Heartland Hospice (Raleigh )

“Based on agency policy, clinical record review, and staff interviews, the agency failed to report a patients claim of physical abuse to Adult Protective Services for 1 of 1 patient reporting abuse (patient #3).Findings included: A policy, Patient Bill of Rights (approved 11/01/20240, received on 12/29/2025 at 4:12 PM from the director of clinical services stated, “The Patient Bill of Rights statement defines the right of the patient to: … Be free of verbal, mental, sexual and physical abuse…”A policy, Assessment of Possible Abuse/Neglect (revised 12/12/2025) received on 12/29/2025 at 2:52 PM from the director of clinical operations stated, “Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor… The clinician will submit a verbal report of suspected abuse/neglect to the proper authorities… within 24 hours…”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for skilled nurse visits 4 times a week for 1 week, 3 times a week for 12 weeks, and 4 PRN (as needed). Review of the clinical record revealed that on 12/15/2025 registered nurse (RN) #7 documented, “Patient becomes tearful during visit and states He [patient’s son] scares me sometimes and hits me sometimes.” Further review revealed that there was no documentation of Adult Protective Services being notified.An interview conducted on 12/29/2025 at 3:32 PM with RN #7 revealed that they were not aware that they were a mandated reporter of abuse and believed that it was necessary to be able to prove that abuse occurred prior to reporting.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide skilled nursing services as ordered in the plan of care for 1 of 3 patients receiving skilled nurse visits (patient #3).Findings included: A policy, The Plan of Care (revised 12/21/2025) received on 12/29/2025 at 3:21 PM from the director of clinical services stated, “Care provided to the patient will be in accordance with the plan of care.”A policy, Patient Bill of Rights (approved 11/01/2024) received on 12/29/2025 at 4:12 PM from the director of clinical services stated, “The Patient Bill of Rights statement defines the right of the patient to: … Receive all services as outline in the plan of care…”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for skilled nurse visits 4 times a week for 1 week, 3 times a week for 12 weeks, with 4 PRN (as needed). Review of the clinical record revealed that during the week of 12/14/2025-12/20/2025 patient #3 received 2 of 3 ordered SN visits. Further review revealed that there was no documentation of a missed SN visit.An interview conducted on 12/29/2025 at approximately 3:00 PM with the director of clinical services revealed that there were only 2 visits documented that week and there should have been 3.”

“Based on clinical record review, the medical social workers (MSW) signed job description, and staff interviews, the agency failed to provide resources for a need identified during the MSW assessment (patient #3).Findings included: MSW #10’s signed job description stated, “General Responsibilities … Identifies and utilizes appropriate community resources and assesses patient/family ability to access them.”Patient #3 was admitted on 12/08/2025 with a diagnosis of hypertensive heart disease with heart failure (long term high blood pressure causing thickening, leading to inadequate blood flow). The plan of care for 12/08/2025-03/07/2025 included orders for medical social worker (MSW) visits 1 time for an evaluation, 1 time a month for 4 months with 2 PRN (as needed). Review of the clinical record revealed that during the MSW visit on 12/10/2025 MSW #10 documented, “Community Resources… Private Duty Caregiver… needed.” Further review revealed that there was no documentation of the patient/family being provided information or resources on private duty caregivers.During an interview conducted on 12/29/2025 at 2:33 PM MSW #10 stated, “My goal was to provide them with a list of agencies, I was going to follow-up sometime after IDG [interdisciplinary group meeting].”During an interview conducted on 12/29/2025 at 3:13 PM the director of clinical services stated, resources should be provided, “As timely as they could.” The agency director of clinical services did not define or elaborate on the word timely when asked.””

