Heartland Hospice (Beltsville)

“Upon patient record review, 3 of 19 (Patients #5,#11,#14) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 5: There was no evidence the legally authorized patient representative received written information about policies on advance directives. The daughter in law of the patient signed all consents without documentation of authority needed per Maryland laws regarding surrogacy. The patient has two living sons with legal authority according to the state. Patients 11, 14: There was no evidence the legally authorized patient representative received written information about policies on advance directives.”

“Upon patient record review, 3 of 19 (Patients #5,#11,#14) did not have evidence of the appropriate documentation for release of confidential information. Patient 5: There was no evidence the legally authorized patient representative signed appropriate documentation for the release of confidential information. The daughter in law of the patient signed all consents without documentation of authority needed per Maryland laws regarding surrogacy. The patient has two living sons with legal authority according to the state. Patients 11,14: There was no evidence the legally authorized patient representative signed appropriate documentation for the release of confidential information.”

“Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 5: There was no evidence the legally authorized patient representative received information about the scope of services covered by hospice services and the limitations on those services. The daughter in law of the patient signed all consents without documentation of authority needed per Maryland laws regarding surrogacy. The patient has two living sons with legal authority according to the state.”

“Upon patient record review, 5 of 19 (Patients #5,#7,#8,#9,#12) 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 5: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 7: The medication profile contained oxygen. Upon home visit, the caregiver stated the patient does not have oxygen. Corrected on site. Patient 8: The medication profile contained oxygen. Upon home visit, it was observed there was no oxygen in the home. Corrected on site. Patient 9: The medication profile contained differing tramadol doses dated 9/10/24 with administration of one 50mg tablet at bedtime and half a 50mg tablet at bedtime with no instructions to administer together for a total of 75mg. Corrected on site. Patient 12: During the home visit, the Director of Nursing at the ALF stated the patient does not have oxygen or senna syrup that was identified on the hospice medication profile. The ALF medication profile also had liquid hyoscyamine instead of tablets, a daily multi-vitamin, docusate tablets, acetaminophen tablets, and an albuterol inhaler that was not on the hospice medication profile.”

“Upon patient record review, 1 of 19 (Patient #6) 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 6: The medical record contained an initial bereavement assessment 8/6/24 with start of care 7/25/24.”

“Upon patient record review, 4 of 19 (Patients #2,#8,#14,#18) 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: The medical record contained documentation identifying patient wound. There was no evidence of wound measurements completed from 8/23/24 to 9/12/24 as required per agency wound policy. Patient 8: The medical record contained wound care orders 9/11/24. There was no evidence of weekly wound measurements and assessments documented on the wound as required per agency wound policy. Patient 14: The medical record contained documentation identifying patient wound to left heel. There was no evidence of weekly wound measurements and assessments between 8/23/24 to 9/3/24 as required per agency wound policy. Patient 18: The medical record contained an order for change in level of care from GIP to routine level of care 7/29/24 upon discharge from the hospital. There was no evidence of any attempts of an RN to call or to make visits until 8/5/24 when patient’s daughter stated they signed on with a different hospice company.”

“Upon patient record review, 4 of 19 (Patients #2,#5,#8,#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 was a high risk for skin impairment and issues with bradycardia as low as 36 beats per minute documented 9/6/24. There was no evidence of problems, goals, and interventions related to skin and cardiac dysfunction included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient was a high risk for skin impairment and had issues with respiratory dysfunction requiring use of oxygen. There was no evidence of problems, goals, and interventions related to skin and respiratory dysfunction included in the plan of care. Patient 8: The medical record contained nursing documentation upon admission identifying patient was high fall risk. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient issues with dysphagia requiring a pureed diet. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care.”

“Upon patient record review, 2 of 19 (Patients #5,#9) 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 5: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 9: The medical record contained two differing orders for tramadol 9/10/24 with administration of one 50mg tablet at bedtime and half of a 50mg tablet at bedtime without instructions to administer together. Corrected on site.”

