Heartland Hospice (Fairview Heights)

“Upon patient record review, 2 of 5 (Patient #1,#5) 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 During record review it was noted each patient and family. Patient#1: During the record review it was noted that wound #1 had no evidence of measurements or assessment the week of 1/18/26. On nurse visit 1/19 the RN documents patient refused wound care and it would be completed on the next visit. The second SN visit that week was completed by LVN who documented on 1/21 that dressing was in place and intact. Agency policy is for RN to complete wound measurement and assessment weekly. Patient#5: During the record review it was noted that there was no evidence of wound measurement the week of 1/12/26 by RN as both SN visits were completed by LVN and contained no measurements. There is also no evidence of wound measurements the week of 1/18/26. On nurse visit 1/19 the RN documents patient refused. The LVN completed the second visit for that week on 1/21 and documented caregiver completed care. Agency policy is for RN to complete wound measurement and assessment weekly.”

“Upon patient record review, 2 of 5 (Patients #2,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained conflicting routes of oral and instructions to crush and administer via G-tube for amlodipine, cilostazol, senna plus, and tramadol. Corrected on site with order clarification and medication profile update. Patient 4: The medication profile contained nursing documentation 12/3/25 identifying new order received for simethicone to be crushed and placed in applesauce or pudding. The profile did not include the instructions for crushing simethicone. Corrected on site with order clarification and medication profile update.”

“Upon patient record review, 1 of 5 (Patient #1) 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 1: The medical record contained nursing documentation upon admission identifying patient has fluid filled blister to left heel, and documentation 12/24/25 stating left heel healing well. There was no evidence of any wound assessments and measurements. Agency policy requires weekly assessments and measurements.”

“Upon patient record review, 1 of 5 (Patient #4) 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 medical record contained nursing documentation upon admission identifying patient history of multiple falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update.”

“Upon patient record review, 1 of 5 (Patient #3) 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 3: The medical record contained an order for social work frequency of 1 PRN. There was no evidence of an anticipated need for social work visits. Corrected on site with order clarification.”

“Upon patient record review, 3 of 5 (Patients #1,#2,#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: The POC contained nursing documentation upon admission identifying patient has fluid filled blister to left heel, and documentation 12/24/25 stating left heel healing well. There was no evidence of a wound care order. Patient 2: The POC contained conflicting routes of oral and instructions to crush and administer via G-tube for amlodipine, cilostazol, senna plus, and tramadol. Corrected on site with order clarifications. Patient 4: The POC contained nursing documentation 12/3/25 identifying new order received for simethicone to be crushed and placed in applesauce or pudding. The order did not include the instructions for crushing. Corrected on site with order clarifications.”

“Upon patient record review, 5 of 19 (Patients #2,#3,#4,#10,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained instructions for two differing doses of fentanyl patches. There was no evidence of instructions to administer together or differentiate if one dose was outdated. Corrected on site with order clarification and removal of former dose from profile. Patient 3: Upon home visit medication reconciliation, the patient stated she does not take the scheduled prednisone and Senna. Patient also stated she takes daily vitamin B12 and aspirin 81mg that were not on the medication profile. Corrected on site with order clarification and medication profile update. Patient 4: The medication profile contained oxygen with no delivery method. Corrected on site with order clarification and medication profile update. Patient 10: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain guaifenesin on hospice profile, contained morphine extended release tablets for a PRN instead of hospice immediate release, and Ondansetron every 6 hours PRN instead of hospice instructions for daily PRN. Corrected on site with order clarification and medication profile update. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain PRNS for acetaminophen, guaifenesin, Levsin, Robitussin, and Tramadol that were on hospice profile. Facility also contained hydroxyzine every 6 hours PRN instead of hospice four times daily, and morphine every 3 hours PRN instead of hospice every 4 hours PRN. Corrected on site with order clarification and medication profile update.”

“Upon patient record review, 2 of 19 (Patients #9,#13) 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 9: The medical record contained an initial bereavement assessment 7/23/24 with admission 4/16/24. Patient 13: The medical record contained an initial bereavement assessment 9/27/24 with admission 9/16/24.”