“Based on record review, interviews, and review of the agency policy, the hospice agency failed to ensure that two of 23 patients (Patient (P) 3 and P4) had their medications reconciled from either the Skilled Nursing Facility (SNF) and/or Group Home to match the medications that the hospice agency ordered. This deficient practice had the potential to affect the accuracy of medications ordered for the patients. Findings include: Review of the agency policy titled, “Safe/Effective Use and Administration of Medications,” revised 07/22/24, indicated, “. . . The clinician will complete and review the medication profile at initial and comprehensive assessments and updates will be considered part of the plan of care . . .” Review of the agency documentation titled, “Medication reconciliation, home care,” revised 05/20/24, indicated, “. . . Medication reconciliation is the formal process of comparing all of the prescription and non-prescription medications that a patient is taking (medication regimen) to an external list (medication profile) of the patients ordered medications. This process should take place any time the patient receives a prescription for a new medication and any time a transition of care or a change in therapy occurs. Medication reconciliation is necessary to identify and resolve medication discrepancies, including duplications, omissions, dosing errors, contraindications, and drug interactions, in order to minimize the risk of adverse drug events and poor patient outcomes. This process requires a team approach that includes the nurse whos reconciling the medications, patient and family, patients practitioners, and pharmacist. Medication reconciliation may occur in conjunction with a medication review, which is a comprehensive and ongoing assessment of the patients medication regimen . . .” 1. Review of P3’s agency provided “Patient Information Report” indicated that P3 was admitted to hospice services on 07/18/22 with a diagnosis of Alzheimers disease. Review of P3s undated “Client Medication Report,” provided by the agency, indicated orders for P3 to receive:acetaminophen 500 milligrams (mg), two capsules every six hours as needed (PRN) for fever/pain,Ativan (used for anxiety) 0.5 mg tablet every four hours PRN,bisacodyl five mg PRN, two tablets daily PRN for constipation, Calmoseptine topical ointment, one inch to perineum with every brief change PRN, Gabapentin (used for neuropathy) 100 mg every eight hours, hydralazine (used for high blood pressure) 25 mg daily, hold for systolic blood pressure less than 110, ipratropium 0.5 mg-albuterol 3 mg/3 milliliters (ml) nebulization solution (used for shortness of breath) give 3 ml every six hours,Levsin (used for excessive secretions) 0.125 mg, one tablet every four hours PRN, Melatonin (used for sleep) 3 mg, one tablet at bedtime (HS), morphine concentrate (used for pain) 100 mg/5 ml, give 0.25 ml PO every four hours PRN, potassium chloride 10 milliequivalent [mEq] three times a week when Lasix administered, andtramadol (used for pain) 50 mg, give one tablet every six hours PRN. Review of P3s SNF provided “Medication Review Report,” dated 02/04/25, revealed no orders for the acetaminophen, Ativan, bisacodyl, Calmoseptin, ipratropium, Levsin, melatonin, potassium chloride, or tramadol as listed on the hospice agency physician orders. In addition, the SNF “Medication Review Report” contained orders for:gabapentin 100 mg, one capsule three times a day,hydralazine 25 mg give one tablet two times a day (BID),sodium bicarbonate 650 mg, give one tablet BID for heartburn. These medications were listed in different dosages than on the hospice agency physician orders.There was no documented evidence that a Registered Nurse (RN) completed a medication review. 2. Review of P4’s agency provided “Patient Information Report” indicated that P4 was admitted to hospice on 12/31/24 with a diagnosis of Alzheimers disease. Review of P4s undated “Client Medication Report,” provided by the hospice agency, indicated orders for P4 to receive:acetaminophen 500 mg, give two capsules PO three times a day (TID), oxygen (given for shortness of breath) two liters (may titrate up to four liters for patients comfort) via nasal cannula PRN, andsenna-s 8.6 mg-50 mg (medication for constipation), give two tablets PO BID PRN. Review of P4s Group Home provided “Physicians Orders,” dated 02/04/25, indicated no documented evidence of orders for the acetaminophen or senna-s. In addition, there is documented evidence to give P4 oxygen three liters via nasal cannula PRN. Additionally, P4’s Group Home “Physician’s Orders,” dated 02/04/25 contained physician orders for:quetiapine (medication for agitation) 12.5 mg daily PRN,milk of magnesium (medication for constipation) 30 ml at HS PRN,anti-diarrhea two mg, two tabs after each loose stool PRN, andantacid 30 ml four times a day. These medications were not listed on P4’s hospice agency orders. It was documented that the RN had completed a medication review on 01/29/25. During an interview on 02/05/25 at 1:30 PM, the Director of Clinical Services (DCS) confirmed that the nurses were responsible for completing a medication review every visit. The DCS confirmed that the hospice medications did not match the SNF medication orders for P3 and did not match the group home medication orders for P4.”