“Upon patient record review, 10 of 19 (Patients #1,#2,#3,#5,#6,#8,#9,#10,#12,#13) 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 1: The medical record contained nursing documentation upon recertification 8/2/24 identifying patient use of a commode, walker, and over the bed table. There was no evidence of orders for the listed equipment included in the plan of care. Corrected on site. Patient 2: The medical record contained an order for a suction machine by error. There was no evidence the equipment was needed by the patient or in the patient’s home. Corrected on site. Patient 3: The medical record contained orders for catheter, wound, and ostomy supplies by error. There was no evidence the supplies were utilized by the patient. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Corrected Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and walker. There was no evidence of orders for the equipment included in the plan of care. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care and an inappropriate order for oxygen equipment that was entered in error. The patient did not have oxygen in the home. Corrected on site. Patient 9: The medical record contained orders for catheter, IV, and wound supplies, an APP mattress and heel protectors by error. There was no evidence the supplies and equipment were utilized by the patient. Corrected on site. The record also contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for a wheelchair included in the plan of care. Patient 10: The medical record contained nursing documentation since admission identifying patient use of a hospital bed and over bed table. There was no evidence of or orders for the equipment included in the plan of care. Patient 12: The medical record contained nursing documentation 8/16/24 identifying patient use of a hospital bed. There was no evidence of an order for the bed included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon recertification 8/29/24 identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care. Corrected on site.”

“Upon patient record review, 2 of 19 (Patients #3,#9) 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 3: The medical record contained nursing documentation upon recertification 7/23/24 identifying patient issue with respiratory dysfunction requiring use of oxygen. There was no evidence the plan of care was updated to include problems, goals, and interventions related to respiratory dysfunction. Patient 9: The medical record contained nursing documentation upon recertification 7/17/24 identifying patient difficulty with swallowing requiring education on aspiration precautions. There was no evidence the plan of care was updated to include problems, goals, and interventions related to dysphagia.”

“Upon patient record review, 2 of 19 (Patients #15,#17) 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. • Ensuring that bereavement services reflect the needs of the bereaved and are completed per care plan. Patients 15, 17: There was no evidence of bereavement tasks completed past the 2 week letter and sympathy card. Assigned tasks in the bereavement care plans included 6 month phone call, quarterly newsletters, and quarterly support group invitations.”

“Upon patient record review, 3 of 19 (Patients #4,#9,#12) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient needs. Patient 4,9: The aide care plan contained a task to transfer patient with no instructions of the level of assistance needed to transfer. Corrected on site. Patient 12: The aide care plan contained a task to transfer patient with no instructions of the level of assistance needed to transfer, and instructions for use of a walker despite nursing documentation patient was bedbound since admission. The medical record also contained nursing documentation 9/6/24 identifying patient need for aspiration precautions. There was no evidence of instructions for the aide regarding aspiration precautions included in the aide care plan.”

“Upon patient record review, 1 of 19 (Patient #14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient 14: There was no evidence of a written certification in the initial CTI upon admission 6/10/24.”

“Upon patient record review, 2 of 19 (Patients #2,#5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 2: The medical record contained an election form identifying the election date as 5/16/24. Start of care did not occur until 5/17/24. Patient 5: There was no evidence the legally authorized patient representative received the patient rights and signed the election statement. The daughter in law of the patient signed all consents without documentation of authority needed per Maryland laws regarding surrogacy given the patient has two living sons.”

“Upon patient record review, 3 of 19 (Patient #5,#11,#14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 5: There was no evidence the legally authorized patient representative received written policies and procedures for managing controlled drugs. The daughter in law of the patient signed all consents without documentation of authority needed per Maryland laws regarding surrogacy given the patient has two living sons. Patient 11, 14: There was no evidence the legally authorized patient representative received written policies and procedures for managing controlled drugs.”