Heartland Hospice (Lincoln)

“Upon patient record review, 1 of 14 (Patient #5) 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 5: The medical record indicated that patient requested to end chaplain services on 04/24/2025. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 06/02/2025. COS-new order written to remove the spiritual care plan from the plan of care during survey.”

“Upon patient record review, 2 of 14 (Patient #2,5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The plan of care has MSW visit frequency ordered as 2 visits a month. No evidence that patient received 2 visits for the month March 2025. The clinical documentation indicated that only one visit occurred for the month of March (03/21/25). No evidence that the visit were missed at the request of the family or that an order was received to change the visit frequency for the month at the time that the record was reviewed. Patient 5: The plan of care has volunteer visit frequency ordered as 2 visits a month. No evidence that patient received 2 visits for the month June 2025. The clinical documentation indicated that only one visit occurred for the month of June (06/05/25). No evidence that the visit were missed at the request of the family or that an order was received to change the visit frequency for the month at the time that the record was reviewed.”

“Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable not acceptable Patient 6: Clinical documentation indicated that the patient requires 2 person assist and uses a Hoyer lift all with transfers due to altered mobility. No evidence that the aide plan of care included those instructions due to altered mobility. COS-new order written to add to those instructions for transfers to the aide plan of care during survey.”

“Upon patient record review 2 of 14 (Patient #3,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: The aide plan of care has a visit frequency ordered as 3 visits for the week of 04/28/2025. No evidence that patient received 3 visits for the week of 04/28/2025. The clinical documentation indicated that only two visits occurred for that week on 04/29/25 and 05/01/25. No evidence that the visit was missed at the request of the family or that an order was received to change the visit frequency for the month. Patient 6: The aide plan of care has a visit frequency ordered as 2 visits a week. No evidence that patient received 2 visits for the week of 04/20/2025. The clinical documentation indicated that only one visit occurred for that week on 04/23/25. There was a missed visit note entered on 04/25/2025 that stated that the visit was completed on 04/24/25. No evidence that the a visit was completed on 04/24/2025 at the request of the family or that an order was received to change the visit frequency for the month.”

“Upon patient record review 2 of 14 (Patient #3,9) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 3: No evidence that a registered nurse made an aide supervisory visit every 14 days between 04/15/25-05/08/25 (23 days). Patient 9: No evidence that a registered nurse made an aide supervisory visit every 14 days between 04/04/25-04/21/25 (17 days).”

“Upon patient record review, 2 of 14 (Patient #8,9) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 8: The RN documented in a clinical note written on 07/12/2025 that a size 22FR catheter was placed in the suprapubic site during her visit. The RNs assessment documentation indicated that a size 16 FR catheter was placed during her visit. COS-visit note addendum completed during the survey. Patient 9: The RN completed an aide supervisory visit on 04/01/2025, indicating that aide was following the plan of care and that no changes need to be made. No evidence that the aide had provided care at that time. Clinical documentation indicated that the aide did not complete her first visit until 04/04/2025.”

“Upon patient record review, 1 of 14 (Patient #1) 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 plan of care has chaplain frequency ordered as once a month. No evidence that patient received a visit for the month of June. No evidence that the visit was missed at the request of the family or that an order was received to change the visit frequency for the month.”