Heartland Hospice

“Upon patient record review, 7 of 19 records (Patient #1,#3,#5,#6,#9,#10,#11) 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 #1: The medication profile contained duplicate Morphine orders; Morphine 100mg/5ml q4h prn SOB or severe pain and Morphine 100mg/5ml q2h prn moderate to severe pain or dyspnea. Corrected on site. Patient #3: The medication profile included Clearlax 17 Gm oral powder prn every morning and Simulant laxative plus 8.6-50mg, 1-2 tabs daily prn. There was not evidence of which order to use these medications and under what conditions to administer the next one. Corrected on site. Patient #5: The medication profile contained Gavilax 17 Gm powder 2x/day prn constipation and MOM 30 ml prn daily constipation. There was not evidence of which order to use these medications and under what conditions to administer the next one. Corrected on site. In addition Prozac, Senna and Zyprexa were all listed as under the tongue for the administration route. Corrected on site. During home visit, the medications on the hospice record contained Tylenol, and Atropine; there was not evidence that these were on the facility MAR. The MAR at the facility contained ASA, Lipitor, Lasix, Lisinopril, Toprol, and Robitussin; there was not evidence that these medications were on the hospice medication profile. Corrected on site. Patient #6: The medication profile contained Metformin 3x/day. During home visit, the patient stated that she took it 2x/day. Senna-Lax was listed as daily and the patient stated that she took 1 tablet 3x/day. Corrected on site. Patient #9: During home visit, the patient’s caregiver provided a bottle of Midodrine 2.5 mg BID for BP <95, and stated that the patient took a dose this am. There was not evidence that this was on the medication profile. Corrected on site. Patient #10: The medication profile contained Dulcolax 10 mg rectal supp daily prn if no BM in 3 days and MOM 30 cc daily prn if no BM in 3 days. There was not evidence of what order to use the medications. Corrected on site. Patient #11: The medication profile contained Humulin R u-500 130 mg 2x/day dated 8/14/24 and Humulin R u-500 103 mg 1x/day dated 6/25/24. It could not be determined what was the correct dosage. Corrected on site. In addition, there were 2 doses of Prednisone; 5mg daily and 2.5mg daily. Corrected on site. Also, Ropinirol 1mg daily and Ropinirol 2mg daily. Corrected on site. The record also indicated that the patient was on oxygen 2-3L/min via nasal cannula. There was not evidence that this was on the medication profile. Corrected on site. During home visit, the hospice medication profile contained Gemtesa 75mg. There was not evidence that this was on the facility MAR. In addition, the facility MAR contained Depakote 250mg daily and 125mg at bedtime. The hospice medication profile did not contain evidence of the 250mg dose. Corrected on site.”

“Upon patient record review, 1 of 19 records (Patient #3) 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 #3: The patient was admitted on 11/14/23. The record indicated that the bereavement assessment was completed on 3/12/24.”

“Upon patient record review, 2 of 19 records (Patient #3,#11) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family’s needs and coordinated 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: The record indicated that the patient had wounds on her abdomen. There was not evidence that the RN assessed the wounds from 9/23/24-10/15/24 and no evidence of measurements from 9/14/24-10/15/24. Patient #11: The record indicated that the patient was on Clobetasol .05% topical cream to her vulva and Lidocaine to her vaginal lesions. There was not evidence of an assessment or documentation regarding any follow-up for this issue.”

“Upon patient record review, 3 of 19 records (Patient #1,#5,#11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #1: The patient was admitted with a diagnosis of cerebral infarct due to unspecified occlusion or stenosis. The documentation included but was not limited to the patient having hemiparesis, hemiplegia, increased neuropathic pain, TIAs vs. seizures 5x/week. She had aspiration pneumonia and had become incontinent. Her diet is puree with nectar thick liquids. There was not evidence of patient/family goals and interventions related to the patients neurological issues, nutrition, seizure precautions or aspiration precautions. Corrected on site. Patient #5: The patient was admitted with Alzheimer’s Disease. Documentation indicated that he was dependent for bathing, dressing, transfers and ambulation. His fluid order was for honey thick liquids. He was at a risk for aspiration and had choking episodes. He was non-verbal, could not walk, had behaviors at times, and had poor trunk support. There was not evidence that the care plan included neurological, Alzheimer’s or nutritional issues. Corrected on site. Patient #11: The record indicated that the patient had MRSA, cellulitis of her bilateral lower extremities, and vaginal lesions. There was not evidence that any of these issues reflected goals and interventions with progress toward goals and outcomes.”

“Upon patient record review, 2 of 19 records (Patient #5,#7) 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. Patient #5: The initial visit frequency for the social worker and the spiritual care counselor was 1 prn. Visit frequency orders were revised after the evaluation visit. Patient #7: A visit frequency dated 10/29/24 for the social worker was 1 prn. Corrected on site.”