“Based on observations, interviews, and record review, the agency failed to provide personal care in a manner to prevent cross contamination for two of six patients (Patient (P) 4 and P15) observed during home visits out of a total sample of 23. This had the potential to increase the risk of infection for the patients. Findings include : 1. Review of P4’s “Patient Information Report,” provided by the agency, indicated that P4 was admitted to hospice on 12/31/24 with a diagnosis of Alzheimers disease. During a home visit on 02/04/25 at 1:00 PM, Certified Nursing Assistant (CNA) 2 was observed completing a bed bath for P4. CNA2 washed his/her hands, put on gloves, and gathered supplies. CNA2 removed P4s clothing and washed P4s upper body. Wearing the same gloves, CNA2 rinsed P4s upper body and obtained a towel and dried P4. CNA2 removed P4s brief and wiped P4s perineal area with wipes. Without changing gloves, CNA2 washed P4s perineal area with soap on a washcloth, rinsed the perineal area with another washcloth, and then dried the area. CNA2 assisted P4 in rolling over to his/her left side and placed a new brief underneath P4. CNA2 then assisted P4 to his/her right side, washed, rinsed, and dried P4s back area. Wearing the same gloves, CNA2 put lotion on P4s back prior to rolling P4 back to his/her back and fixing the brief. CNA2 washed P4s legs and feet and then took the same cloth and washed P4s face. CNA2 rinsed and dried P4s legs and feet and placed new clothes on P4. Wearing the same gloves, CNA2 removed the basins from the overbed table and wiped down the overbed table with the same gloves on. An attempt to interview CNA2 was made on 02/05/25 at 5:15 PM; however, there was no answer and/or answering machine. There was no return call prior to the survey exit. 2. Review of P15’s “Patient Information Report,” provided by the agency, indicated that P15 was admitted to hospice on 07/12/24 with a diagnosis of chronic kidney disease (CKD). During a home visit on 02/04/25 at 8:30 AM, CNA1 was observed completing a bed bath for P15. CNA1 washed his/her hands, put on gloves, and gathered supplies. CNA1 washed, rinsed, and dried P15s hair, and then washed P15s face and removed his/her clothing. CNA1 washed, rinsed, and dried the upper front part of P15’s body, unfastened the patient’s brief and pushed it under the patient, washed the lower half of P15’s body, and applied petroleum jelly and lotion to the patient’s legs. CNA1 then washed P15s perineal area, and assisted P15 in rolling over to his/her right side. CNA1 removed P15s brief and threw it away. Wearing the same gloves, CNA1 washed, rinsed, and dried P15s back and buttocks. CNA1 then applied lotion. CNA1 applied a new brief, assisted P1 in rolling back over to his/her back and to his/her left side, adjusting the brief, and then back to his/her back. CNA1dressed P15. CNA1 got P15 up once he/she was dressed by the assistance of the stand lift and placed P15 in the recliner. Once P15 was in the recliner, CNA1 removed his/her gloves and washed his/her hands. An attempt to interview CNA1 was made on 02/05/25 at 12:30 PM, and a left voice message; however, there was no return call prior to the survey exit. During an interview on 02/05/25 at 1:30 PM, the Director of Clinical Services (DCS) indicated that gloves should be changed when going from a dirty area to a clean area.”

“Upon patient record review, 2 of 23 (Patient #12, 21) 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 #12 - SOC 10/09/23 - Initial bereavement completed 10/17/23. Patient #21 - SOC 10/10/22 - Initial bereavement completed 12/05/22.”

“Upon patient record review, 1 of 23 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #13 - Comprehensive assessment on 11/20/23 then again on 12/07/23”

“Upon patient record review, 2 of 23 (Patient #9, 14) 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 #9 - Order written on 10/31/23 “okay to decrease feeding to 3xday instead of 5” did not include type, amount, or bolus, gravity or pump. Patient #14 - Order written on 12/08/23 Dilaudid “....via port via PCA weekly with sterile dressing change with bag change”.”

“Upon patient record review, 4 of 23 (Patient #7,8,13,15) 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 #7 - Music Therapy visit frequency 2 PRN. Patient #8 - Volunteer visit frequency 1 wk 1, 8 PRN. Patient #13 - MSW 1wk1 6 PRN, SC 2wk1, 5 PRN Patient #15 - MSW 1 wk1 6 PRN, SC 1wk 1, 3PRN”