8s bathroom. The MSWs visit on 8/19/24 included the same visual hallucination. The 8/19/24 notes included that the hallucinations were a concern for the patient. The medical recorded included, “;She was so fixed with the memory of the person in the mirror and with the young boy in her mind it was difficult to get other information.” Her medical record was reviewed. There was no documentation of intervention related to the hallucinations identified on any of the above visits to address these symptoms. The RVP of the hospice was interviewed on 8/22/24 at 10:00 AM and patient #8s medical record was reviewed in her presence. The RVP confirmed there were no interventions or goals created to address the hallucinations in the Patient #8s POC. Patient #8s POC, dated 8/16/24, documented included a primary diagnosis of moderate protein calorie malnutrition. RN visits on 8/17/24 and 8/20/24 completed by Hospice RNs did not include nutrition assessments. The medical record for both visits documented the field “;Was the patient nutritional status assessed” and the response “;No.” The subsequent field “;Why was the nutritional status not assessed?” had the response, “;Not appropriate at time of evaluation.” Patient #8s ongoing symptoms were not assessed. The Regional Vice President (RVP)of the Hospice was interviewed on 8/22/24 at 10:00 AM. The RVP confirmed nutrition assessments addressing primary diagnosis related symptoms were not completed during RN visits on 8/17/24 and 8/20/24. The Agency failed to ensure that Patient #8s health concerns and symptoms were addressed with interventions and assessments.”

“Based on record review and interview the agency failed to ensure the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions for one of 19 patients (Patient #11) whose records were reviewed. Patient #11 was a 83 year old female admitted to hospice on 2/27/24 with a primary diagnosis of Chronic Kidney Disease. Additional diagnosis include protein calorie malnutrition, and type 2 DM. She received SN, HHA, Chaplain and SW services. Her medical record, including the POC, was reviewed. Patient #11s plan of care included “;Caregiver to putnystatin [sic] [put nystatin] on BID until resolved.” Nystatin is an antibiotic ointment used for the management of skin infections and rashes. There was no other detail or specificity to this order. It was unclear where the nystatin was to be applied and no detail on what was to be resolved. The RVP was interviewed on 8/22/24 beginning at 9:30 AM, and Patient #11s medical record was reviewed in her presence. She confirmed there was no documentation Patient #11s Nystatin order was specific to include necessary details. She stated she knew Patient #11 had a rash on her groin, but she confirmed there should be more documentation related to the Nystatin. The hospice failed to specify patient order to include all relevant information.”

“Based on record review and staff interview the agency failed to ensure the current and revised plan of care included updated goals and interventions or assessments for pain and symptoms for 2 of 19 patients (Patient #8 and #19) whose record was reviewed. This had the potential for needs to go unmet. 2. Patient #8s POC, dated 8/16/24, included a primary diagnosis of moderate protein calorie malnutrition. RN visits on 8/17/24 and 8/20/24 completed by Hospice RNs did not include nutritional assessments. The medical record for both visits included the field “;Was the patient nutritional status assessed” and the response “;No.” The subsequent field “;Why was the nutritional status not assessed?” documented the response, “;Not appropriate at time of evaluation.” It was unclear why a nutritional assessment was not completed. Patient #8s ongoing symptoms were not assessed. The RVP of the Hospice was interviewed on 8/22/24 at 10:00 AM. The RVP confirmed nutrition assessments addressing primary diagnosis related symptoms were not completed during RN visits on 8/17/24 and 8/20/24. The Agency failed to ensure that Patient #8s health concerns and symptoms were addressed with interventions and assessments. Patient #11 was a 83 year old female admitted to hospice on 2/27/24 with a primary diagnosis of Chronic Kidney Disease. Additional diagnosis include protein calorie malnutrition, and type 2 DM. She received SN, HHA, Chaplain and SW services. Her medical record, including the POC, was reviewed. Patient #11’s POC did not include updates to goals. Examples include: Patient #11s plan of care included, “;Patient pain [sic] will report pain at her comfort goal 4/10 or less through 3/22/24.” It was unclear what Patient #11s current measurable pain goal was after 3/22/24. Additionally, it was unclear why the current care plan, a document created on 6/13/24, included goals that had expired. The RVP was interviewed on 8/22/24 beginning at 9:30 AM, and Patient #11s medical record was reviewed in her presence. She stated she did not know why the current care plan showed goal that had expired. She stated she could not find documentation regarding Patient #11s updated pain goal. The agency failed to include Patient #11s POC included updated goals for the management of pain.”

“Based on review of clinical record, and staff interview, it was determined that the hospice failed to follow orders outlilned on the plan of care for one of 19 patients (Patient #11) whose record was reviewed. Patient #11 was a 83 year old female admitted to hospice on 2/27/24 with a primary diagnosis of Chronic Kidney Disease. Additional diagnosis include protein calorie malnutrition, and type 2 DM. She received SN, HHA, Chaplain and SW services. Her medical record, including the POC, was reviewed. Patient #11s comprehensive care plan report included, “;Using aseptic technique, insert 16Fr 30ml Balloon catheter to continuous bedside drainage related to comfort. Catheter to be changed every 3 months and PRN per complications.” The order was dated at Patient #11s start of care and was on her current care plan for her current certification period. There was no documentation in Patient #11s medical record of her catheter being changed. The RVP was interviewed on 8/22/24 beginning at 9:30 AM, and Patient #11s medical record was reviewed in her presence. She confirmed there was no documentation Patient #11s catheter was changed as ordered. The hospice failed to provide services as order on Patient #11s POC.”