“Upon patient record review, 8 of 19 records (Patient #1,#3,#4,#5,#6,#9,#10,#11) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record contained orders for duplicate Morphine orders; Morphine 100mg/5ml q4h prn SOB or severe pain and Morphine 100mg/5ml q2h prn moderate to severe pain or dyspnea. Corrected on site. Patient #3: The record included orders for Clearlax 17 Gm oral powder prn every morning and Simulant laxative plus 8.6-50mg, 1-2 tabs daily prn. There was not evidence of which order to use these medications and under what conditions to administer the next one. Corrected on site. Patient #4: The record indicated that the patient had a Foley catheter upon admission. Documentation by the nurse dated 9/5/24 and 9/12/24 did not indicate the presence of the catheter. There was not evidence of an order to remove the catheter. Patient #5:The record contained an order for Gavilax 17 Gm powder 2x/day prn constipation and MOM 30 ml prn daily constipation. There was not evidence of which order to use these medications and under what conditions to administer the next one. Corrected on site. Also, Prozac, Senna and Zyprexa were all listed as under the tongue for the administration route. Corrected on site. In addition, the MAR at the facility contained ASA, Lipitor, Lasix, Lisinopril, Toprol, and Robitussin. There was not evidence of an order for these medications in the hospice record. Patient #6: The record contained an order for Metformin 3x/day. The patient stated that she took it 2x/day. Senna-Lax was ordered as daily and the patient stated that she took 1 tablet 3x/day. Patient #9: The patient’s caregiver provided the bottle of Midodrine 2.5 mg BID for BP <95, and stated that the patient took a dose this am. There was not evidence of an order. Patient #10: The record contained an order for Dulcolax 10 mg rectal supp daily prn if no BM in 3 days and MOM 30 cc daily prn if no BM in 3 days. There was not evidence of what order to use the medications. Corrected on site. In addition, the facility MAR contained Depakote 250mg daily and 125mg at bedtime. The hospice record did not contain evidence of an order for the 250mg dose. Corrected on site. Patient #11: The record contained orders for Humulin R u-500 130 mg 2x/day dated 8/14/24 and Humulin R u-500 103 mg 1x/day dated 6/25/24. It could not be determined what was the correct dosage. Corrected on site. In addition, there were 2 doses of Prednisone; 5mg daily and 2.5mg daily. Corrected on site. Also, Ropinirol 1mg daily and Ropinirol 2mg daily. Corrected on site. The record also indicated that the patient was on oxygen 2-3L/min via nasal cannula. There was not evidence of an order. Corrected on site.”

“Upon patient record review, 2 of 19 records (Patient #3,#11) 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 plan of care included the patient’s progress towards outcome/goals related to Massage Therapy. There was not evidence that the patient was receiving massage therapy. Corrected on site. Patient #11: The record indicated a prn visit by the social worker on 11/12/24 due to the possibility of suicide ideations. There was not evidence of an update to the plan of care regarding goals and interventions. Corrected on site.”

“Upon client record review, 2 of 19 regards (Patient #4,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: A volunteer frequency was ordered for a meet and greet dated 9/4/24 then 2x/week until 9/25/24 when the frequency was revised to 2x/month. There was not evidence of visits between 9/8/24-9/14/24 and only 1 visit for the week of 9/15/24-9/21/24. Patient #6: The visit frequency for the social worker was for an evaluation, then 2every 2m2, 2m2. The record indicated that the social worker conducted an evaluation on 9/30/24 followed by routine visits on 10/9/24, 10/23/24, and 11/6/24.”

“Upon observation, and record review, 2 of 19 records records (Patient #3,#9) did not contains evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Patient #3: The record indicated that the patient had a fall on 11/2/24. There was not evidence of a fall report. Corrected on site. Patient #9: The record indicated that the patient had a fall on 11/10/24. There was not evidence of a fall report. Corrected on site.”

“Upon patient record review 3 of 19 records (Patient #1,#4,#14) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The aide visit frequency was 2x/week. For the weeks beginning on 9/8/24, and 10/13/24, the record indicated only 1 documented visit or missed visit note each of these weeks. Patient #4: The aide plan of care indicated to shampoo every visit. For the dates of 10/22/24 and 10/23/24, the documentation by the aide indicated ‘per frequency, not needed.’ Patient #14: The aide visit frequency was 1w13 effective 9/30/24. There was not evidence of a visit for the 1st week beginning 9/30/24”

“Upon patient client record review, 4 of 19 records (Patient #1,#2,#4,#6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: The record indicated a missed visit note entered on 9/20/24 by the aide that did not contain evidence of the date that the visit was missed. Documentation was incomplete. Patient #2: The aide plan of care indicated for bathing, dressing, offer toilet assistance every visit with ‘EXT.AST’ in the comment area for each of these tasks. This abbreviation was not included in the agency policy and procedure manual. Corrected on site. Patient #4: The certification of terminal illness for the period 8/30/24-10/28/24 had the statement, ‘Patient has emesis nations as well as delusions.’ This statement is unclear. Patient #6: The record indicated a missed visit document entered by the spiritual care counselor on 10/31/24 with no indication of the date that the visit was missed. Corrected on site. In addition, the admission legal paperwork indicated that the patient had a Living Will, DPOH, and a DNR. The patient was listed as a full code. The code status of the patient was not clear.”

“Upon client record review, 3 of 19 records (Patient #1,#8,#11) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #1: The visit frequency for the spiritual care counselor was for an evaluation followed by 2 every 2m2, 2m2. The record indicated that an evaluation was conducted on 8/30/24 followed by routine visits on 9/10/24, 9/23/24, 10/8/24, 10/22/24 and 11/7/24. Patient #8: The social worker visit frequency was for an evaluation followed by 2 every 2m2, 2m1, 1m1. The record indicated that the evaluation was conducted on 8/21/24 followed by routine visits on 9/16/24, 9/30/24, 10/9/24, 10/14/24 and 11/6/24. Patient #11:The frequency for the bereavement counselor was 1m1, 2m1, 1m1, effective 9/13/24. The record indicated that visits were conducted on 9/3/24, 9/17/24, 10/1/24 and 10/16/24.”