“Upon patient record review, 3 of 19 (Patients #3,#6,#7) 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 3: There was no evidence of weekly wound measurements and assessments between 9/1/25 and 10/2/25 as required per agency policy. Nurse documentation stated patient refused however refusal documentation required per policy was not completed. Patient 6: There was no evidence of weekly wound measurements since admission 9/17/25 and no weekly assessments as required per agency policy between 9/22/25 and 10/13/25, and 10/13/25 to date of review 11/4/25. Patient 7: There was no evidence of weekly wound measurements and assessments between 9/29/25 and 10/21/25 as required per agency policy.”

“Upon patient record review, 4 of 19 (Patients #2,#6,#7,#12) 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 2: The medical record contained nursing documentation upon admission identifying patient history of seizures and high risk for falls. There was no evidence of problems, goals, and interventions related to seizure precautions and fall safety included in the plan of care. Corrected on site with plan of care update. Patient 6: The medical record contained documentation identifying patient prescriptions of Eliquis and insulin since admission. There was no evidence of problems, goals, and interventions related to risk for bleeding and endocrine dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 7: The medical record contained nursing documentation upon admission identifying patient has issues with dyspnea upon minimal exertion since admission. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 12: The medical record contained nursing documentation upon admission identifying patient is high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update.”

“Upon patient record review, 1 of 19 (Patient #13) 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 13: The medical record contained an order to discontinue spiritual care scheduled visits and allow 2 PRN visits 9/23/25. There was no anticipated need for spiritual care and order stated care was to be discontinued per patient request. Corrected on site with order clarification.”

“Upon patient record review, 5 of 19 (Patients #2,#3,#4,#10,#14) 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 2: The medical record contained orders for two differing doses of fentanyl patches. There was no evidence of instructions to administer together or differentiate if one dose was outdated. Corrected on site with order clarification and discontinuation of former dose. Patient 3: Upon home visit medication reconciliation, the patient stated she does not take the ordered prednisone and Senna. Patient also stated she takes daily vitamin B12 and aspirin 81mg that hospice did not have orders for. Corrected on site with order clarification. Patient 4: The medical record contained an order for oxygen with no delivery method. Corrected on site with order clarification. Patient 10: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility orders did not contain guaifenesin on hospice record, contained morphine extended release tablets for a PRN instead of hospice immediate release, and ondansetron every 6 hours PRN instead of hospice instructions for daily PRN. Corrected on site with order clarification. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility orders did not contain PRNS for acetaminophen, guaifenesin, Levsin, Robitussion, and Tramadol that were on hospice profile. Facility also contained orders for hydroxyzine every 6 hours PRN instead of hospice four times daily, and morphine every 3 hours PRN instead of hospice every 4 hours PRN. Corrected on site with order clarification.”

“Upon patient record review, 5 of 19 (Patients #3,#5,#6,#8,#14) 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 equipment and supply needs. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a commode. There was no evidence of an order for the commode included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a shower bench. There was no evidence of an order for the bench included in the plan of care. Corrected on site with order received. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care. Corrected on site with order received. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, overbed table, Hoyer lift, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received.”

“Upon patient record review, 2 of 19 (Patients #7,#13) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 7: The medical record contained nursing documentation upon recertification assessment 9/29/25 identifying patient is high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update. Patient 13: The medical record contained nursing documentation upon recertification assessment 10/21/25 identifying patient history of seizures. There was no evidence of problems, goals, and interventions related to seizure precautions included in the plan of care. Corrected on site with plan of care update.”

“Upon patient record review, 3 of 19 (Patients #16,#17,#18) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patients 16,17:There was no evidence the bereavement care plan tasks of sending out memorial service invitations was completed. After leadership investigation, the memorial invitations were sent but not documented. Corrected on site with late entry documentation. Patient 18: There was no evidence the bereavement care plan tasks of sending out a sympathy card, one month letter, and memorial service invitation were completed. After leadership investigation, the memorial invitations were sent but not documented. Corrected on site with late entry documentation.”

“Upon patient record review, 2 of 19 (Patients #6,#14) did not have evidence that the hospice provided the following information: • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Hospice medication information specific to each patient Patient 6: Upon observation during home visit, the facility did not have a signed CTI with physician narrative of eligibility, election form, advance directives, or names of hospice personnel involved with hospice care. Corrected on site with delivery of missing documentation. Patient 14: Upon observation during home visit, the facility did not have any CTIs prior to the most recent benefit period ending 10/30/25, election form, advance directives, or names of hospice personnel involved with hospice care. Corrected on site with delivery of missing documentation.”