Hearthstone Hospice

“It is required that all hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records, interviews, document review and interviews which revealed the hospice: Failed to ensure that that the hospice aide the hospice aide received at least 12 hours of in-service training during each 12-month period {HSRM.18. I/L620/418.76(d)}; Failed to ensure that a registered nurse provided written patient care instructions for the hospice aide {HCDT.15.I/L625/418.76(g)(1)}; and Failed to ensure the hospice aide reported changes to the registered nurse {HCDT.18.I/L628/418.76(g)(4)}. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.76, Hospice Aide and Homemaker Services. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visits of patients who elected hospice it was revealed the agency did not ensure the patient’s current prescription and over-the-counter drugs were included on the medication profile. CLINICAL RECORD 2/HOME VISIT 2: During the home visit with the registered nurse (RN) (Personnel Record 1), the RN was observed performing wound care. The medication being used for wound care was ordered as follows (according to the label present on the medication): Gentian Violet 1%, apply a small amount to area twice daily until healed, dated 05/13/2026 by the physician. This medication was not included on the patient’s medication profile dated 06/29/2026. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 07/01/2026, she stated she would review with the nurse and have her update the medication list.”

“It is required that a hospice aide receives at least 12 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. In-service training may be offered by any organization and is supervised by registered nurse. The hospice maintains documentation that demonstrates that requirements 1 and 2, above, have been met for each aide. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personal record reviewed of the hospice aide it was revealed that the agency did not ensure the hospice aide received at least 12 hours of in-service training during each 12-month period. PERSONNEL RECORD 2: The hospice aide with a hire date of 12/18/2023 was reviewed and revealed no documented evidence at least 12 hours of in-service training during each 12-month period. There was no documented evidence that the aide had 12 hours of in-service training for the years 2024 and 2025.The only in-service was for infection control, HIPPA, Emergency preparedness, abuse and neglect, no other additional training in personnel record. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 06/30/2026, she stated that she had found the requirement but had not been aware of it prior to today.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 13 of 14 (93%) clinical records reviewed of patients who elected the hospice benefit it was revealed that the agency did not ensure that a registered nurse provided written patient care instructions for the hospice aide. CLINICAL RECORD 1: The patient’s election of benefits was dated 10/14/2025. A review of the hospice aide care plan dated 06/11/2026 to 08/09/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 2: The patient’s election of benefits was dated 02/26/2026. A review of the hospice aide care plan dated 05/27/2026 to 08/24/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 3: The patient’s election of benefits was dated 12/01/2025. A review of the aide care plan dated 05/30/2026 to 07/28/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 4: The patient’s election of benefits was dated 12/11/2025. A review of the aide care plans dated 04/10/2026 to 06/08/2026 and 06/09/2026 to 08/07/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 5: The patient’s election of benefits was dated 12/26/2025. A review of the aide care plans dated 03/26/2026 to 06/23/2026 and 06/24/2026 to 08/22/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 6: The patient’s election of benefits was dated 06/25/2024. A review of the aide care plans dated 06/15/2026 to 08/13/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 7: The patient’s election of benefits was dated 04/23/2026. A review of the aide care plans dated 04/23/2026 to 07/21/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 8: The patient’s election of benefits was dated 01/10/2025. A review of the aide care plans dated 03/06/2026 to 05/04/2026 and 04/26/2026 to 07/24/2026did not include instructions on how often to perform tasks. CLINICAL RECORD 9: The patient’s election of benefits was dated 01/26/2026. A review of the aide care plans dated 01/26/2026 to 04/25/2026 and 04/26/2026 to 07/24/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 10: The patient’s election of benefits was dated 02/09/2026. A review of the aide care plans dated 06/09/2026 to 08/07/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 11: The patient’s election of benefits was dated 06/07/2025. A review of the aide care plans dated 06/07/2025 to 07/06/2025 did not include instructions on how often to perform tasks. CLINICAL RECORD 12: The patient’s election of benefits was dated 06/28/2024. A review of the aide care plans dated 12/20/2025 to 01/12/2026 did not include instructions on how often to perform tasks. CLINICAL RECORD 13: The patient’s election of benefits was dated 08/12/2025. A review of the aide care plans dated 04/09/2026 to 06/07/2026 did not include instructions on how often to perform tasks. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 07/01/2026, she stated that she agreed that the instructions to the hospice aide were not present.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed of patients who elected hospice aide services it was revealed that the agency did not ensure the hospice aide reported changes to the registered nurse. CLINICAL RECORD 3: There was no documented evidence that the registered nurse was notified that tasks ordered on the aide plan of care were not completed. The hospice aide visit note dated 05/27/2026, where the tasks shower, shampoo/style hair, and assist with feeding were documented as “Not Applicable this visit” and a comment “No water pressure”. There was no documented evidence that the RN was notified that the assigned task was not completed. CLINICAL RECORD 4: There was no documented evidence that the registered nurse was notified that tasks ordered on the aide plan of care were not completed. The hospice aide visit note dated 06/08/2026, where the bed bath task was assigned in the aide’s plan of care; however, the hospice aide documented “shower” as completed. There was no documented evidence that the RN was notified that the assigned task was not completed. CLINICAL RECORD 5: There was no documented evidence that the registered nurse was notified that tasks ordered on the aide plan of care were not completed. The hospice aide visit note dated 06/08/2026, where the bed bath task was assigned in the aide’s plan of care however, the hospice aide documented “shower” as completed. There was no documented evidence that the RN was notified that the assigned task was not completed. CLINICAL RECORD 6: There was no documented evidence that the registered nurse was notified that tasks ordered on the aide plan of care were not completed. The hospice aide visit note dated 06/18/2026, where the task assigned to record bowel movement and size was documented as not applicable to this visit. There was no documented evidence that the RN was notified that the assigned task was not completed. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 07/01/2026, she stated that she agreed the documentation did not reflect that the registered nurse was notified, but that they would provide education to the clinical staff and have all aide plans of care updated.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical record reviewed revealed the agency did not ensure that the patient’s clinical record contained physician certification and recertification of terminal illness as required. CLINICAL RECORD 8: The patient’s election of benefits was dated 01/10/2025 with diagnosis of Essential (primary) hypertension. The patient resided in a facility. There was no documented evidence of a recertification of terminal illness for the benefit period 01/04/2026 to 03/05/2026. CLINICAL RECORD 12: The patient’s election of benefit was dated 06/28/2024. There was no documented evidence of a recertification of terminal illness for the benefit period 12/20/2025 to 01/12/2026. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 07/02/2026, she stated she does not know what happened, but the recertification of terminal illness for the benefit periods that were missing was dated incorrectly in the system, and they will be putting a ticket in the electronic medical record to find out what happened.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed the agency did not ensure that the patient’s clinical record contained physician orders. CLINICAL RECORD 2: The patient’s election of benefit was dated 02/26/2026 with diagnosis of Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease. The patient resided in a facility. A review of plans of care for benefit periods 02/26/2026-05/26/2025, 05/27/2026-08/24/2026 revealed there was no documented evidence for an order to flush the foley catheter. A clinical record visit note dated 07/01/2026 that the patient’s foley was flushed with normal saline, however, there was no order for the Foley catheter flush in the clinical record. CLINICAL RECORD 13: The patient’s election of benefit was dated 08/12/2025. The patient was discharged on 06/07/2026, however, there was no documented evidence that a discharge order was in the clinical record. During an interview with the Administrator/Director of Clinical Services (Personnel Record 6) on 07/01/2026, she stated she does not know why the orders were not entered into the clinical record, but that communication was had with the physician and the orders were received.”